(UroToday.com) The 2021 European Association of Urology (EAU) annual meeting had a Controversies in Bladder Cancer 2021: Rapid-fire debates session. The session was introduced by Dr. Ashish Kamat with chairs of the session, Professors Joan Palou and Arnulf Stenzl. There were five rapid-fire debates with case-based discussions, multiple presenters have the opportunity to discuss nuances of common dilemmas facing urologic oncology patients and providers and to use these evidence-based debates to provide clear, rational guidance on the timely management of difficult situations in bladder cancer.
In this rapid-fire debate, Dr. Peter Black reintroduces the classic debate of ileal conduit or content diversion in an unselected patients with normal kidney function. Dr. Hugh Mostafid of the United Kingdom argues for ileal conduit, while Dr. Jens Bedke of Germany argues for continent diversion.
Case: 74 year old woman, BMI 26, PMH HTN, prior appendectomy only, former smoker. Lives independently, and is socially and physically active.
Presented with gross hematuria.
Undergoes TURBT. MIBC on final pathology. Noted to have right hydronephrosis and after PCN placement, eGFR normalizes > 60.
Undergoes neoadjuvant chemotherapy (ddMVAC) and tolerates well.
Now returns for discussion of cystectomy and wants to know about urinary diversion recommendation.
Dr. Mostafid first highlights the factors to consider lie in two categories:
- General or patient-specific (life expectancy, mental function, frailty, QOL, decision regret)
- Organ specific (renal function, sexual function, complications, reoperation rate)
First in the UK and the EU this patient would have an approximately 20 your life expectancy.
He notes that this puts her at risk of chronic health conditions down the line (she already has HTN), and need to counsel her about 20 year outcomes not just the first year. Ideally, should also counsel her future caregivers (including her children).
- Dementia / Alzheimers and cognitive decline is becoming more common in the aging population, especially in women
From a quality-of-life standpoint there have been multiple studies haven’t demonstrated new significant difference in global quality-of-life regardless of urinary diversion. There are many patients that have very good quality of life with a ileal conduit.
On the other hand, he reports that patients with content diversion have increased bother from incontinence, particularly nighttime incontinence, and sexual dysfunction.
Ultimately, based on study by Check et al.1, “after adjusting for all other factors the bladder reconstruction method was not significantly associated with decision regret at 6 and 18 months.”
With regards to renal dysfunction there has been historical concerned for deterioration with the ileal conduit. However, he notes that renal function deteriorates with age. But, when compared, there was no difference between ileal conduit and continent diversion, when other factors were matched.
- He did comment that neobladder introduces additional sites of obstruction that ileal conduit does not have (vesicourethal anastomosis)
With regards to long-term complications the rates are similar between ileal conduit and continent diversion, ~30%. Complications do increase over time.
- Uretero-ileal stricture is ~9% - but for neobladders, an additional 9% can get vesico-urethral stricture
- 22% of patients with continent diversion have nocturnal incontinence
Based on all the above due to her 20 your life expectancy, risk of increased frailty, decreased mental function and potential burden of care on her family he recommends ileal conduit.
Dr. Bedke start off by reviewing the case. He knows that she likely has cT3 disease based on hydronephrosis. However there’re a few things that are unknown in this patient – preoperative continence, clinical downstaging with NAC, biological age, frailty, attitude towards catheterization, personal decision.
His counterpoint regarding life expectancy is that any patient with bladder cancer, especially MIBC, regardless of treatment likely does not have the same life expectancy as the average patient. Survival is not driven only by bladder cancer diagnosis. In a study by Hautman et al.2, at 20 years, there was a difference of 39.7% in the cancer-specific and overall survival (59.7% 20-year CSS vs. 20% 20-year OS). Hence, other causes of death are introduced. And in this patient depending on her final pathology in response to chemotherapy her survival maybe even less.
She is functionally independent and socially active. Hence a major goal should be to reduce postoperative complications and preserve quality-of-life. He feels this is best achieved with a neobladder.
