After one century of urinary diversion, this issue still remains one of the most fascinating chapters in urology. Main reasons for replacing the bladder are bladder cancer, neurogenic bladder dysfunction, intractable detrusor overactivity and chronic inflammatory disease of the bladder such as interstitial cystitis, tuberculosis or schistosomiasis [1▪▪]. Creativity of many surgeons led to a multitude of innovations. All these intellectual creations had to be realized and had to withstand the proof of time. Errors and negative developments were made; different surgical schools created dogmas and stood against ideas of others, often overlooking the actual needs of the patients. Personal vanity of the so-called opinion leaders delayed professional cooperation. As the experience with different surgical techniques, their complications and their troubleshooting increased, we find ourselves now in a phase of adaption. We are trying to find an individual solution for the real needs and request of the patients.
The present article focuses on this so-called tailored surgery and will review the recent literature regarding an individualized and tailored urinary diversion.
In radical cystectomy, severe postoperative complications are almost always related to urinary diversion. ‘No one dies due to the cystectomy but rather due to the diversion’, argued Professor Hohenfellner Rudolph at the Societe International de Urologie in Singapore in 2000. These words of wisdom sound sloppy, but reflect a deep truth. Therefore, it is essential to tailor the right diversion correctly to the individual patient, thus minimizing the risk and maximizing patient benefit. This adaption or tailoring differs widely when taking into account different perspectives, which may lead to completely different solutions.
The following perspectives will be processed:
- surgical/medical preferences/surgical training;
- patients’ expectancies/social circumstances;
- comorbidities/oncological circumstances;
- quality of life (QoL);
- demography; and
- evidence-based medicine (EBM).
Anatomy varies widely, which can have a strong repercussion on urinary diversion, since most diversions require reconstruction of intestinal segments. There are two major aspects – firstly, the vessel supply and secondly, the bowel anatomy.
It is well known that the ileocolic artery shows many variants . This artery supplies the ileocoecal region, and any alteration which reduces the blood flow of this artery is a potential cause for intestinal necrosis, often involving the whole ileocoecal region . Severe arteriosclerotic alterations are more frequent in the superior mesenteric artery than in the inferior ones and affect at first the ileocolic artery in the intestinum . In case of vascular comorbidity, it would be good advice to avoid this critical region. In this case, the use of large bowel is an appropriate alternative. On the contrary, the use of large bowel should be avoided if the patient has an aortic stent or an infra-renal aortic substitution with a prosthesis, since the inferior mesenteric artery is closed in case of these approaches. The left colon and the sigmoid receive their blood supply through the Riolan anastomosis between the medial colic artery and the superior rectal artery. Any interruption of the Riolan anastomosis can cause life-threatening complications.
Another aspect is the length of the bowel or the shortness of the mesentery in the ileocoecal region. A long sigmoid is inviting the surgeon to use this segment for a diversion. It lies at the entrance of the small pelvis and can easily be moved to the urethral stump in case of neobladder creation. If used as a conduit, the isolated sigmoid segment has to be turned for only 90° and can take any place in the mid or upper abdomen. Sometimes, the mesentery of the ileum is foreshortened and keeps it under tension if the new configurated ileal neobladder is attached to the urethral stump. In this case, it is recommended to incise the visceral peritoneum of the mesentery to gain length. In this case, the vessels can be stretched and particularly small veins can be lacerated. Hence, it is much safer to use the sigma.
Higher risk of anastomotic dehiscence is a common argument in urology for avoiding a large bowel anastomosis. There is a lack of data regarding whether the use of intestinal segments from one part of the gut (ileum) as conduit diversion would be better than one from another part (colon) [1▪▪]. Only one study fulfils the criteria for EBM. Kristjansson et al.[5,6] compared ileal conduit with colon conduit, and there were no statistically significant differences in all outcome measures.
SURGICAL/MEDICAL PREFERENCES/SURGICAL TRAINING
Ileal conduits have become the gold standard for incontinence diversion  and indeed remain the procedure of choice in patients with contraindications to continent diversion [8▪]. ‘Because absorption of electrolytes is reduced in ileal urinary reservoirs, it should be used for creating bladder substitution’, sustained Hautmann et al.. It seems that the ileum is the most appropriate intestinal segment to be used for any kind of bladder substitution; however, there is no evidence to support that, as stated in the Cochrane Collaboration Review from 2012 [1▪▪]. A crucial factor, which has an often unrecognized influence on the selection of urinary diversion, is the limited surgical experience that most urologists have in working with the different gut segments and is therefore also responsible for the high complication rate in case of surgical revisions of urinary diversions . Most urologists are trained in handling small intestine, but not in using large bowel. Hence the indications are tailored to the surgeons’ abilities, and not to the actual medical request, anatomical situation or best promising solution. This may explain the reluctance to use the transverse conduit in irradiated patients  even though the ileal conduit has a high complication rate in this setting.
