EAU 2019: Case-Based Debate: Ileal Conduit or Continent Diversion: Which is a Better Choice for Most Patients?

Barcelona, Spain (UroToday.com) In the Common Problems in Muscle Invasive and Advanced Bladder Cancer: Evidence-Based Debates session at the 2019 European Association of Urology meeting EAU 2019, Dr. Morgan Roupret presented the following case to facilitate the debate between Drs. John Taylor  and Joan Palou titled: "Case-based debate: Ileal conduit or continent diversion: Which is a better choice for most patients?"  The patient case was as follows: a 69-year-old, 95 kg, male with a history of myocardial infarction and chronic renal insufficiency (CrCl 54 ml/min) with high grade localized muscle-invasive bladder cancer.  In this clinical scenario, both physicians agreed in favor of a radical cystectomy with pelvic lymph node dissection as the standard of care, but then debated the reconstructive merits of incontinent cutaneous versus orthotopic continent diversion.

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.