Using 15 years of data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), our study evaluated temporal trends in urinary diversion following radical cystectomy. It explored how these patterns varied across age, sex, and race. The longitudinal scope and national representation of NSQIP allowed us to move beyond single-center experience and examine how diversion practices have evolved across diverse clinical settings.
The most notable finding was a steady decline in the use of continent urinary diversion over time, with a corresponding rise in incontinent diversion. This trend persisted despite ongoing advances in surgical technique, perioperative care, and patient selection. Importantly, the decline was not limited to traditionally higher-risk groups. Even among younger patients and males, historically considered ideal candidates for continent diversion, the likelihood of receiving a continent reconstruction decreased significantly over time.
Sex specific analyses were particularly revealing. While the use of continent diversion among female patients remained low and relatively stable throughout the study period, males demonstrated a pronounced decline, effectively narrowing the historical gap between sexes. This pattern suggests that changes in surgeon practice, institutional norms, or counseling strategies may be playing a larger role than patient eligibility alone.
Several factors may contribute to these trends. Although high-volume centers may have the technical capacity to perform continent diversion, practice patterns may still favor incontinent reconstruction, particularly in settings where minimally invasive approaches or operative efficiency are emphasized. In addition, variability in surgeon and institutional volume persists, and the technical complexity and learning curve associated with continent diversion may limit its broader adoption. Finally, evidence suggesting comparable long-term quality of life outcomes between ileal conduit and continent diversion may further influence both surgeon and patient decision-making.
Patient counseling itself may also be evolving. With greater emphasis on shared decision making, patients may prioritize shorter operative times, lower perioperative risk, and reliability over potential long-term functional advantages. In this context, the ileal conduit may increasingly be viewed as an acceptable and sometimes preferred choice rather than a secondary option.
While our study is limited by the lack of long-term functional outcomes, patient-reported measures, and institutional-level variables, it provides a contemporary national perspective on diversion practice patterns. The consistent decline in continent diversion raises important questions about how surgical innovation, training, institutional incentives, and patient values intersect in modern bladder cancer care.
Take Home Message
Despite ongoing surgical advancements, the use of continent urinary diversion after radical cystectomy has declined nationally over the past 15 years, including among traditionally favorable candidates. These trends likely reflect changes in surgical practice and counseling that extend beyond patient selection alone, including institutional preferences, surgeon experience, and evolving perceptions of the functional value of continent reconstruction.
Written by: Marwan Zein, Towfik Sebai, Baraa AlJardali, Yara Ghandour, Bilal Alameddine, and Albert El Hajj
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon.