Determining when to recommend continent urinary diversion

For many bladder cancer patients diagnosed with muscle-invasive disease and in cases of high-risk progressive noninvasive disease, cystectomy is an effective treatment, offering disease-specific survival of about 87%.1 Bladder cancer survivors, however, face a multitude of health-related consequences following cystectomy. These are mostly related to urinary diversion and reconstruction. While improvements in perioperative care have decreased the surgical morbidity following cystectomy,2 the complications and functional consequences associated with urinary diversion remain problematic. As a result, the functional and health-related quality of life issues following cystectomy are substantial for this group of cancer survivors. The impact of urinary diversion has long been recognized as a major shortcoming of cystectomy and has prompted interest in limiting the adverse functional effects associated with surgical removal of the bladder. Several forms of continent urinary diversion have been developed and refined with the objective of decreasing the burdens associated with diversion.3,4 In addition, the options and recommended use of continent diversion have expanded during the past decade, and currently, proponents of continent diversion estimate that 80% of men and greater than 65% of women with invasive bladder cancer are candidates for orthotopic continent urinary diversion.5 Most cystectomy patients, however, do not receive continent reconstruction.6 Although the reasons are not entirely clear, significant baseline infirmity and comorbidity, technical complexity, risk of complications7 and uncertainty regarding a health-related quality of life benefit have likely limited widespread adoption of continent reconstruction. Although the optimal type of urinary reconstruction has not been firmly established,7–9 continent diversion offers potential advantages through maintenance of anatomic voiding, approximation of normal functional voiding and preservation of preoperative body image. Previous work has shown that complications following this type of diversion are modifiable and that cancer control and survival are independent of the type of urinary diversion used.3,10,11 Experienced groups have reported improvement in short- and long-term complications3 as well as satisfactory urinary continence in up to 95% of patients following continent urinary diversion.12 While these results are likely not generalizable and may overestimate the health-related quality of life benefit of continent orthotopic urinary diversion, they do underscore the potential benefit of continent diversion when used in the right setting. Still, comparisons of functional outcomes and health-related quality of life in bladder cancer survivors managed with continent and incontinent urinary diversion have been difficult to interpret. To date, methodology has been limited7–9,13 and results have been mixed.14–20 While general health-related quality of life appears to be similar in both,21 specific issues concerning body image, problematic urine leakage and decreased sexual functioning have been inconsistent, although more commonly reported following ileal conduit diversion.22 Even so, each type of urinary diversion is associated with a different set of well-described treatment-related effects. In those managed with ileal conduit, concern centres around the urinary stoma, external urinary appliance and the consequent negative impact on body image. Other factors that appear to be of particular concern to this group include urinary leakage, skin irritation and excoriation, sexual dysfunction and gastrointestinal problems.23–29 Urinary incontinence, particularly nighttime incontinence, appears to be the principal issue in patients managed with continent orthotopic urinary diversion. Catheterization poses its own set of concerns related to frequency, discomfort and inconvenience following continent nonorthotopic urinary diversion and in men and women who catheterize following orthotopic diversion because of urinary retention.8 The impact of suboptimal outcomes may affect quality of life beyond the obvious functional impairments documented to date. Several prior studies have found that patients treated with orthotopic continent diversion are more likely to travel, to engage in leisure activities and to suffer fewer social deficits than those managed with incontinent diversions.19,22,30–32 Others have found that urinary leakage is a greater concern among patients treated with ileal conduit, compared with continent diversion,14,33,34 which may contribute to less social behaviour. In truth, the negative consequences of incontinent diversion and positive functional outcomes following continent diversion have likely been exaggerated in opposite directions. As noted previously, direct comparisons of incontinent and continent urinary diversion are challenging for a variety of reasons. Issues related to the advanced age of the average cystectomy patient, varying levels of infirmity and, in some cases, relatively low baseline functioning undoubtedly contribute to detected differences in functional outcomes between urinary diversion groups. Few studies, however, have accounted for these important differences, making much of what has been reported susceptible to confounding by indication. This circumstance underscores a principal challenge in this area of outcomes research; continent urinary diversion patients tend to be more active and healthier than their older, more infirm ileal conduit counterparts, and comparison of functional and health-related quality of life outcomes may therefore not be balanced. A second limitation in urinary diversion comparisons relates to the lack of disease-specific outcome measures. Most previous research has relied on general measures, which are typically unresponsive to the most clinically relevant differences, or have used informally developed questions, in which case the ability to reliably detect true differences is uncertain. Unfortunately, few reliable, responsive and valid health-related quality of life instruments are currently available for bladder cancer, and those that have been developed are in the early stages of validation and disseminated use.8,35–37 Consequently, health-related quality of life assessment in the area of urinary diversion has been incomplete to date, and as a discipline, we are just now embarking on reliable measurement. Undoubtedly, functional outcomes, health-related quality of life and the survivorship experience can be improved following cystectomy and urinary diversion. Determining the extent of the problems associated with various types of urinary diversion will be an essential component in this effort. In the case of orthotopic continent urinary diversion, surgeons have underestimated the prevalence of urinary incontinence, and patient-reported problems with urinary leakage and lack of control are apparent in greater than 50% of cases.37 Importantly, while urinary function is impaired following continent diversion, patients do not appear to be significantly bothered,37 suggesting that adaptation to functional impairments is also common. It is quite possible that factors such as patient values, expectations and preference for maintaining anatomic urinary function (voiding per urethra) in exchange for some impairment of normal voiding function (full urinary control) influence recovery and health-related quality of life following urinary diversion. For some patients, particularly those who are younger, more active and motivated to avoid an external urinary appliance and maintain anatomic voiding, continent diversion is likely the right choice. For others, incontinent diversion may be preferable. While all surgeons involved in treating bladder cancer strive to limit the adverse impact of cystectomy, we can still do better. Tailoring the approach to urinary diversion is appealing because so much of how a patient recovers and adapts following surgery is mediated by their expectations and values. The marginal patient — the cases in which functional detriments are further exacerbated by expectations that are unmet by postdiversion outcome — is where major improvement can be achieved. Understanding the determinants of optimal care — knowing in which cases, for which patient and in which settings to recommend continent diversion — is a key element in this process.

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