PATIENTS’ EXPECTANCIES/SOCIAL CIRCUMSTANCES
Most patients have the desire to continue with their life as they did before the cystectomy. Despite extensive counselling, many postsurgical inconveniences are not well recognized and accepted by the patient. After a first phase of satisfaction to have defeated the illness, the phase of disillusion soon has a strong impact on the psycho-social well-being of the patient.
Also, social and cultural factors influence the selection of the urinary diversion. In many parts of the world, a urinary bag may be socially unacceptable or economically unrealistic as a permanent solution. In these cases, a continent diversion must be tailored. In the Third World countries, rectal pouches are often the only solution for such cases in medical as well as socioeconomical terms.
Wheel chair drivers request particular attention. An orthotopic bladder replacement creates major care problems; therefore these patients are better served with a continent reservoir with a cutaneous stoma or an incontinent diversion. Apart from the use of the appendix or the intussusception of the invaginated ileal nipple in the ileocoecal valve, we can use a multiplicity of efferent segments, such as the Monti–Yang [11,12] procedure, the serosa lined technique from Abul Enein, the Roth–Kälble efferent segment or as a simpler solution – the neo-appendix in the Mixed Augmentation Ileum and Zecum III pouch.
Comorbidity is one of the most important factors for differential indication and therefore for the selection of urinary diversion. The guidelines of different urological associations recommend us to perform a neobladder ‘whenever possible’. In reality, reaching a decision is, however, often more complex than that. In a series from the Netherlands from 2014 with 2455 patients, 63% of the patients suffered from at least one serious comorbid condition and 32% had at least two comorbid conditions [13▪▪]. Only 14% of the patients were classified preoperatively as American Society of Anesthesiology 1. The most frequent comorbidities seen in candidates for cystectomy were: hypertension (34%), diabetes (26%), cardiovascular disease (26%) and pulmonary diseases (27%) [13▪▪]. There is a common association of age with comorbidity. The percentage of patients with more than two comorbid conditions is three-fold higher for patients aged above 75 years compared to patients aged below 60 years.
Although radical cystectomy has been suggested to have a survival benefit for elderly patients, these patients generally do not undergo this type of surgery due to the higher risk of morbidity and postoperative mortality . In the Dutch series from Goossens-Laan et al.[13▪▪], only 13% of the patients aged over 75 years underwent cystectomy, showing how much this therapeutic option is under-utilized. There is a general tendency of treatment becoming progressively less invasive as age and comorbidity increase. The critical factor for success of any treatment in the elderly or comorbid patients is patient selection and tailored therapy.
A continent diversion requires a mentally and physically active patient who is motivated to maintain the reservoir, and who can cooperate properly with the healthcare givers. The patient must technically be able to catheterize the urethra or the cutaneous stoma. If psychosocial circumstances or medical reasons preclude this level of cooperation, the patient might be better served with an incontinent diversion [8▪].
There are, however, other factors, apart from patients’ motivation or requests, which determine the selection of the diversion. A serum creatinine level above 150 mol/l is a sign of compromised renal function. In this case, any continent diversion should be avoided, considering that the glomerular filtration rate will decrease by 1 ml/min each year after the age of 65 years, as a normal ageing process . Modern pouches and neobladders are high-volume, low-pressure reservoirs, where reflux is rare and the benefit of an anti-reflux implantation is outweighed by the higher renal functional loss and reoperation rate (18–20%) [1▪▪,9]. A simple end-to-side anastomosis has a risk of up to 2% to develop a stricture, whereas an anti-refluxive technique implicates a risk of 18–20%.
Also, oncological criteria preclude patients from a neobladder. The urethral resection margin must be free from any dysplasia in men. In case of female patients, the bladder neck must be free from cancer involvement, as well as no tumour extension into the vaginal wall or in the paravaginal pedicles must be present.
