EAU 2018: The Critically Ill Patient with Locally Advanced Bladder Cancer – Ureterocutaneostomy? NO

Copenhagen, Denmark (UroToday.com) Dr. Siemer from Germany provided the rebuttal to Dr. Pycha’s “yes” for ureterocutaneostomy in the critically ill patients with locally advanced bladder cancer. As Dr. Siemer notes, when treating the critically ill patient there is a balance between survival and quality of life/potential complications. 

The ureterocutaneostomy is actually an old procedure first described by Le Dentu in 1889. The pros are no intestinal violation, however the cons are possible stomal stenosis, ureteric stents, infections and hospitalizations. The conduit was first described in 1930 and made popular with Bricker’s description of his procedure in 1952. The pros of a conduit are that it is an established method with no stents and thus fewer infections, however the cons are that it requires a longer operative time, as well as violation of the gastrointestinal tract. Numerous quality of life studies over the past decade have compared urinary diversion types, with seemingly no difference in ileal conduit vs ureterocutaneostomy. Dr. Siemer cited Dr. Pycha’s 2008 study comparing complications in three incontinent urinary diversions (ileal conduit, n=55; colon conduit, n=34; uretero-ureterocutaneostomy, n=41), noting that over a median follow-up of 16 months, the overall complication rate was 23.6% [1]. Those undergoing an ileal conduit the lowest rate of complications at 18.1%, colon conduit 26.4%, and uretero-ureterocutaneostomy 32%. Late surgical reintervention was most common in those with an ileal conduit (20%), followed by colon conduit (5.8%) and uretero-ureterocutaneostomy (2.4%).

To summarize the literature, ureterocutaneostomy appears to have lower complication rates, lower operative times, and equal quality of life. But, as Dr. Siemer notes, is this the perfect option in reality? According to Dr. Siemer, published complications usually are not clinically relevant, whereas in reality ureterocutaneostomy (what is not shown in the studies) is associated with frequent stent changes, dislocated stents, infected stents resulting in complications, and multi-resistant germs. The 30-day mortality rate for patients >75 years of age with ureterocutaneostomy is 7.7% compared to 5.9% for those with small bowel urinary diversion, however the 90-day mortality rate is 17.3% for ureterocutaneostomy patients compared to 6.9% in the small bowel urinary diversion group. 

Dr. Siemer provided several take-home messages:

  • Quality of life is equal or worse for ureterocutaneostomy compared to ileal conduit
  • Most patients have permanent stenting and stomal-related complications are common
  • There have been many modifications in the technique with few significant improvements in outcomes
  • Infections and hospitalizations are common, with a higher 90-day mortality rate
  • Careful patient selection for the operation is crucial, including only performing the procedure at high volume centers
  • Ultimately, if patients are not fit for surgery, there should be no operation and subsequently no ureterocutaneostomy


Presented by: Stefan Siemer, University Clinics of Saarland, Homburg, Germany

References:
1. Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Eur Urol 2008;54(4):825-832.

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark

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The Critically Ill Patient with Locally Advanced Bladder Cancer – Ureterocutaneostomy? YES 
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