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EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
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Ileal Conduit as the Standard for Urinary Diversion After Radical
Cystectomy for Bladder Cancer
Renzo Colombo a,*, Richard Naspro b
a
Department of Urology, University Vita-Salute San Raffaele, Scientific Institute H. San Raffaele, Milan, Italy
b
Urology Unit, Humanitas Gavazzeni Hospital, Bergamo, Italy
Article info
Abstract
Keywords:
Complications
Continent urinary reservoirs
Ileal conduit
Quality of life
Radical cystectomy
Stoma
Surgical anastomosis
Urinary bladder neoplasms
Urinary diversion
For >30 yr, the ileal conduit (IC) has been considered the ‘‘standard’’ urinary
diversion for bladder cancer patients submitted to radical cystectomy. It is universally recognised as being the most clinically adequate, cost-effective, and
reliable solution in the long term. During the last two decades, this surgical
procedure has been challenged by the dissemination and the excellent clinical
outcome of bladder substitutions, which gave the surgeon options in supporting
the patient’s final choice. Despite this, from a survey of recent literature, IC remains
a widely used urinary diversion in most urologic centres. In particular, it is most
frequent in female patients and in patients >70 yr with high preoperative comorbidities and unfavourable clinical tumour stage.
Enhanced recovery protocols with standardised perioperative plans of care or
‘‘fast-track’’ approaches as well as advances in postoperative patient surveillance
have consistently decreased the overall morbidity related to the IC procedure.
Although technically simpler to perform when compared with continent reservoirs, IC has not been associated with lower complications. This can be explained
partly by the more unfavourable clinical characteristics of patients who undergo
the procedure and partly by technical surgical errors. Postoperative complications
strictly related to IC contribute to reduce the postoperative quality of life. These
complications include uretero-ileal anastomotic strictures and stomal, peristomal,
and abdominal wall-related complications. Most prospective studies, however,
found no difference in overall quality of life when comparing different types of
transposed intestinal segment surgery.
# 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, Università ‘‘Vita-Salute’’, Ospedale San Raffaele, Via
Olgettina, 60, 20132 Milano, Italy. Tel. +390226432306; Fax: +390226432969.
E-mail address: [email protected] (R. Colombo).
1.
Introduction
Despite recent impressive achievements in radiochemotherapy-related approaches and molecular-based therapies, radical cystectomy (RC) remains the elective
treatment for both muscle-invasive bladder cancer (MIBC)
and selected non-MIBC cancers [1]. Countless retrospective
studies unquestionably support RC’s excellent oncologic
outcomes and satisfactory postoperative quality of life
(QoL) at long-term follow-up. Although much of the clinical
evidence coming from these studies is of low quality, major
international guidelines strongly recommend RC as the
elective treatment for MIBC [2].
Recent improvements in surgical techniques have
contributed to favour the patient’s acceptance of this
major surgery. Technical refinements concerning both
extirpative time, including sexual sparing procedures and
reconstructive time with novel surgical solutions to divert
1569-9056/$ – see front matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eursup.2010.09.001
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
urine, have consistently improved the patient’s postoperative QoL.
For >30 yr, the ileal conduit (IC) has been considered the
‘‘standard’’ urinary diversion method for most patients
submitted to RC. It is recognised as the most clinically
adequate, reliable, and cost-effective solution. In the mid1980 s, the IC was challenged by the introduction of both
orthotopic bladder substitution (OBS) and cutaneous
continent reservoir concepts [3]. During the last 20 yr, a
variety of surgical OBS improvements have been introduced
progressively into clinical practice and proposed more and
more often to bladder cancer patients as the best compromise between oncologic radicality and postoperative QoL
[4]. This surely advocates for reconsidering the role of IC;
therefore, the real question is whether IC should still be
considered the standard urinary diversion procedure
following RC.
2.
Ileal conduit in the contemporary era
The IC technique is based on the use of a short segment of
ileal bowel to allow urine to traverse the abdominal wall
and empty through a cutaneous stoma into a dedicated
stoma collection device. The first description of the IC
urinary diversion must be attributed to Seiffert [5] in 1935.
However, the technique was subsequently refined and
popularised by Bricker in the 1950s [6]. Further surgical
variants, mainly concerning the ileo-ureteral implant,
introduced by Wallace [7], Le Duc et al. [8], Saudin and
Pettersson [9], and Taguchi (see Lee et al. [10]), did not
substantially change the original technique, which
remained the reference for urinary diversion against which
all other types of post-RC surgical solutions have been
compared and judged.
On the one hand, it has been stated that the major
qualifying points of IC are represented by the relatively
simple surgical technique and the low rate of inherent
postoperative complications. On the other hand, a visible
stoma, the need for lifelong stoma care, and the related
limitations in terms of social relationships, lifestyle, and
leisure activities are well-recognized disadvantages of this
procedure [3]. Whether IC is actually an easy-to-perform
intervention with overall limited postoperative complications remains a questionable issue. The overall long-term
functional results are far from those expected from an ideal
procedure [11], and the presence of a visible or malfunctioning stoma could be related to long-life anxiety and
depression [12]. The fact is that dissemination of IC
diversion and its acceptance in socially advanced countries
remain disparate.
According to a recent report by the Urologic Diseases in
America Project [13], among 27 494 patients submitted to
RC between 2001 and 2005 from the Nationwide Inpatient
Sample, 4539 (16.5%) underwent a continent urinary
diversion and 22 955 (83.5%) underwent an IC. Interestingly, a significant trend towards the more liberal use of the IC
during the last few years has been registered in some US
contexts. The monoinstitutional report by Lowrance et al.
[14] showed that OBS accounted for 47% of all urinary
737
diversions in 2000 and for only 21% in 2005. Likewise, the
recent study by Manoharan et al. [15] showed that of all
patients (mean age: 69 yr) submitted to RC between 1992
and 2007 at a department of urology in Miami, Florida, 56%
underwent IC and 41% underwent OBS. The trend is similar
in many European contexts. The Swedish Bladder Cancer
Register study was completed by including >90% of all
patients with newly diagnosed bladder cancer treated
with RC between 1997 and 2003, and IC and continent
reconstruction were accomplished in 64% and 36% of cases,
respectively [16]. Likewise, the German population-based
study by Bader et al. [17] showed that IC was selected in up
to 64% of overall cases after cystectomy. Similarly, a French
national survey published in 2008 by the French Association
of Urology confirmed the IC as the most frequent post-RC
urinary diversion (84%) [18].
This scenario seems to contrast with that at some
reference centres where, in the same period of time, a much
higher percentage of patients underwent OBS (Ulm, 66%;
Bern, 54%; Mansoura, 39% [19]). It clearly emerges that
continent reconstructions are more often completed at
academic departments than at county hospitals, demonstrating a substantial provider influence on the choice of
post-RC surgical solution.
The report published in 2007 by the members of
Consensus Conference on Bladder Cancer and the Société
Internationale d’Urologie, including >7000 patients from 13
urologic departments [3], probably reflects the current
distribution in the frequency of urinary diversions at
reference centres. In this report, OBS accounted for 47%
(30–66%) and IC accounted for 33% (22.6–64%). It is evident
that the rate of patients submitted to any kind of diversion
varies widely among high-volume institutions, and very
little is known about the reason for this variation. The same
study showed that surgical solutions different than IC and
OBS are used only marginally in most urologic departments:
anal diversion (10%), continent cutaneous diversion (8%),
and incontinent cutaneous diversion (2%). When analyzing
the mentioned studies, and regardless of the characteristics
of the urologic centres, IC unquestionably remains the most
frequent approach in female patients and in those >75 yr
with less favourable TNM classification.
3.
Patient preparation
A complete preoperative anaesthesiologic assessment
including cardiac testing, renal and hepatic function, and
correction of modifiable medical disease such as hypertension, cardiac arrhythmias, and anaemia should be completed in all patient candidates for RC.
During the last decade, enhanced recovery protocols
with standardised perioperative plans of care or ‘‘fast-track’’
(FT) schedules have also emerged as tools to assist RC
patients. Particularly, the FT protocols incorporate innovative aspects such as non-narcotic analgesics, limited bowel
preparation, early institution of an oral diet, and drainage
management and have been recognised by many clinical
studies [20] as a promising approach in RC followed by the
use of intestinal segments.
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EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
The use of bowel preparation using polyethylene glycol
or sodium phosphate oral solution has been recommended
and adopted for a long time in patients who are suitable for
intestinal surgery to reduce the incidence of postoperative
ileus, wound infections, and digestive anastomotic dehiscence [21]. However, when only the small bowel is being
used, scant evidence supports bowel preparation. A simple
cleaning enema the night before surgery as part of an FT
regimen was documented to be a reliable and effective
approach in patients who underwent IC diversion [22]. In IC
patients, the urologist or stoma therapist should mark the
site of the stoma, and the patient should test the appliance
and wear the definitive urine collection device for 1 or 2 d
before surgery. The stoma therapist may represent a key
figure in the perioperative and postoperative management
of these patients. Likewise, before surgery, patients should
be fully informed about the risks and benefits of IC and
surgical alternatives. Sufficient time should be given to
patients to realize the impact of everyday aspects related to
the urinary diversion selected before obtaining the informed consent. Often, before a final decision has been
taken, counselling of the patient and the family is required,
with the help of psychologists, oncology nurse specialists, or
patients who have previously undergone the chosen
procedure.
the type of urinary diversion [24]; however, as recently
shown in an overview by Froehner et al. [25], the IC is the
urinary diversion of choice (>70%) in daily clinical practice
for elderly patients (>70 yr). In the same setting and even
more for patients >75 yr of age with severe comorbidities or
with incurable disease requiring cystectomy mainly for
symptom control, IC competes with cutaneous ureterostomy, decreasing both surgical trauma and complication
rates.
Although OBS has been successfully performed in female
patients [26], at present, IC remains the most frequent
urinary diversion in females. Mean older age at time of
bladder cancer diagnosis and high rates of both urinary
incontinence and hypercontinence reported in some
experiences, together with a relative increase of postoperative complications after OBS, play roles in preferring IC in
the female population [3].
5.
Surgical technique step by step and practical
suggestions
RC with pelvic lymphadenectomy should be completed by
respecting well-defined surgical steps, as summarized by
Stein and Skinner [27] and by Bhojwani and Mellon [28].
5.1.
4.
Indications and contraindications to ileal
conduit
Since the introduction of continent urinary reservoirs into
clinical practice, the paradigm for choosing a urinary
diversion after RC has substantially changed. Currently, only
one QoL study suggests that bladder substitutions score
higher than IC [23]. To date, however, we should consider OBS
as the first option for all RC patients and identify those for
whom an orthotopic reconstruction might not be the ideal
solution. In this way, rather than the standard, IC may be
considered the most frequent alternative solution in all cases
that are unsuitable for orthotopic substitutions. An absolute
contraindication to continent urinary diversion of any type is
compromised renal function due to long-standing obstruction or chronic renal failure, particularly when serum
creatinine levels exceed 150–200 mol/l. Severe hepatic
dysfunctions represent a well-known contraindication to
OBS. Likewise, patients with compromised intestinal function should be oriented to an incontinent diversion. In
addition, OBS is contraindicated in cases of anal sphincter
mechanism deficiency or when urethrectomy is required. An
impaired intellectual ability and the lack of manual dexterity
may be considered as relative contraindications for bladder
reconstruction because some patients may not be able to void
with adequate use of abdominal straining, to manage
programmed night-time awakenings, and to perform selfintermittent catheterisation when needed. History of pelvic
irradiation, urethral stricture, neurologic disease, and willingness for regular follow-up are additional reasons for
preferring an IC to OBS [3,24].
In properly selected cases, high-volume centres report
similar complication rates in elderly patients regardless of
Choice and preparation of the ileal segment
A segment of 12–18 cm of ileum proximally to the
ileo-caecal valve is measured and generally tagged by
sutures. Preserve intact at least 15 cm of terminal ileum to
avoid metabolic disturbances related to salt absorption.
Care must be taken to adapt the length of isolated ileal
segment to the physical conformation of the patient (eg,
longer for obese patients). Do not use a too short an ileal
segment to avoid stretching and tension of the cutaneous
stoma. Likewise, avoid the use of a redundant segment to
prevent residual urine volume and urinary infections of
both conduit and renal units. In patients who have
undergone prior radiation, carefully select a segment of
ileum unaffected by radiation.
The mesentery of the iliac segment selected is incised
and prepared in a sequential manner using Kelly clamps and
3-0 free ties. Large feeding vessels must be avoided during
this process to prevent vascular damage of both ileal
segment and digestive anastomosis. Haemostatic surgery
devices such as bipolar scissors, harmonic scalpels, or
stapling devices may be of help, as may transillumination by
using a satellite lamp at right angles to the bowel.
The mesentery needs to be delicately dissected near the
tagged sutures to allow a GIA stapler or noncrushing clamps
to be placed. The bowel segment is divided, and the end of
the ileal segment that will be exteriorized is marked.
Proximal and distal ends of ileum are then anastomosed.
The digestive anastomosis may be completed by using
staplers or by handmade standard sutures either side to side
or end to end. Verify that the lumen of the completed
intestinal anastomosis is sufficiently wide, avoid any
traction on the suture, and prefer the peristaltic direction.
Reinforce the staple lines with 3-0 sutures. Remember to
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
[()TD$FIG]
[()TD$FIG]
739
Fig. 2 – The isolated ileal segment to be used as a conduit is lying below
the digestive anastomosis, and the mesentery window of the ileo-ileal
anastomosis is sutured.
Fig. 1 – (a) Internal transmesentery ileal hernia and (b) internal ileal hernia
through the conduit and the peritoneum of the abdominal lateral wall.
accurately close the mesentery window of the ileo-ileal
anastomosis with 3-0 absorbable sutures to prevent an
internal transmesentery ileal hernia (Fig. 1a).
Ultimately, the isolated ileal segment should be lying
below the digestive anastomosis (Fig. 2). The distal closed
end of the ileal segment is excised and opened to allow
copious irrigation of its lumen with saline solution. The ileal
loop is oriented to allow peristalsis to proceed in the
antegrade direction towards the cutaneous stoma.
5.2.
to avoid ischemic reactions or strictures at the ileo-ureteral
anastomosis.
5.3.
Ileo-ureteral anastomosis
After sending the ureteral stumps for a frozen-section
[()TD$FIG]histology (to exclude any residual tumour), the ureters are
Preparation of the ureters
The isolation of the right ureter is distally limited, only
rarely requiring an extended dissection of the caecum
peritoneum or the mesentery root. The left ureter generally
requires a more proximally extended isolation by dissecting
the insertion of the sigmoid peritoneum. The left ureter is
then transposed to the right side of the pelvis through a
tunnel prepared at the base of the sigmoid mesentery in
front of the common iliac vessels. Identifying the distal ends
of the left ureter using a long tag suture may be of help to
complete this passage (Fig. 3).
Extend the isolation of ureters, preferably along their
lateral side, to preserve the vascular pedicles running
medially. Avoid any traumatic handling of the distal
ureteral tracts. Check that the retrosigmoidal tunnel is
sufficiently wide enough and accurately prepared (digitally
or by means of a gentle curved clamp), taking care not to
damage the sigmoid vascular pedicle.
Verify that the left ureter, when brought in the right side,
is not flaccid or stretched through the retrosigmoidal tunnel
Fig. 3 – Isolation of the ureters. The left ureter generally requires a more
proximally extended isolation. Transposition of the left ureter to the
right side of the pelvis through a tunnel prepared at the bases of the
sigmoid mesentery in front of the common iliac vessels.
740
[()TD$FIG]
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
Fig. 4 – Ileo-ureteral anastomosis. (a,b) The original Nesbit technique
adopted by Bricker: The proximal end of the conduit is left closed, and
the ureteral ends are spatulated and anastomosed directly and
separately with a refluxing technique along the antimesenteric side of
the conduit. (c–f) Wallace variants: The ends of the ureters are widely
spatulated, (c,d) conjoined together ‘‘head to head’’ (Wallace I) or (e,f)
oriented in the opposite, ‘‘head to tail’’ direction (Wallace II), and then
directly anastomosed to the proximal end of the ileal segment. (g,h) Le
Duc et al antirefluxing anastomosis technique: The ends of ureters are
spatulated, laid down on the ileal tracks, and secured to mucosal
margins.
anastomosed to the ileal segment. This step may be
completed according to one of the different surgical
proposed variants. In the original version, represented by
the Nesbit ureteral implantation technique as adopted by
Bricker [6] (Fig. 4a and b), the proximal end of the conduit is
left closed. The ureteral ends are spatulated and anastomosed directly and separately by an interrupted 4-0
polyglactin suture at 1–3 cm from each other with a
refluxing technique along the antimesenteric side of the
conduit.
According to the Wallace [7] variant, the ends of the
ureters are widely spatulated; conjoined together ‘‘head to
head’’ (Wallace I; Fig. 4c and d) or oriented in the opposite,
‘‘head to tail’’ direction (Wallace II; Fig. 4e and f); and then
directly anastomosed to the proximal end of the ileal
segment. A running 4-0 Vicryl or Monocryl 4-0 suture is
generally used to hold the ureters together and to connect
them to the conduit. Le Duc et al. [8] proposed an
antirefluxing anastomosis technique. In this variant, the
proximal border of the IC is opened along the antimesenteric line for about 2–3 cm. The ureters are separately
inserted into the ileal lumen and secured to the external
side by several interrupted stitches. The ileal mucosa is
distally incised for 1–2 cm starting from each ureteral entry.
The ends of ureters are spatulated, laid down onto the ileal
tracks, and secured to mucosal margins by using an
interrupted 4-0 Vicryl suture (Fig. 4g and h).
The decision of which anastomosis technique to perform
should consider the length (when similar on both sides,
prefer Wallace; when disparate, such as in obese patients,
prefer Bricker) and the diameter of ureter. Both Bricker and
Wallace techniques are widely proven to be reliable and
safe, providing acceptable rates of ureteral strictures [29].
When renal function is a concern, an antirefluxing
anastomosis might be preferred. In the absence of special
indications, use the most familiar technique. Take care to
perform this step with a minimal touching technique.
Regardless of the kind of anastomosis performed, a
feeding tube is passed into each ureter and drawn through
the distal end of the conduit. The tubes should be secured to
the ureters and the ileal mucosa using 3 or 4-0 absorbable
sutures.
The size of the feeding tube should conform with the
diameter of each ureter. Take care to distinguish the left
from the right ureteral tubes to obtain a separate diuresis
collection. The new generation of long-lasting single-J
90-cm stents can be used to avoid sutures. Check the
integrity of the uretero-ileal anastomosis using some saline
solution gently injected into the distal end of the conduit
and repair any leakage intraoperatively.
5.4.
Exteriorisation and accomplishment of the stoma
A circular skin excision in the previously marked stoma
location is performed and an adequate crossed window is
provided through the rectus fascia. The preferred location of
the ileal stoma is the right abdominal quadrant between the
umbilicus and the anterior-superior iliac spine. The muscle
layers including rectus of abdomen are bluntly dissected, and
the distal portion of the ileal loop is brought through the
abdominal wall to the skin. The ileal end with a 2-cm nipple is
secured to the rectus fascia with 3-0 Vicryl sutures placed at
the 3, 6, 9, and 12 o’clock positions. The stoma is then
completed by folding the distal margin of the conduit to
obtain a 1-cm nipple by suturing the mucosa to the skin with
multiple interrupted 4-0 Vicryl sutures. The ureteral stents
are secured with a suture of 2-0 Vicryl to the skin, and an
external urine collection device is placed. A 20-French Foley
catheter may be placed in the ileal loop for extra drainage.
Verify that the ileo-cutaneous anastomosis is tension
free; otherwise, do not hesitate to redo it. Accurately define
the location of the stoma: A location too close to the iliac
spine or the umbilicus may expose to a frequent detachment of the stoma device and determine persistent urinary
leakage. In left-handed patients or in case of previous
surgical skin injury at the inferior abdominal right quadrant,
the stoma can be located in a different position, taking care
to avoid kinking or stretching of ureters and conduit.
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
[()TD$FIG]
741
selected cases. Data from fast-track regimens support the
early administration of oral fluids (day 1) and, if successful,
the early restoration of oral feeding. The abdominal drains
are removed when they stop draining, whereas the ureteral
stents are generally removed 8–12 d postoperatively. The
role of the stoma therapist is recognized as essential for
long-term stoma reliability. Patients should be educated
about the most adequate kind of stoma to wear, how and
when to replace it, and how to avoid complications related
to incorrect handling of the cutaneous device.
6.
Ileal conduit by laparoscopic and robotic assisted
procedure
Fig. 5 – The mesenteric pedicle is twisted causing severe ischemic
damages to the ileal conduit.
Verify that the excision of both skin and fascia conforms
to the wideness of the conduit. A narrow transfascial
passage increases the risk of stomal stenosis and retraction;
conversely, a wide passage favours prolapses and parastomal hernias.
5.5.
Closure
The bowel anastomosis must be reinspected by verifying
adequate vascular supply and excluding enteric leakage.
Likewise, the IC is revised and checked for tension and
vascular supply. The uretero-ileal anastomosis is generally
dropped back into the retroperitoneum, and the omentum,
when available, is used to wrap the area. One drain is
usually left near the area of the ureteral implant, and the
other drains the pelvis.
Check that the mesenteric pedicle is not twisted. This can
cause severe ischemic damage (Fig. 5). Secure the lateral
peritoneum of the caecum to the lateral profile of the IC
using few interrupted stitches to prevent an internal ileal
hernia through the conduit and the peritoneum of the
abdominal lateral wall (Fig. 1b). The irrigation of the
abdominal cavity with antibiotic or normal saline solution
is suggested.
5.6.
Postoperative care
Mandatory surgical intensive care unit admission is
probably no longer necessary when performing adequate
recovery room observation, invasive blood pressure monitoring, and tailored fluid replacement. The nasogastric tube
can usually be removed at the end of surgery or the day
after. Postoperative artificial nutrition does not appear to
affect the return of bowel function and is suggested only in
The IC may also be performed in the course of pure
laparoscopic RC (LRC) or robot-assisted RC (RARC) following
the same surgical steps described for open surgery. The
rationale for both LRC and RARC with urinary diversion
mainly relates to reduced corporeal trauma, perioperative
complications, and hospital stay. However, these procedures were shown to be more time consuming and costly
when compared to open surgery [30,31]. In addition, some
concerns about oncologic outcomes and the need for a
consistent learning curve have limited the dissemination of
these techniques.
Risks and benefits of RARC have been confirmed recently
in a review by Chade et al. [32] including 19 clinical
experiences comparing LRC and RARC with open surgery. In
these studies the extracorporeal reconstruction for IC was
generally preferred to reduce the operative time. Growing
evidence supports both feasibility and safety of intracorporeal diversions without increasing overall morbidity [33].
In addition, oncologic outcomes after RARC were recently
shown to be similar to those after open surgery [34]. To
date, however, the heterogeneous tumour characteristics
and the lack of long-term follow-up preclude any definitive
comparison analysis between different procedures. Randomized trials are advocated for this issue.
7.
Complications
Complications related to RC with IC have been widely
reported and have been described in up to 56% of cases [24].
Although technically simpler to perform compared to
continent reservoirs, IC has not been associated with lower
complications [3,11]. This can probably be related to the
more unfavourable oncologic characteristics and higher
comorbidities of the patients who undergo this procedure
[35,36]. However, the Nationwide Inpatient Sample [13–37]
report could not correlate the risk of postoperative complications after RC with the kind of surgical solution after RC.
When comparing different urinary diversions in the
literature, it should be considered that reporting of shortand long-term complications after RC is not standardised,
few series are prospective, patient selection is not uniform,
and length of follow-up is often inconsistent. Complications
related to the extirpative time (RC) are well described in
review publications [38].
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EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
Table 1 – Frequently reported early and late complications
following radical cystectomy and ileal conduit
Early
Late
Bowel related
Intestinal anastomosis related
Ureteral-ileal anastomosis leakage
Enteric fistula
Bowel obstruction
Prolonged ileus
Conduit necrosis
Stoma related
Abdominal wall related
Conduit stenosis
Uretero-enteric anastomosis
stricture
Hydronefrosis
Kidney failure
Metabolic changes
Some complications are strictly related to IC and have
been distinguished between early (<90 d) and late (>90 d)
[4] (Table 1).
7.1.
Early complications
7.1.1.
Related to the uretero-ileal anastomosis
Leakage of the uretero-ileal anastomosis is one of the most
challenging adverse events, accounting for up to 7% of cases
[24]. This complication is more frequently related to
inadequate surgical technique, such as tension at the
anastomosis, devascularisation and rotation of the ureters,
or defective suture rather than to the kind of uretero-ileal
anastomosis performed (ie, Bricker vs Wallace; Fig. 4) [38].
A conservative approach during the early postoperative
period concerning nutrition, diversion, drainage, and
treatment of any sepsis is generally sufficient. In the long
term, leakage can determine fibrosis of the anastomosis,
leading to upper urinary tract complications.
7.1.2.
Bowel-related early complications
Paralytic ileus is described in up to 22% of cases and
represents one of the most important determinants of the
length of hospitalisation [38]. Type of preoperative bowel
preparation, fasting prior to surgery, postoperative pain
control, and inadequate surgical procedure are well-defined
conditioning factors for ileus. Small bowel obstruction may
be treated with nasogastric tube, intravenous fluids, and
bowel rest; however, sometimes a surgical intervention can
be required when an internal hernia is suspected or
documented (Fig. 1).
Intestinal anastomosis leakage is a potentially catastrophic complication if not recognized early and accounts for an
increase in the mortality rate [35]. A significant difference
between stapled and hand-sewn ileostomy closures could
not be found in literature [37]; however, this complication
is frequently related to surgical errors.
7.2.
Late complications
7.2.1.
Uretero-ileal anastomotic strictures and deterioration of renal
function
Benign strictures have been described in about 7–14% of
cases and commonly occur during the first 2 yr after surgery
[35]. Endoscopic and percutaneous management procedures are viable treatment options; however, an open
surgical revision is often needed for a definitive treatment
[39]. The type of uretero-ileal anastomosis (Bricker vs
Wallace) does not affect stricture incidence [40,41].
Meticulous handling and preparation of the distal ureter
are essential to minimise the risk of urine leak and
postoperative strictures [42]. Tunnelling antireflux techniques are not useful [3] for IC reservoirs and have been
described to carry a higher risk of stenosis in a randomised
trial [43]. Clinical studies reporting long-term follow-up
showed that up to 50% of patients submitted to ureterointestinal refluxing anastomosis will develop upper urinary
tract alterations, but only in 12% of cases do the renal
changes become clinically significant [11].
7.2.2.
Stomal, peristomal, and abdominal wall-related
complications
These complications are extremely frequent (15–65%)
[44,45] in IC patients and contribute significantly to reduce
the overall QoL of the patients. The most frequent skin
disorders are typically caused by chemical injury (irritant
contact, dermatitis pseudoverrucous lesions, alkaline encrustation), mechanical injury (pressure ulcer, stripping
injury, mucocutaneous separation), infection (candidiasis,
folliculitis), and immunologic disorders (allergic contact
dermatitis) [46]. The role of the stoma therapist in both
prevention and management of these complications is
essential.
Parastomal hernia, prolapse, stenosis, and retraction of the
stoma have been reported in up to 31% of cases [44–46] and
represent a frequent cause for reoperation after IC.
Hernias may occur in the wound or adjacent to stomas
and may require surgical revision, often without disrupting the whole conduit or reservoir. Parastomal hernia is
an incisional hernia secondary to a fascial defect
surrounding the conduit. It has been described as
10–15% of cases; however, the true rate of this
complication remains undefined because most patients
are asymptomatic or prefer not to treat the condition
[46]. Contributing factors include obesity [47], malnutrition, chronic cough, and use of steroids. Although most
parastomal hernias can be managed conservatively,
approximately 30% of patients require surgical intervention due to obstruction, pain, and bleeding. The use of
meshes to reinforce weakened fascial planes around
stomas and relocation of the stoma to the contralateral
side should be considered [48].
Stoma prolapse is relatively rare in IC (1.5–8% of cases)
[49] and is substantially attributable to impaired vascularisation of the ileal segment combined with chronic
infection. Nonsurgical management includes the use of a
prolapse belt, although this carries the risk of stoma
necrosis. Stoma stenosis is related quite exclusively to the
use of ileum for cutaneous diversion. It has been described
as 2.5–8.5% of cases at a median of 10 yr after surgery
[50,51] and is associated with loss of peristalsis, thickening
of the walls, and narrowing of the skin. Stenosis at the skin
level can be managed by dilating the stoma; however,
surgical revision may be necessary after the obstruction is
relieved and sepsis is resolved.
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
7.3.
Quality of life
743
[2] Stenzl A, Cowan NC, De Santis M, et al. The updated EAU guidelines on
muscle-invasive and metastatic bladder cancer. Eur Urol 2009;
The rationale behind the development of OBS is typically to
provide a good overall QoL by restoring a voiding habitus
close to the patient’s preoperative condition. Despite this
assumption, the literature has failed to demonstrate
potential superiority when comparing QoL of men who
underwent RC with OBS and RC with IC [3]. Although most
studies were retrospective and used diverse instruments to
assess QoL, big differences were not shown in overall QoL,
which was generally acceptable for most forms of urinary
diversion [52]. Only one study reported better QoL with
OBS compared to IC using a validated QLQ-C30 questionnaire [23]. The main flaws regarding QoL assessment are
to be found in the actual definition of QoL itself, the
diverse questionnaires adopted, and the differences in
perception of QoL in different countries [53,54]. Careful
patient selection and accurate preoperative discussion and
counselling with the patient and relatives and the
oncologic team (surgeon, oncologist, oncologic nurse,
stoma therapist, and a psychologist) are the key steps to
achieving adequate compliance that can reflect postoperative improvement of overall QoL, regardless of the urinary
diversion chosen.
55:815–25.
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diversion Urology 2007;69(Suppl 1):17–49.
[4] Hautmann RE. Urinary diversion: ileal conduit to neobladder. J Urol
2003;169:834–42.
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[11] Madersbacher S, Schmidt J, Eberle JM, et al. Long term outcome of
ileal conduit diversion. J Urol 2003;169:985–90.
[12] Iborra I, Casanova JL, Solsona E, et al. Tolerance of external urinary
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8.
Conclusions
Diseases in America Project. Urinary diversion and morbidity
after radical cystectomy for bladder cancer. Cancer 2010;116:
331–9.
The IC can still be considered an appropriate surgical
solution after RC in most patients because of the relative
simplicity of the surgical technique, the acceptable complication rate, and the satisfactory postoperative QoL.
This urinary diversion remains widely advisable for
elderly patients and for those with compromised renal
function, with severe comorbidities, or who are unfit to
manage continent reservoirs. The test of time has demonstrated that the long-term reliability of this procedure
strictly depends on a rigorous surgical technique.
[14] Lowrance WT, Rumohr JA, Clark PE, Chang SS, Smith Jr JA, Cookson
MS. Urinary diversion trends at a high volume, single American
tertiary care center. J Urol 2009;182:2369–74.
[15] Manoharan M, Ayyathurai R, Solowy MS. Radical cystectomy for
urothelial carcinoma of the bladder: an analysis of perioperative
and survival outcome. BJU Int 2009;104:1227–32.
[16] Jahnson S, Damm O, Hellsten S, et al. Urinary diversion after
cystectomy for bladder cancer: a population based study in Sweden.
Scand J Urol Nephrol 2010;44:69–75.
[17] Bader P, Westermann D, Frohneberg D. Urinary diversions: which
one is right for which patient? Urologe A 2009;48:127–36.
[18] Mottet N, Castagnola C, Rischmann P, et al. Quality of life after
Conflicts of interest
cystectomy: French national survey conducted by the French Association of Urology (AFU), the French Federation of Stoma Patients
The authors have nothing to disclose.
(FSF) and the French Association of Enterostomy Patients (AFET) in
patients with ileal conduit urinary diversion or orthotopic neobladder. Prog Urol 2008;18:292–8.
Funding support
[19] Somani BK, Nabi G, Wong S, et al. How close are we to knowing
whether orthotopic bladder replacement surgery is the new gold
None.
standard?—evidence from a systematic review update. Urology
2009;74:1331–9.
Acknowledgements
[20] Olbert PJ, Baumann L, Hegele A, Schrader AJ, Hofmann R. Fast-track
concepts in the perioperative management of patients undergoing
radical cystectomy and urinary diversion: review of the literature
The authors would like to thank Ms. L. Wood and Mr. J.
Mannell for the linguistic revision of the manuscript and Mr.
Nicola Spreafico for the figures.
[21] Tabibi A, Simforoosh N, Basiri A, Ezzatnejad M, Abdi H, Farrokhi F.
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