Nowadays also, a massive extensive pelvic disease, positive lymph node or previous radiation therapy is not considered as a contraindication for the neobladder . Radiation induces degeneration of the artery wall and intimal hyperplasia, which leads to an occlusive arterial disease [4,15]. Radiation arteriopathy is a dose-dependent process which develops many years after radiation exposure after a latent period. Vessels affected by radiation arteriopathy are at risk to develop a stenosis or thrombosis after surgery . Therefore, any intestinal segment exposed to prior radiation therapy should be excluded of the use in reconstructive surgery. In reality all the above mentioned facts cause such disastrous life circumstances that a benefit to the patients is more than questionable. In these cases, less is more – the simpler the better.
The oncological outcome of cystectomy depends primarily on tumour stage. Nowadays, the overall 5-year survival under curative intent reaches 50–72% in large-scale studies [16,17]. Whereas a 5-year overall survival can be expected in up to 80%, in cases of lymph node-negative, organ-confined tumours, this range drops to less than 30%, if lymph-positive. Whenever possible, taking the comorbidities, the biological age and the QoL into account, an orthotropic replacement should be considered. If the patient does not fulfil all of these requirements, an incontinent diversion is always better. However, there are situations in which cure is impossible, and cystectomy and diversion are only palliation. In these cases, a simple diversion without intestinal anastomosis is to be preferred. It reduces the abdominal complications, the reintervention rate and the severity of the whole approach. An ureterocutaneostomie [18▪,19,20] can be safely performed with a very low complication rate. The local tumour and therefore the most sequelae are overcome, but the overall survival time remains unchanged.
The situation in nononcogenic diseases is different. Prognosis and therapeutic options depend mainly on the renal function [21▪], and success following urinary diversion is usually measured by preservation of renal function, improvement of QoL and prevention of serious complications. Here, more sophisticated diversion techniques are used and the main goal is a continent diversion, especially in young patients, due to body imaging. In older patients, a conduit remains a good option despite only 50% of the patients experiencing a fair outcome [21▪]. The long-term mortality is reported with 25% [21▪] and is attributable to recurrent urinary tract infections.
QUALITY OF LIFE
Despite a magnitude of published data, the majority is of low quality. Therefore, in a recent review, only 21 studies could be taken into consideration. None of the studies was randomized and only four studies were prospectively designed. From the published data, it still remains unclear if one form of diversion is superior to another in terms of QoL [22▪]. Sixteen studies reported no difference in QoL between continent and incontinent diversions. Four studies reported a better QoL with continent diversion, two of which had younger patients, whereas one study reported a better QoL in incontinent diversions. We should never forget that socio-cultural characteristics, as well as the economical standard, play a major role in QoL outcomes. Only in adolescent and young adults, a continent diversion led to a higher QoL.
The Western population is ageing and the mean age of cystectomized patients is increasing [13▪▪,14]. Well established continent diversions are mandatory in younger and healthier patients. For the old and oldest patients, an ureterocutaneostomy is a good option and will experience a renaissance. Age alone cannot be an exclusion criterion for cure or palliation . Continent rectal reservoirs are still mandatory in environments which cannot guarantee an adequate healthcare assistance and are often associated with socioeconomical difficulties.
There is still uncertainty about the best surgical approach. Options available at present include the following: conduit diversions (ileal or colonic conduit), continent diversions (rectal reservoir or continent cutaneous diversion), neobladders with various segments or ureterocutaneostomies [1▪▪]. The evidence is very limited. Only five studies met the inclusion criteria for the Cochran systematic review, and they conclude that there is no evidence that replacement (orthotopic or continent diversion) is better than conduit diversion in bladder cancer. There was no evidence that bladder reconstruction was better than conduit diversions for benign disease. If using ileal segments for the creation of a neobladder is of an advantage compared to using an ileocolonic segment, is also uncertain in terms of lower rates of nocturnal incontinence. In summary, the authors stated that there is a very small amount of usable evidence.
Despite ileum conduit being the most used urinary diversion, we have a multitude of techniques available for the construction of tailored urinary diversion to guarantee the safest solution in combination with the highest QoL. It requests an adequate training of urologists in the use of all gut segments. If we as urologists do not accept this challenge in reconstructive surgery, we will lose parts of urinary diversion to general surgeons.
Whenever possible and reasonable, a neobladder with a refluxive ureteral implantation should be performed. The more sophisticated techniques using the transverse or the ileocoecal segments are reserved for patients after irradiation, in children or in cases when the body image is of great importance. If the appendix is not available as the efferent segment, there are other solutions feasible, creating a neoappendix or utilizing the serosa-lined principles. The rectal reservoir is still an excellent solution in environments lacking infrastructure and economically under-developed regions.
