After extirpative management of bladder cancer, urinary diversion can play an integral role in patient outcomes and perceived quality of life. Choices for urinary diversion typically include ileal conduit (IC), neobladder (NB) and continent urinary reservoir (Indiana Pouch, IP). Both short- and long-term quality of life outcomes as well as postoperative complication rates have been studied among these different types of diversions. A urinary diversion is life-altering, and the best choice for patients not only involves the consideration of clinical characteristics, such as baseline renal function, that may preclude patients from a NB or IP, but also allowing patients to have an adequate understanding of the options and the potential effect on quality of life. Patient satisfaction is predicated on this balance between patient choice and what may be the most clinically appropriate option.

Figure 1. Clavien complication rates of urinary diversion after radical cystectomy.

At Indiana University, we identified 233 patients between 2011 and 2013 who underwent cystectomy with urinary diversion (139 IC, 39 IP and 55 NB patients).¹ At the 30-day postoperative mark, patients undergoing IP creation experienced higher overall complication rates (p=0.009) compared to IC or NB (fig. 1). However, there was no difference in Clavien Grade III-V complication among the groups (p=0.884). Longer-term health related quality of life (HRQOL) measures have also been measured using the Bladder Cancer Index (BCI) in patients who were operated on at our institution from 1991 to 2009 with a total of 128 patients completing the survey in this period.² The mean time between radical cystectomy and survey completion in this cohort was 11 years with all patients having at least 6 years of followup. Urinary function was significantly better in IC and IP patients compared to NB patients (fig. 2, p=0.0013). This difference may have been due to the focus on urinary leakage in the BCI, which preferentially affects NB as leaks are relatively rare with IC or IP. Patients who underwent IP did experience more bowel issues, which may be related to the technical aspect of creating the pouch with the ascending colon (p=0.0095).² Our group also used the Functional Assessment of Cancer Therapy–Vanderbilt Cystectomy Index (FACT-VCI) for the various diversion types to assess HRQOL over a median of 12.3 months of followup.³ FACT-VCI was composed of a general questionnaire with specific aspects in physical, social, emotional and functional well-being. In this HRQOL study, 146 patients from 2015–2018 were analyzed, with 83 IC, 32 NB and 31 IP patients. The findings demonstrated a difference in the general category and particularly with functional and social well-being in favor of NB compared to IC. However, on a more global scale, no differences were noted in the FACT-VCI questionnaires among the urinary diversion types (fig. 3). This study also accounted for changes in scores over a median followup of 12.3 months, which demonstrated notable improvement in scores at the 12 month mark.³ Factors such as age and other medical comorbidities may play a role in the differences between these groups, as patients were significantly older and had more medical comorbidities in the IC group. Patients undergoing NB creation had a higher baseline FACT-VCI score which is likely reflective of a younger and healthier group.

Figure 2. BCI. NB (blue), IP (red), IC (green) in males ≥65 years old (A), males <65 years old (B) and females <65 years old (C). †‡NBs had significantly worse urinary function scores. *Bowel bother was significantly worse with IPs. **Sexual function was not measured.

Figure Figure 3. FACT-VCI comparing various urinary diversion types. TOI, trial outcome index.

Surgical complications of urinary diversion have been studied by other institutions, which further elucidates the driving factors for early and late complications. Nieuwenhuijzen et al found that IC patients were more likely to develop early complications compared to IP or NB, but later patients that had IC experienced fewer complications.⁴ Patients with early complications had higher ASA^® (American Society of Anesthesiologists^®) scores and may have been the reason for IC patients having higher complication rates in the early postoperative period. While our study did not investigate medical comorbidities as the driver of early complications, our study did have more patients with higher ASA and body mass indexes receiving ICs. The relatively similar complications rates between urinary diversion groups may speak to the fact that patients were appropriately counseled and received the ideal urinary diversion based on medical comorbidities.

Various centers have also experienced similar findings to our group, where patients with NBs may have a slightly improved HRQOL. Many of these studies did not include continent urinary reservoirs (ie IPs) in the analysis. However, patient health and age may be confounding variables that affect these findings. Dutta et al also found similar findings to our group, where HRQOL favored NB over IC but was not significant (p=0.09) and overall satisfaction was slightly higher in the NB group (96% compared to 85% in the IC group).⁵ In categories of general health, physical functioning, physical health, social functioning and energy, NBs scored higher than ICs.⁵ It is important to note that patients undergoing NB creation were younger, and these scores may have reflected the baseline clinical characteristics. Clements et al found that patients experienced initial detriments to HRQOL within the first 3–6 months postoperatively but typically recovered after 12 months of followup.⁶ Patients who underwent IC creation had worse sexual functioning and body image scores that did not recover to baseline compared to continent diversion. Patients who received a continent diversion had significantly better baseline scores with sexual, urinary and physical function, but had lower social function scores compared to IC patients.⁶

While NB or IP patients may derive better quality of life measures, this effect may be due to the baseline characteristics of these patients, who tend to be younger and healthier. Although it may be tempting for patients to undergo continent diversions when comparing HRQOL scores, this should be balanced with medical comorbidities that may increase the risk of surgical complications. Optimal patient satisfaction will come from proper counseling of patients and being able to weigh the potential quality of life benefit to the real risk of potential complications from a morbid procedure.