Diversion tactics

Urinary diversion—surgically constructing a neobladder—is arguably the gold standard for patients undergoing radical cystectomy, except when contraindications apply, such as compromised renal and intestinal function.

Still, the frequency of urinary diversion is trending downward, hovering around 10% or fewer in U.S. medical centers.

“We want to keep urinary diversion alive because patients want it,” said Siamak Daneshmand, MD, professor of urology (Clinical Scholar) and director of urologic oncology at the University of Southern California/Norris Comprehensive Cancer Center.

Dr. Daneshmand led Saturday’s Instructional Course, “Urinary Diversion: Current Indications, Techniques and Management of Complications,” presenting current clinical indications for urinary diversion with an overview of each type of urinary diversion technique, including the Studer pouch and the Hautmann pouch, and factors that can influence whether providers and patients choose urinary diversion.

“At least two-thirds of patients presenting for cystectomy are likely to be reasonable candidates for some sort of urinary diversion,” Dr. Daneshmand said. “While there may not be a consensus on improvement in quality of life, most patients and many providers consider continent diversion to be an attractive option.”

Although surgical training can drive the selection of urinary diversion technique, “there really is no one right urinary diversion,” Dr. Daneshmand said. “The most important thing to do is provide patients with realistic expectations by informing them of continence and complication expectations and have them weigh the given risks and benefits based on their lifestyle, motivation and priorities.”

Early complications of urinary diversion include bowel anastomosis leak, diarrhea, constipation, urine leak, infection and dehydration, said Eila C. Skinner, MD, professor in the department of urology at Stanford University, who followed Dr. Daneshmand’s presentation with a discussion on managing complications of urinary diversion.              

“There’s rarely a need to reoperate except for severe leak, rectal injury or refractory small bowel obstruction,” Dr. Skinner said. “The most common early complications can be avoided using [enhanced recovery after surgery] techniques.”

Dr. Skinner noted that alvimopan for enhancing gastrointestinal recovery and decreasing the amount of postsurgical narcotics can help minimize postoperative complications. She also offered recommendations for managing long-term complications, including uretero-ileal stenosis, kidney stones, infection and metabolic complications, which are common to all types of urinary diversion, she said.

Matthew D. Dunn, MD, associate clinical professor and director of endourology and stone disease in the department of urology at the University of California Los Angeles, concluded the course with a discussion on endoscopically managing common complications of urinary diversion, including kidney stones, foreign bodies, hematuria, afferent valve stenosis, upper tract recurrence and uretero-enteric strictures. Patients with these complications can present with recurrent urinary tract infections, hematuria, dull ache and central abdominal pain associated with intermittent anuria.               

“Most recurrent pouch-related problems can be managed or at least diagnosed endoscopically,” Dr. Dunn said, “but open surgery is better for strictures greater than one centimeter.”