Articles

Reconstructive Urology

Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications and Functional Results of Four Different Diversions

By: Jakko A. Nieuwenhuijzena 1, Remco R. de Vriesa 1, Alex Bexa, Henk G. van der Poela, Wim Meinhardta, Ninja Antoninib and Simon Horenblasa lowast

European Urology, Volume 53 Issue 1, April 2008, Pages 834-844

Published online: 01 April 2008

Keywords: Cystectomy, Diversion, Bladder cancer, Functional results, Complications, Ileal conduit, Indiana, Orthotopic, Neobladder, Metabolic

Abstract Full Text Full Text PDF (444 KB)

Abstract

Purpose

We present a single institute experience of the four most widely used diversions after cystectomy in 281 patients, with an evaluation of the association between clinical factors, complication rates, functional results, and metabolic complications.

Materials and methods

Between 1990 and 2005, 281 consecutive cystectomies were performed at our institute. Four different diversions were offered: an ileal conduit according to Bricker (IC; 118 patients), an Indiana pouch (IP; 51 patients), and orthotopic diversions after cystectomy/neobladder (N; 62 patients), or sexuality-preserving cystectomy and neobladder (SPCN; 50 patients).

Results

Forty-four percent developed early complications: IC 48%, IP 43%, N 42%, and SPCN 38%. High ASA score was the only variable significantly associated with early major complications (ASA 1 vs. 3: HR, 0.32; 95%CI, 0.14–0.72). Late complication rate was 51% with fewer complications in the IC group, IC 39%, IP 63%, N 59%, and SPCN 60% (HR, 0.32; 95%CI, 0.14–0.72), which was explained by fewer uncomplicated urinary tract infections (one third of all late complications) in the IC group. There were no differences in experienced late major complications. We found no significant association between tumour stage, ASA, age, preoperative radiotherapy, gender, and diversion-related complication rates.

Complete daytime and nighttime continence, respectively, was achieved in 96% and 73% after IP, 90% and 67% after neobladder, and 96% and 67% after SPCN. Metabolic changes were found in 24% of the patients: 21% after IC, 26% after IP, and 28% after orthotopic diversion (neobladder and SPCN combined); low vitamin B12 was measured in 23%, 15%, and 15% respectively.

Conclusions

Cystectomy with any subsequent diversion remains a procedure with considerable morbidity. High ASA score was associated with more early complications. Orthotopic diversions provide good functional results, but at the cost of more late complications compared with ileal conduits. We found no evidence that age, ASA score, positive lymph nodes, extravesical tumour growth, or previous radiotherapy were contraindications per se for any diversion.

Take Home Message

Cystectomy remains associated with significant morbidity, but this association does not seem to be related to the type of diversion. Type of diversion should be selected according to local tumour stage, hand function, and renal function, instead of fear of complications.

Keywords: Cystectomy, Diversion, Bladder cancer, Functional results, Complications, Ileal conduit, Indiana, Orthotopic, Neobladder, Metabolic.

Footnotes

a Department of Urology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

b Department of Biostatistics, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

lowast Corresponding author. The Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Department of Urology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel. +31 20 5122559; Fax: +31 20 6692554.

1 These authors contributed equally to this work.

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