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Wei Shen Tan: Good afternoon to our audience today. We have a great privilege today to speak to two very eminent gurus in bladder cancer. I'm Shen Tan from MD Anderson Cancer Center, and we've got Dr. Bochner today who is based at Memorial Sloan Kettering, as well as Dr. Stenzl, who is chair at Tübingen University in Germany, and also Secretary General of the EAU. Thank you very much for taking the time for us to speak to you today. So Dr. Bochner, today we'll be discussing about choice of diversion, ileal conduit versus continent diversion. And in your mind, when you see a patient in clinic, what goes through your mind in terms of selecting who should get what type of urinary diversion?

Bernard Bochner: That's a great question because I think it's probably one of the most personalized decisions that we end up making as bladder cancer surgeons. There are some absolute contraindications, I think for doing specific diversions. For instance, a neobladder is not going to be done in somebody with overt involvement of the urethra. Pretty straightforward. Somebody with severe renal dysfunction is not going to do good with a continent diversion, as well as somebody with severe hepatic dysfunction. And then there's some of the strange individual issues like active inflammatory bowel disease, where you want to try to stay away from using a lot of bowel, people with prior colon resections, that kind of thing. That leaves a lot of people, at least from a cancer perspective, who are going to be very good candidates.

And then we put into play what we know about the long term outcomes of continent diversions and ileal conduits. And at Memorial, about 50% of patients are offered a continent diversion following cystectomy. Individual practices will vary a little bit. The percentage of continent diversions is actually even higher in some of the other practices within our group. Well above the national level, which is only about 15% and hasn't really moved much, certainly hasn't moved in what I would consider the right direction for quite some time, despite 40 years now of good long-term clinical data.
It's very individualized what patients want, what patients can handle. I think that for instance, men and women are both potentially very good candidates and the indications are pretty well-defined. Women without an overt involvement of the bladder neck area, the ability to do self-catheterizations if they need to, as well as adequate renal and hepatic function, it makes the majority of women great candidates as well.

Wei Shen Tan: And Dr. Stenzl, would you agree, is there anything else that you would add on what Dr. Bochner mentioned?

Arnulf Stenzl: I think Dr. Bochner really outlined there are possibilities to do it and then there are, of course, contraindications and not everyone should have it. But definitely more than I would say in the [inaudible 00:03:08] study, 10 to 12%, that's way too low. If we have an average age of 67 years and organ confined disease, that means there should be more patients. Of course, if there is a motivation, that's necessary for the patient apart from the oncological aspects and the motivation in the patients I see is very high. It's usually higher than what you can do afterwards due to oncology or side effects or possible morbidity.

But it is also a fact that these patients, apparently, in some hospitals, are not really offered the possibility of having an orthotopic neobladder. Because if you think of what a patient wants when he comes in and you tell him "You have an advanced bladder cancer and your bladder has to come out", he wants to have another one, he wants to have a new one, he doesn't want to have a stoma right away. And that may be even the motivation for the patient to go away from the actual best treatment oncological treatment and say, "Okay, I'll stay away. I don't want to lose my bladder." And then we are having a problem there that the patient doesn't get adequate treatment because he doesn't want to have the offered subsequent urinary type of urinary diversion.

Wei Shen Tan: Okay, thank you for that. And Dr. Bochner, in your mind, concentrating on oncological factors, in a patient with a suspicious lymph node or let's say T3 disease with high risk features, would you still consider neobladder as a form of diversion or would you rather these recommend that these patients would get a conduit?

Bernard Bochner: No, I'd absolutely still recommend that. And the reason is that the extirpative part of the procedure is really not affected, ultimately, by the type of diversion you're going to do. We would not be offering an orthotopic reconstruction in somebody with an excessively large tumor that's involving the apex of the prostate, but that is really quite unusual to have a tumor that's that advanced. And the fact that their pelvic lymph nodes... Again, there have been studies that have been now published for many years that have demonstrated the effects of pelvic recurrences on people with neobladders. And the reality is that the neobladder function in general is usually not significantly altered. And if it is, it's usually managed by a catheter. But at that point, as we know, pelvic recurrent disease is associated with a very poor outcome. And so if I have a patient with more advanced disease and we're going back into a consolidative surgery after definitive chemotherapy and they're motivated to do an neobladder and the apex otherwise comes out clear, I would have no problem in offering that to patient.

