Ileal Conduit vs Orthotopic Neobladder: Which One Offers the Best Health-Related Quality of Life in Patients Undergoing Radical Cystectomy?

Ileal conduit (IC) has been considered for decades the ‘‘standard’’ urinary diversion for bladder cancer patients submitted to radical cystectomy. It has been recognized as being the most clinically adequate, cost-effective and reliable solution in the long term and remains in most countries the most commonly used diversion after radical cystectomy. During the last decades, this surgical procedure has been challenged by the dissemination and the good clinical outcome of bladder substitutions. It would appear initially to most patients and even practitioners that orthotopic neobladder (ONB) should be the standard diversion following radical cystectomy as it aims to replace the bladder reservoir while IC imposes a stoma and a and a urostomy appliance and thus should be performed only in cases where ONB is contraindicated. However, clinical experience shows that ONB has functional limitations and that its rate of complications in the long term is substantial and possibly higher than that of IC. On the other hand, a pouching system can be in some patients significantly detrimental to their body image with secondary consequences on various daily activities.

This highlights the importance of the preoperative choice in the absence of a contraindication to one or the other procedure. Indeed, once a urinary diversion (UD) has been performed, reverting to another type of UD secondarily is a non-standardized procedure. The patient should be counseled according to existing evidence and recommendations. However, a debate is still ongoing due to a lack of solid evidence. Firstly, there are no randomized studies – which are probably non-feasible - and patients cannot be their own controls as they will never experience the other UD. Secondly, appraising the impact of a specific UD on QOL and moreover comparing the impact of different UDs is a complex issue where various baseline characteristics including age, disease stage, and socio-cultural aspects may constitute a substantial source of heterogeneity.

We decided to set-up a multicenter prospective study to evaluate the impact of IC and ONB on French patients [1]. A randomized design was ruled out because of the expected recruitment difficulties. As for the impact of UD evaluation, we decided to use a validated, self-administered and specific questionnaire instead of a generic instrument. The Bladder Cancer Index (BCI) fulfilled these criteria and the translation in French was validated [2]. Additionally, we added supplemental questions exploring body image and evaluated the patient’s overall satisfaction with the UD through a single, simple question on a visual analogic score (VAS). Selection bias related to the non-randomized design of this study was clearly reflected by the finding that average age was higher in those patients choosing to undergo IC for their diversion. However, this reflects real-world clinical practice. When measuring the three main domains, urinary, bowel and sexual health, we found no significant difference between the groups at 6 or 12 months except for urinary function subdomain that was more favorable in the IC group due to better urinary control and fewer leaks. We also found that ONB had an advantage over IC regarding body image. It was noteworthy that most patients in both groups reported an excellent VAS when asked about the degree of satisfaction regarding their UD despite a poor sexual satisfaction. The most likely explanation is the thorough explanation given preoperatively to the patients by the surgeon and a specialized nurse which allows a personalized choice of an informed patient who expects the disruptions he encounters following surgery and tends to adjust his life accordingly.

Several studies aimed to evaluate QOL following different UD. The discrepancy of these studies’ conclusions could be explained by different populations, different study design, different follow-ups, but also different means of evaluating QOL. This warranted a systematic search and meta-analysis that we published recently [3]. The results of this meta-analysis were quite similar to the findings of our study [1] regarding urinary, bowel and sexual health. Data about body image according to the type of UD was too scarce to be included in this meta-analysis.

References
1. Jacques Irani, Gaunez Nicolas, Eric Huyghe, Morgan Roupret, Raphael Briffaux, Stephane Larre, Christian Pfister, Nicolas Mottet, and Yann Neuzillet: Quality of life outcomes after neobladder and ileal conduit following cystectomy for bladder cancer using a validated bladder-specific instrument: A prospective multi-institutional study. Journal of Clinical Oncology 2016 34:2_suppl, 359-359
2. Gaunez N, Larré S, Pirès C, Doré B, Wei J, Pfister C, Irani J : French translation and linguistic validation of the questionnaire Bladder Cancer Index (BCI). Prog Urol. 2010 May;22(6):350-3.
3. Ziouziou I, Irani J, Wei JT, Karmouni T, El Khader K, Koutani A, Iben Attya Andaloussi A : Ileal conduit vs orthotopic neobladder: Which one offers the best health-related quality of life in patients undergoing radical cystectomy? A systematic review of literature and meta-analysis. Prog Urol. 2018 Mar 20. doi: 10.1016/j.purol.2018.02.001.

Written by:
Professor Jacques Irani, Chief of Service, Paris-Sud University Hospital, University Hospital of Bicetre, Department of Urology

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