AUA 2023: What is the "Best" Diversion: Conduit or Neobladder?

(UroToday.com) The 2023 AUA annual meeting included the Bladder Cancer Forum, featuring a debate discussing whether a conduit or neobladder is the best form of urinary diversion. Dr. Sima Porten started this session with a case presentation of a 74 year old Caucasian man who presented with painless gross hematuria. He subsequently underwent a work up with a cystoscopy followed by TURBT showing a 5 cm left trigone tumor adjacent to the ureteral orifice, 3 satellite tumors, with an examination under anesthesia showing a mobile bladder. Pathology from the TURBT showed an enteric type adenocarcinoma of the bladder cT2 positive for lymphovascular invasion. His staging CT scan and additional work up, including upper and lower endoscopy, were consistent with cT2N0M0 adenocarcinoma of the bladder. His medical history was significant for hyperlipidemia, hypertension, arthritis, asthma, erectile dysfunction, and base cell skin cancer. His surgical history included a knee arthroscopy, wrist surgery, and dermatology procedures. His social history included being a retired teacher, married, former smoker (25 pack year – quit 10 years ago), and spending time outdoors (camping, hiking, surfing, fishing). His creatinine was 0.8 and eGFR was 65 mL/min/1.73 m². Dr. Porten then polled the audience asking “Which diversion option would you recommend for this patient?”

• 52%: Ileal conduit
• 48%: Ileal neobladder
• 0%: Other continent diversion
• 0%: Other incontinent diversion
• 0%: Neither, I would recommend bladder preservation

Dr. Bernie Bochner then took the position of using an ileal conduit for urinary diversion, although he does note that he does a high volume of neobladder urinary diversions. The traditional selection for a conduit is as follows:

• Frail, poor mentation
• Extensive comorbidities
• No concern for body image
• Requires external assistance
• Poor renal function
• Poor hepatic function

Alternatively, the traditional criteria for selecting a patient for a neobladder is as follows:

• Highly motivated
• Limited comorbidities
• Concern for body image
• Desire to eliminate a stoma
• Adequate renal function
• Adequate hepatic function

Dr. Bochner emphasizes that there are certainly several absolute contraindications to a neobladder, including overt involvement of the urethra, positive urethral margin at the time of cystectomy, and severe renal or hepatic dysfunction. Contraindications or considerations for perhaps not performing a neobladder include (i) sphincteric damage with severe incontinence, (ii) severe urethral stricture, (iii) inability to perform self catheterization, (iv) dementia, poor compliance, (v) advanced age, with specific considerations for regaining urinary control, particularly at night time. Generally, historical reports suggest that daytime continence returns before night time continence:

Furthermore, night time continence takes longer to regain with increasing age:

In 2022, Dr. Bochner’s group published results of their MSKCC experience assessing health-related quality of life for patients undergoing radical cystectomy.¹ This included 411 patients undergoing surgery from 2008 to 2014, of which 14 separate patient-reported outcome measures at the presurgical visit and at 3, 6, 12, 18, and 24 months after radical cystectomy were collected. Among these patients, 205 underwent ileal conduit and 206 continent diversion, with the following baseline demographics:

At baseline, patients receiving continent diversion reported better mean physical (p < 0.001), urinary (p = 0.006), and sexual function (p < 0.001), but lower social function (p = 0.015). After radical cystectomy, GEE modeling showed physical function scores decreasing 5/100 points by 6 months, and subsequently stabilizing or returning to baseline. By 12 months, social function improved by 10/100 points among continent diversions, while remaining stable among ileal conduits. Global quality of life exceeded baseline scores by 6 months. Sexual function scores were low before radical cystectomy, with limited recovery post-operatively. Psychosocial domains were stable or improved, except for 10/100-point worsening of body image among ileal conduits. The GEE model estimates for patients undergoing ileal conduit for specific domains are as follows:

Dr. Arnulf Stenzl then discussed how these patients should be given a neobladder urinary diversion. He states that the decision making process includes taking into consideration (i) type, location and extension of the tumor, (ii) life expectancy, (iii) frailty, (iv) comorbidities, and (v) personal desire and motivation. Historical studies assessing location of recurrence after an ileal neobladder suggest extravesical disease (62%) as the most common location, followed by lymph node involvement (20.2%), and bladder neck involvement (9.1%). With regards to life expectancy, Dr. Stenzl notes that a 74 year old man in the US is expected to live until the age of 79, compared to Austria where he would be expected to live until 82 years of age. As follows is an example of a clinical frailty scale that Dr. Stenzl uses in the clinic:

In 2021, Hautmann et al. published their single center series of 35 years of functional outcomes and complications following ileal neobladder reconstruction in male patients without tumor recurrence.² Among 259 men with more than 60 months of follow-up (median 121, range 60-267), 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). The overall day time continence rate was 90% compared to 82% nighttime continence rate. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%.

Dr. Stenzl notes that complications from ileal conduits are not uncommon and can be major. These include pyelonephritis (5-23%), ureteral obstruction (2-22%), urinary calculi (3-16%), and stomal complications (2-62%):

Dr. Porten then repeated the poll to the audience with the question “Which diversion option would you recommend for this patient?” with the exact same results as the pre-debate poll:

• 52%: Ileal conduit
• 48%: Ileal neobladder
• 0%: Other continent diversion
• 0%: Other incontinent diversion
• 0%: Neither, I would recommend bladder preservation

Dr. Porten noted that this patient ultimately underwent an open radical cystoprostatectomy (nerve-sparing), standard template lymph node dissection, and ileal neobladder with an uneventful recovery. Pathology demonstrated pT2bN0(29) enteric type adenocarcinoma, moderately differentiated, negative margins. At 3 years (age 77 years of age) he has no evidence of disease, is continent during the day, leaks occasionally at night, especially if he does wake up to empty, and wears one pad. He is still physically active, but did require a coronary stent for angina 2.5 year after his cystectomy. He uses intracavernosal injections for erectile dysfunction.

Dr. Porten concluded this debate between ileal conduit versus neobladder for urinary diversion with the following take-home messages:

• Neobladder is an under-utilized urinary diversion in patients undergoing radical cystectomy despite excellent functional outcomes
• Neobladder urinary diversion should be seriously considered and recommended for more patients, not just in young
• Some patients will be best suited for an ileal conduit, given that there are true contraindications and some patients will be too frail

Moderator: Sima P. Porten, MD, MPH, University of California-San Francisco, San Francisco, CA

Debater: Bernard H. Bochner, MD, FACS, Memorial Sloan-Kettering Cancer Center, New York, NY

Debater: Arnulf Stenzl, MD, Eberhard Karls University of Tübingen, Tübingen, Germany 

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023

References:

1. Clements MB, Atkinson TM, Dalbagni GM, et al. Health-related quality of life for patients undergoing radical cystectomy: Results of a large prospective cohort. Eur Urol 2022 Mar;81(3):294-304.
2. Hautmann RE, Volkmer B, Egghard G, et al. Functional outcome and complications following ileal neobladder reconstruction in male patients without tumor recurrence. More than 35 years of experience from a single center. J Urol. 2021;205(1):174-182.