Which is the best diversion: conduit or neobladder?
Friday’s debate featured the pros and cons of both types of urinary diversion to help inform true shared decision-making with your patients.
Continent bladder replacement (neobladders) was developed and widely used beginning in the mid-1980s. Many institutions across the United States and internationally began offering this type of diversion to half or more of their patients undergoing cystectomy, and many published series show long-term safety, patient satisfaction and overall good functional results. Yet nearly 90% of patients undergoing cystectomy will have a standard ileal conduit diversion with a stoma requiring an external bag. Should neobladder diversion be recommended to more patients in lieu of ileal conduit?
Friday's "Crossfire: Controversies in Urology: Ileal Conduit vs. Neobladder: 68-Year-Old Man Who Wants a Neobladder but Is Unsure About Catheterizing," debated the rationale for recommending a neobladder or a standard ileal conduit for an index patient, a healthy 68-year-old man with a recent diagnosis of muscle-invasive bladder cancer but without medical contraindications, who theoretically asks, “Which type of diversion is best for me?”
“There are only a few real medical contraindications to a neobladder,” said session moderator Eila C. Skinner, MD, chair of the department of urology and professor of urology at Stanford University in California. “Every urologist who does cystectomies says they let their patient decide what type of diversion they want. But, in fact, it’s easy to steer patients to what you want to do.”
Anne Schuckman, MD, associate professor of urologic oncology at the Keck USC School of Medicine in Los Angeles, presented evidence highlighting the perioperative safety of neobladder surgery and the low rates of complications, such as incontinence, urinary retention and infections.
“Up to 25% of patients experience early complications for all diversions, but neobladder infections stabilize over time,” she said. Conversely, the complication rates of ileal conduits increase slowly over time. “Many patients are willing to accept short-term risks for a long-term payoff,” Dr. Schuckman said.
Mark Tyson, MD, MPH, associate professor of urology at the Mayo Clinic in Phoenix, reviewed quality-of-life literature that supports patient satisfaction with neobladder reconstruction. “When adjusted for age, neobladders result in better quality of life for younger, fitter patients,” he said. With a neobladder, patients appreciate improved general health, the ability to more easily use public bathrooms and a better body image.
Joshua Meeks, MD, PhD, professor of urology at Northwestern University in Chicago, argued that there is limited data on the long-term burdens of neobladders. “The neobladder is probably not the best choice for patients with bladder cancer,” he said. “What happens if these patients have a recurrence of their cancer? When patients have complications, the neobladder makes it so much harder. What if more treatment is needed?”
Amy N. Luckenbaugh, MD, assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee, outlined the benefits of an ileal conduit, including lower operative time and lower length of stay, fewer postoperative complications and readmissions, improved simplicity of care and maintenance, and equivalent quality-of-life outcomes. Overall, “humans are adaptable. They will learn to live with whatever you throw at them,” she said.
AUA Guidelines endorse a fair discussion of all forms of urinary diversion. “Both types of diversion have acceptable outcomes, and the choice should reflect the patient's own values and priorities," Dr. Skinner said.
