ESOU18: Robotic Assisted Radical Cystectomy Does Not Always Confer the Right Urinary Diversion

Amsterdam, The Netherlands (  Urinary diversion after performance of radical cystectomy (RC) can be done in several ways. Orthotopic reconstruction in the right patient, with well performed nerve-sparing surgery, and adequate follow up provides excellent clinical, oncological and functional outcomes. Nevertheless, we are witnessing a worldwide decline of usage of orthotopic reconstruction and a  growing shift to ileal conduits (IC) is seen, in high volume centers as well. 

According to Dr. Thalmann, there are several reasons for this:

1.The introduction of robotic assisted radical cystectomy (RARC). The challenge is mainly in the reconstruction part of the procedure, clearly shifting surgeons to chose to perform IC instead of orthotopic neobladder. RARC with intra-corporeal urinary diversion with an orthotopic neobladder is feasible but requires a substantial learning curve and is a complex procedure.

2. Surgical/hospital volume: low volume surgeons have poorer functional results with orthotopic diversion, so choosing to perform IC diversion is much more intuitive for them. 

3) Reimbursement issues: in times of increasing health care costs, non continent urinary diversion is less prone to complications, especially in the early postoperative phase, with shorter hospitalization times. This leads to a shorter patient turn around and less readmissions.

4) Patient follow up: patients with continent urinary diversion require regular follow up and training by specialized nursing personnel which is costly, time consuming and can potentially impose large distances of travel for the patient. 

5) Patient age: due to an increased life expectancy in the last 20 years, a shift towards older patients undergoing surgery might favour the use of IC diversion, but the better life expectancy has also been accompanied by a better general health status.

All these factors may explain the fact that fewer continent orthotopic urinary diversions are performed. However, this does not justify depriving patients of a possible and attractive alternative to the IC diversion.

Speaker: George N Thalmann, MD Department of Urology, Universit├Ąt Bern, Switzerland

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands