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Patients undergoing cystectomy for bladder cancer may have some options when selecting the most appropriate type of urinary diversion.

Each form of urinary diversion has some pros and cons, according to Richard E. Greenberg, MD, of Fox Chase Cancer Center in Philadelphia.

Urinary diversion is essentially broken down into two categories: incontinent diversion, which constantly drains urine into a bag, and continent diversion, which stores urine until the patient empties the diversion.

The most common form of incontinent urinary diversion is the ileal conduit, according to Nima Almassi, MD, a urologist with the Cleveland Clinic. With an ileal conduit, the surgeon creates a method of urinary drainage using a portion of the small intestine, which is placed at an opening on the surface of the abdomen to create a stoma.

"Patients receiving this type of urinary diversion wear a small bag on their belly and urine drains continuously to the bag," Almassi said. "The bag has a small valve at the bottom, and patients empty the bag when needed."

Almassi said that this is the most common type of urinary diversion performed overall and is the simplest for patients to manage.

One form of continent urinary diversion is the neobladder. This "new" bladder is also built from a part of the small intestine, and that new pouch is connected to the urethra. Patients who get a neobladder are able to empty the neobladder through the urethra.

Another type of continent urinary diversion is called the Indiana pouch. This pouch is made with a portion of the large intestine. As with the other types of diversions, the ureters are connected to the pouch. Urine drains through the ureters to the pouch and then that pouch is connected up to the skin. Patients must learn to drain that pouch by passing a catheter through the opening in the skin into the pouch.

Method Selection

All three methods use portions of the intestine, which is designed to reabsorb, Almassi pointed out. For continent diversions, the intestine will reabsorb some electrolytes or toxins that the kidney is trying to excrete through the urine. For patients with kidney disease or diminished kidney function, neobladder or the Indiana pouch may not be the best option.

The ileal conduit is commonly used in older patients, as the other types of diversion can be more difficult to manage. "The ileal conduit method has been around the longest, and we have a lot of long-term follow-up in terms of how to manage problems," Greenberg said.

However, the ileal conduit does have related issues. For example, patients may experience issues including complications with the stoma such as hernia. Also, patients with an ileal conduit have to wear the bag on their belly 24 hours a day, Almassi said.

"There is definitely a change in body image that takes some time getting used to, but overall patients seem to adjust well," said Almassi, who added that recent studies with long-term follow-up have demonstrated that patients report a high-quality of life after cystectomy.

Patients who do not want to wear the bag externally might pursue a continent diversion method, even though it may require more upkeep.

"I have been performing the neobladder technique for about 10 years routinely, and I tend to be a bit more selective in my patient population for these," Greenberg said. "I don't like to perform these in patients with locally advanced disease and generally don't perform these on women."

Greenberg also said he avoids the neobladder in patients with prior radiation to the pelvis, for example, from rectal or prostate cancer.

The acute and semi-acute recovery is longer for neobladders compared with an ileal conduit, Greenberg said. Additionally, the surgery takes almost twice as long and involves some very technical sewing skills.

Living with the neobladder also requires an understanding and commitment from the patient that the bladder will need to be emptied every few hours day or night. Often patients will have to be instructed on proper techniques for emptying the neobladder.

"Patients may have some leakage or urinary incontinence," Almassi noted. "Another potential issue is developing retention or difficulty fully emptying the neobladder."

Retention or incomplete emptying tends to be more common in women than men. In this case, patients will have to learn to pass a catheter into the neobladder to empty it.

Patients who select a neobladder or Indiana pouch must also be counseled that candidacy for those techniques is confirmed when the patient is under anesthesia.

"To be a candidate for the neobladder at the time of surgery, the surgeon has to ensure that there is a negative margin at the spot where the bladder is disconnected from the urethra," Almassi said. "If there is evidence of cancer at the margin, then that patient is not a candidate for a neobladder."

Considerations and Patient Satisfaction

For patients who are candidates for all three types of urinary diversion, surgeons should discuss expectations of what life is like with all three. These discussions should address the upkeep and maintenance of each approach. Almassi said he often connects patients with people who have undergone the different types of diversion to help them understand all the possibilities.

Somewhat surprisingly, the rate of continent diversion has declined in the U.S. in recent years by more than 10%. A examining trends in urinary diversion from 2004 to 2013 showed that continent diversion decreased from 17.2% of procedures in 2004-2006 to 12.1% in 2010-2013 (P<0.01). High-volume facilities, higher income, academic programs, and patients traveling more than 60 miles were all associated with use of continent diversion.

Diversion selection often depends on patient values and priorities, Almassi said.

"We have many bladder cancer patients who are living years and decades after cystectomy," he said. "Overall, we find that these patients are satisfied with the diversion type they selected."

A of decision regret in patients that underwent cystectomy with either ileal conduit or neobladder from 2013 to 2015 found no difference in decision regret for one form of urinary diversion compared with the other. However, patients who were more informed experienced less decision regret.

"Patients who are well informed tend to be the most satisfied," Almassi said. "Information is critical for the patient to come to the best decision for themselves."

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