EAU 2017: Increasing use of incontinent urinary diversion: A total population analysis of radical cystectomies in Germany from 2006 to 2013

London, England (UroToday.com) Management of non-metastatic muscle-invasive bladder cancer or high-volume/recurrent non-muscle invasive bladder cancer is still primarily radical cystectomy (RC). However, with every decision to proceed with RC, a major decision point is which type of urinary reconstruction the patient should get – often, this involves a discussion with the patient regarding lifestyle goals, as the management of incontinent urinary diversions (typically an ileal conduit) versus continent catheterizable or continent urinary orthotopic neobladders are significantly different. Besides patient input, however, other factors such as anatomic feasibility, prior radiotherapy, concomitant GI disorders, renal function, and patient comorbidities and health status help determine the type of urinary diversion.

The authors allude to this and aimed to assess trends in urinary diversion and describe in-hospital outcomes of all radical cystectomies. They retrospectively analyzed a nationwide German hospital billing system for bladder cancer cases between 2006 and 2013 who underwent RC. Based on urinary diversion type (incontinent or continent), they assessed utilization rates, in-hospital mortality, and transfusion rates.

A total of 53,057 cases were included. Total RC and urinary diversion utilization rates are highlighted in the figure below – the total number of RC’s increased during this time period, and the proportion of incontinent urinary diversions followed. The number of continent urinary diversions remained relatively stable.

chart 7

The types of urinary diversion are shown below:

chart 7b

This, as discussed with the author, represents a specific practice patter. Cutaneous ureterostomies are commonly performed in this institution.

When comparing patients by specific type of diversion, patients receiving cutaneous ureterostomies were considerably older (74.4 years) than patients with an ileal conduit (71.3 years), orthotopic neobladder (63.1 years) or continent pouch (61.1 years; p<0.001). On multivariate analyses, younger age and male sex were the strongest determinants of receiving a continent diversion, though hospitals with higher case volume were also more likely to provide a continent urinary diversion.

For their secondary outcomes, they found that on univariate analysis, in-hospital mortality rates were higher for patients with incontinent (5.7%) than for patients with continent urinary diversion (2.2%; p<0.001). Likewise, transfusion rates were higher for patients with incontinent urinary diversion (65.5%) vs. continent urinary diversion (48.1%) (p<0.001). Unfortunately, no MV analysis was completed – the presenting author mentioned that this was done separately, but the results are not yet available.

Based on these findings, the authors conclude that: “The increasing age of patients with assumably higher comorbidity led to a significant increase of incontinent urinary diversion in Germany. Incontinent urinary diversion however, entails higher rates of mortality and transfusion. Thus, the clinical choice of urinary diversion could serve as an integrating surrogate parameter for patient comorbidity.”

However, this is an inappropriate conclusion to make. As the authors clearly state, which most data supports, patients undergoing incontinent diversion are older with higher comorbidities. Likely, the in-hospital mortality and transfusion rate findings are a result of the comorbidities and age, rather than the diversion type itself.

However, the trends in incontinent vs. continent urinary diversion probably speak to the increasingly number of RCs performed in older, sicker patients. The overall number of continent diversions has remained relatively stable.

Presented by: Christer Groeben

Co-authors: Koch R., Baunacke M., Wirth M., Huber J.

Institution(s):
1. TU Dresden, Medical Faculty Carl Gustav Carus, Dept. of Urology, Dresden, Germany
2. TU Dresden, Medical Faculty Carl Gustav Carus, Dept. of Medical Statistics and Biometry, Dresden, Germany

Written by: Thenappan Chandrasekar , Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 -March 24-28, 2017- London, England
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