SIU 2017: SIU-ICUD Joint Consultation on Bladder Cancer - Urinary Diversion

Lisbon, Portugal (UroToday.com) In this chapter, Dr. Rodriguez-Faba covered urinary diversions. However, there is little in this talk that is new since the 2012 guidelines. As such, we will review key highlights of his talk.

Main take-home message: Urinary diversions need to be discussed with the patient. This includes extensive discussion of complications and risks/benefits!
The highest technical complexity is associated with intracorporeal diversion (robotic). However, the main risk factors for complications are:
  1. Related to surgeon experience and technique
  2. Patient factors
Most of the recommendations in this section are Grade C, LOE 3-4. However, they do strongly encourage the following:
  1. report complications on clavien-dindo scale
  2. As most complications are related to urinary diversion, complex cases need to be done at high volume hospitals (HVHs).
Secondary Tumors
Adenocarcinoma is the most common secondary malignancy, and may have latency period of 20 years. However, most diversions don’t increase the risk. Ureterosigmoid diversion is associated with a very high rate of adenocarcinoma development, so these patients require annual colonoscopy after 10 years (LOE 3, Grade C).

Prior Radiation
Radiation affects the viability of the bowel used for UD. As such, may alter options for UD, complications risk, and long-term outcomes.
  • Will affect choice of bowel segment
  • Requires meticulous surgery to help reduce complications
  • Doing an orthotopic bladder diversion in patient with prior radiation should be done at HVH, in selected patients
ERAS protocols
ERAS protocols have been proliferating. However, there are enough variations that it is hard to make any broad recommendations. They clearly reduced hospital stays, transfusion rates and hospital costs. However, oncologic outcomes are not clearly different. Comparable rates of readmissions, oncologic outcomes, and complications.

Key shared features of most ERAS protocols:
  1. Preoperative counseling and teaching
  2. Optimizing preoperative nutrition
  3. Omission of preoperative bowel preparation
  4. Avoid hypovolemia and overhydration intra-o
  5. Avoid opiod analgesics intra-op (epidural, etc.)
  6. No Nasogastric tube or early removal postoperatively (LOE 2b, Grade B)
  7. Early advancement to oral diet
  8. Almivopan (Level 3, Grade C)
  9. Chewing gum, early mobilization (level 3, grade C)
Hospital/surgical volume
This was emphasized repeatedly. 
  • Increased hospital volume was associated with increased rates of continent diversion (LOE 3, Grade B).
  • Strongly recommended to be done at HVH (LOE 3, Grade B)
He then briefly reviewed the UD options (ileal conduit, orthotopic neobladder, continent cutaneous diversions, ureterostomies), but there were no strong guidelines provided.

Lastly, he discussed palliative diversions for patients with median survival of 100 days. While often done for symptoms, many of these patients often spend 25-50% of their remaining days in the hospital. The benefit of this procedure remains in question.

Presented by: Oscar Rodriguez-Faba 

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal
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