Based on Demaegd et al.3, in patients with ASA 1, neobladder patients actually had less postoperative complications than ileal conduit patients. A meta-analysis by Cerruto et al.4 suggested better HRQOL outcomes with neobladder than ileal conduit.
He then focused a little bit on the pathology. Since this patient had cT3 disease to begin with, there is concern for trigone tumor involvement.
- Urethral recurrences in female patients are rare (Stenzl et al.)5
- But, risk factor includes trigonal involvement
- He notes that urethral frozen sections (which he would do before proceeding to neobladder) is reliable. (Laukhtina et al.)6
The receipt of neoadjuvant chemotherapy would not sway his decision making as there is no data to suggest different outcomes for ileal neobladder vs. conduit after cisplatin based chemotherapy.
Lastly he brings up the issue of cost. What upfront cost maybe higher with a neobladder, long-term costs are higher with a conduit (due to supplies). He provided data from the German DRG calculator.
So, based on better quality of life data, lack of impact from NAC, if there is a negative frozen section on her urethra intraoperatively and due to lower costs, he would favor a neobladder.
Ultimately the group discussion leaned towards shared decision making. Surgeons should be able to offer both, explain the risks of both and help guide the patient. Patient regret will be the least if they choose the diversion.
Peter Black, MD, Senior Research Scientist, Vancouver Prostate Centre Professor, Department of Urologic Sciences, University of British Columbia, Vancouver Prostate Center
Hugh Mostafid, FRCS (Urol), FEBU, Consultant Urological Surgeon and Senior Lecturer, The Stokes Centre for Urology, Royal Surrey County Hospital, Guildford, England
Jens Bedke, MD, Professor and Chairman, Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
Written by: Thenappan (Thenu) Chandrasekar, MD – Urologic Oncologist, Assistant Professor of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, @tchandra_uromd on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.
1. Check DK, Leo MC, Banegas MP, et al. Decision Regret Related to Urinary Diversion Choice among Patients Treated with Cystectomy. J Urol. 2020 Jan;203(1):159-163. doi: 10.1097/JU.0000000000000512. Epub 2019 Aug 23. PMID: 31441673.
2. Hautmann RE, de Petriconi RC, Pfeiffer C, et al. Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Eur Urol. 2012 May;61(5):1039-47. doi: 10.1016/j.eururo.2012.02.028. Epub 2012 Feb 22. PMID: 22381169.
3. Demaegd L, Albersen M, Muilwijk T, et al. Comparison of postoperative complications of ileal conduits versus orthotopic neobladders. Transl Androl Urol. 2020 Dec;9(6):2541-2554. doi: 10.21037/tau-20-713. PMID: 33457228; PMCID: PMC7807350.
4. Cerruto MA, D'Elia C, Siracusano S, et al. Systematic review and meta-analysis of non RCT's on health related quality of life after radical cystectomy using validated questionnaires: Better results with orthotopic neobladder versus ileal conduit. Eur J Surg Oncol. 2016 Mar;42(3):343-60. doi: 10.1016/j.ejso.2015.10.001. Epub 2015 Nov 9. PMID: 26620844.
5. Stenzl A, Jarolim L, Coloby P, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer. 2001 Oct 1;92(7):1864-71. doi: 10.1002/1097-0142(20011001)92:7<1864::aid-cncr1703>3.0.co;2-l. PMID: 11745259.
6. Laukhtina E, Rajwa P, Mori K, et al.; European Association of Urology Young Academic Urologists Urothelial Carcinoma Working Group (EAU YAU). Accuracy of Frozen Section Analysis of Urethral and Ureteral Margins During Radical Cystectomy for Bladder Cancer: A Systematic Review and Diagnostic Meta-Analysis. Eur Urol Focus. 2021 Jun 11:S2405-4569(21)00162-0. doi: 10.1016/j.euf.2021.05.010. Epub ahead of print. PMID: 34127436.