Dr. Taylor began the session by arguing in favor of an ileal conduit urinary diversion. He stated that personalized patient-focused decision making is always necessary. However, in the majority of cases, the ileal conduit is the appropriate reconstructive technique. He used a comparison to a tank of gas, where neoadjuvant chemotherapy and cystectomy at least temporarily, lower patients’ functional status from their homeostasis. As patients get older in age, they typically have “less reserve in their tank” to bounce back to their baseline. Dr. Taylor suggested that ileal conduits, which tend to be a shorter operation with less post-operative care, can get patients back to their baseline more quickly. Following neobladder reconstruction, patients must learn how to catheterize, irrigate, and void to regain control, which is a significant commitment.
In the latter part of the session, Dr. Palou argued in favor of a neobladder. First, he stated that conduits are filled with stomal complications: stenosis, retraction, and parastomal hernias. He suggested a trifecta in bladder cancer of disease-free, continence and potency, similar to prostate cancers. Dr. Palou suggested that surgeon experience and preference plays an important role in patient decision making, similar to radical versus partial nephrectomy for kidney cancer. The following may be relative contraindications and are important in patient selection: preoperative radiotherapy, complex urethral stricture disease, sphincter-related incontinence, age, comorbidities, intestinal disease, obesity, and locally advanced or node-positive disease. Studies have demonstrated good functional and oncologic outcomes comparing the standard approaches to nerve sparing or robotic procedures. Studying quality of life outcomes, continent diversions have shown superior emotional and body image outcomes compared to cutaneous diversions.
In summary, there is no “right” answer, and each patient must be treated individually. Both physicians recommend offering the best you can do for your patients and to be there to explain, talk, clarify and repeat.
Presented by: John A. Taylor, Professor, Director of Basic Urologic Research and the Co-Leader of the D3ET Program at the University of Kansas Medical Center, Department of Urology, University of Kansas Health System, Kansas City, Kansas, and Joan Palou, MD, PhD, FEBU, Chairman at the Department of Urology, Fundacio Puigvert, Barcelona, Spain
Written by: David B. Cahn, DO, MBS, @dbcahn, Fox Chase Cancer Center, Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.