Wei Shen Tan: And Dr. Stenzl, what are your thoughts about that? And also what about in patients, let's say that were quite young when they had their ostectomy and maybe their neobladder and they're now approaching 80 years old or so, dexterity, mobility is more of an issue. Do you see that some of these patients would then you would have to do a conduit for these patients? What are your thoughts?

Arnulf Stenzl: Well, first of all, I totally agree that an enlarged node, even not knowing whether that enlarged node comes from the tumor or from something else is not really a contraindication. Positive margin, that will be the only one, especially R2. Then that is something where you may think that he may need some palliative radiation or something like that. That will be a contraindication. But that is a rare thing that you will go into surgery, in these cases anyway, with today's possibilities of imaging and staging. But there are good data for long-term outcome with regards to orthotopic neobladder. You have data. There is some data from USC. There is data from Europe, from Germany, where you have like 10, 15, 20 and beyond years of people with an orthotopic neobladder. And most of them, not everyone, it's not perfect, but most of them will not have a need to change the form of urinary diversion.

The ones I have seen and the ones I had to do an change from an orthotopic neobladder to ileal conduit would be severe functional problems. Tumor, only if the primary surgeon did not really look for the margins well enough. It's difficult to criticize that, if you haven't been at the surgery. But that is something where you may think about, but usually these cases are not the ones where that you have to do systemic therapy. And with orthotopic neobladder, you can do that systemic therapy. Radiation is rare. That's what I would see as the only real problem with an orthotopic neobladder versus an ileal conduit.

Bernard Bochner: It's interesting in that we have had some patients that have required pelvic radiation after their orthotopic, and it's been my experience that the ileum actually tolerates the radiation pretty well. It's been very unusual to see a severe complication related to the neobladder when they do get the pelvic radiation. My experience is very similar to switch somebody from a neobladder to a conduit as they get into their eighties. That's usually sort of the last thing that you'd want to consider doing. And so it brings up an interesting point because it also highlights what that natural history is with time. And we do see some limitations on who should and shouldn't get the neobladder. As people do age, the experiences that it takes longer for them to regain the daytime control and the level of nighttime control is not going to be as high.

And so over the years, I've lost my enthusiasm for offering it in men who are in their eighties, for instance, largely because it takes them the whole first year before they really get pad-free during the daytime, and that's going to affect their quality of life. And in that setting, doing a good conduit probably provides them the opportunity to get back physically doing the things that they want to do. I think we probably both agree that there are limitations on who we're going to offer it on. And we've learned this over the decades because we've offered it to many people, but it's not 90% of people that are going to be good candidates. But it's definitely not 10 to 15% that should be getting it. Should be significantly greater than that.

Arnulf Stenzl: I truly agree. I mean 50-plus percent of the patients should have an orthotopic neobladder, of course depending on the tumor. I agree with increasing age, but more not the increasing age, more it's the frailty that really plays a role. And I've had an 82-year-old gentleman, he was a colonel in the army. He can put his butts together easily, and he was happy as can be. I was trying to be restrictive, but he said, "I want it." And he's motivated and he knows that he has a lesser chance of having incontinence. But I think there is a possibility of selection. But again, somebody younger may not be a good candidate due to his general appearance and general status.

Wei Shen Tan: And moving on to discussion about quality of life, I think it's quite clear that a lot of patients, when they're diagnosed with bladder cancer and they need a cystectomy, they want to preserve what they define as normality, meaning like a neobladder. But sometimes some people might not be suitable or might regret that decision because they might not be aware about all the extra risk of complications and also the effort that they need to put on to activate the neobladder and so on. What are your thoughts in terms of the literature, in terms of quality of life? Because it's very hard to compare these patients actually.

Bernard Bochner: The first pitfall is that the patients are severely selected, in most of these series, for who's getting a conduit and who's getting a neobladder. We just published a very large series of over 400 patients that we followed longitudinally over two years with 15 different standardized measures before surgery, three, six months, a year, year and a half, and two years. And there was about a 10-year age difference between the patients getting a neobladder and the conduit. Again, that goes along with what Arnulf mentioned, is that there is a clear selection on who's going to get it. The neobladder patients are younger, their creatinine's better, they're more likely to have gotten pre-operative chemo because they've got good renal function. And what we see in that group of people is that after about three months, in almost every single domain we measured, they get back to their baseline.

It's what we've been seeing in the clinic for 20 years is that when it's done correctly in well selected people, they do it very well. Interestingly, when we look at the conduit patients now who are now 10 years older and in their seventies, they also do quite well. And their long-term recovery is very similar to what their baseline is except for body image. People who are getting conduits really don't recover that body image. So I think we got to be very careful, in men and women where body image is driving a lot of their quality of life, these are people you may want to select for an internal reservoir.

Arnulf Stenzl: Yeah, especially activity. Now the more active there are with let's go swimming, going to the gym, and other things, then that really plays a role whether they have a stoma or whether they have an orthotopic neobladder. We did a quality of life study some time ago, and we looked also at different at ileal conduit versus orthotopic neobladder. Was a questionnaire and stuff like that. And then we had questions which we asked.
And for example, what we were surprised to see that sleeping disturbance, as an example, was a bigger problem in the ileal conduit patients. And then we tried to find out why. Well, if they lose their plate at night by moving around, then it soaks the entire bed. If that happens a couple of times because of their, I don't know, scars or folds or stuff like that, then they're really totally panic in a way or subconsciously panic that this may happen again. And they have more sleeping disorders than the was orthotopic neobladder, even though they're more in incontinent at night, but they can do it with diapers and that is something where you can work on.

Bernard Bochner: I have a question for you. We've been doing this now for 30 years. What do you think the biggest barriers are? Why is it 15% of people, or 10% of people in some countries, are getting reconstructed? And we're seeing so many conduits despite all the data that we've generated over these years?

Arnulf Stenzl: I think that the biggest problem is training. And the biggest problem is that we do not have confident urologic surgeons, not enough confident urologic surgeons, to do a good orthotopic neobladder. So that they're not trained enough, they have not seen it during their training, and even though they have seen it, they have not done it under supervision enough. If they talk to a patient that comes in there consenting, that they will talk about more problems and more complications because that's their own experience.

Bernard Bochner: Give own push one way or the other.

Arnulf Stenzl: Yeah, right. It's their own experience that comes in. There was some areas, especially in Europe, where radiation was done for prostate cancer because there was not enough experience for radical prostatectomy. Eventually, we were able to train people more into the finesse of pelvic surgery. And you can do the same thing for the urinary diversion, preparatory already during the cystectomy. And if that happens, then there will be, not zero complications, but less complications and complications that weigh out the disadvantages in the mid and long term.

Wei Shen Tan: Before we conclude, Dr. Bochner, can you tell our audience the key points and message you want to get across when counseling patients about diversion type and who should have it?

Bernard Bochner: What I tell people is that there are several options that are available, and none of them are new. They've been around for decades, they've been well studied, and fortunately, we know that in the hands of high volume surgeons and facilities, the outcomes can be very good. And then I go through exactly what to expect, what the natural history of the recovery will be, the quality of life data that's available, and it's a discussion with the patient. And as Dr. Stenzl just mentioned, many patients come in having already had a discussion, and so they may already be clouded with data that may not be the reality in certain centers. In some centers, maybe with less optimal outcomes, that's what they're telling the patient, but that's not necessarily what they need to accept. So it's a discussion. And there are options, and we're going to make whatever works for folks, and we have to make sure that people are realistic, as well.

There are certainly some circumstances where one diversion type will be better than the other, and it's important that you give people the opportunity to have that. But the key is to make sure we give them the opportunity. That surgeons do feel comfortable offering these options. And I agree, it really comes down to training and experience and repetition, because otherwise it becomes a self-fulfilling prophecy. You do fewer, and because of that, the ones you do do have more problems so you back off even further. And if you're an attending in a training situation, that means your trainees are seeing fewer and fewer. So they're graduating their training programs without the confidence of having seen enough and knowing what the key points are. But I think it's reversible. I hope it is. We're trying very hard with the people that we're training, but we still have work to do.

Wei Shen Tan: And Dr. Stenzl, any key points that are take-home messages?

Arnulf Stenzl: No, I think Dr. Bochner really addressed these points. First of all, we want to cure the patient from his disease, from his bladder cancer. But if we have somebody come in 60, 65 years old, his life expectancy after being cured from that disease is going to be at least two decades. 20 years. And that means his life has not stopped. He wants to be active, he wants to be normal again, he wants to do what his or her friends are doing. And for that reason, I think we should undergo that goal to have enough trained urologic surgeons to allow these men and women to have a normal bladder like nature has given us and allowing them to do a normal life without any obstacles and maybe even thus forget their actual disease.

Wei Shen Tan: Great. Thank you very much for your time today. Thank you.

Arnulf Stenzl: Thanks a lot.