Due to the demographic pressure, solutions for ageing patients are mandatory and the ureterocutaneostmies will experience a renaissance as a diversion which avoids an intestinal anastomosis and hence minimizes the complication rate. Age alone is not a reason to preclude a patient from cure.
Quality-of-life studies showed no differences between continent and incontinent diversion, with the exception of younger patients who prefer the continent diversion for body image purposes. EBM remains sparse and there is no evidence for the best surgical approach.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
1▪▪. Cody JD, Nabi G, Dublin N, et al. Urinary diversion
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It is a must for every reconstructive surgeon. This review explains how evidence is acquired and what are the difficulties. It is disillusioning how small amount of usable evidence exists. Some dogmas were unmasked. It becomes clear that collaborative multi centre studies are needed.
2. Endo Press Tuttlingen, Hohenfellner R. Fisch M, Hohenfellner R, Pycha A. Supply of large bowel and common anatomical variants. The use of large bowel in urologic surgery. Second ed2014; 36–38.
3. Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep 2008; 10:341–346.
4. Möllmer H Severe atherosclerosis is more frequent in the superior mesenteric artery than in the inferior mesenteric artery. In Fisch M, Hohenfellner R, Pycha A, editors. The use of large bowel in urologic surgery. Endo Press: Tuttlingen; 2014. pp. 36–45.
5. Kristjansson A, Grubb A, Mansson W. Renal tubular dysfunction after urinary diversion
. Scand J Urol Nephrol 1995; 29:407–412.
6. Kristjansson A, Bajc M, Wallin L, et al. Renal function up to 16 years after conduit
(refluxing or antirefluxing anastomosis) or continent urinary diversion
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7. Colombo R, Naspro R. Ileal conduit
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8▪. Lee RK, Abol-Enein H, Artibani W. Urinary diversion
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This study gives an overview of the recent options in urinary diversion. Criteria for patients selection are very well explained also the psychological background and the impact on reconstructive surgery.
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12. Monti Pr, Lara RC, Dutra MA, et al. New technique for the construction of efferent conduits based on the Mitrofanoff principle. Urology 1997; 49:112–125.
13▪▪. Goossens-Laan CA, Leliveld AM, Verhoeven RHA, et al. Effects of age and comorbidity on treatment and survival of patients with muscle-invasive bladder cancer. Int J Cancer 2014; 135:905–912.
This study reports the influence of age, socio-economic status and the presence of serious comorbidity on treatment choice and survival in a population-based series of 2445 patients in the Netherlands. It shows how much curative options are under-utilized in the elderly.
14. Hollenbeck BK, Miller DC, Taub D, et al. Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older. Urology 2004; 64:292–297.
15. Rijbroek A, Vermeulen EG, Slotman BJ, et al. Radiation induced arterial disease. Ned Tijdschr Geneeskd 2000; 144:353–356.
16. Yuh B, Wilson T, Bochner, et al. Systematic review and cumulative analysis of oncologic and functional outcomes after robotic assisted radical cystectomy. Eur Urol 2015; 67:402–422.
17. Gschwend EJ, Retz M, Kuebler H, et al. Indications and ocological outcome of radical cystectomy for urothelial bladder cancer. Eur Urol 2010; 9 (Suppl 1):10–18.
18▪. Berger I, Wehrberger C, Ponholzer A, et al. Impact of the use of bowel for urinary diversion
on perioperative complication and 90-day mortality in patients aged 75 years or older. Urol Int 2015; 94:394–400.
This study reports the experience of a strategy to reduce the complication rate of radical cystectomy using an urinary diversion without an intestinal anastomosis. The obtained complication reduction reached 15% compared to the control group.
19. Berger I, Martini T, Wehrberger C, et al. Perioperative complications and 90-day mortality of radical cystectomy in elderly (75+): a retrospective, multicentre study. Urol Int 2014; 93:296–302.
20. Lodde M, Pycha A, Palermo S, et al. Uretero-ureterocutaneostomy (wrapped by omentum). BJU Int 2005; 95:371–373.
21▪. Johnson EU, Singh G. Long term-outcomes of urinary tract reconstruction in patient with neurogenic urinary tract dysfunction. Indian J Urol 2013; 29:328–337.
This review summarizes all possible option of bladder replacement in neurogenic patients and the individual outcomes of each approach.
22▪. Ali AS, Hayes MC, Birch B, et al. Health-related quality of life (HRQoL) after cystectomy: comparison between orthotopic neobladder
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