Urinary Diversion after Radical Cystectomy - Morgan Roupret
June 17, 2019
Morgan Roupret, MD, PhD, Professor of Urology, Sorbonne Université, Paris (UPMC), ESOU chairman, Paris, France
Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.
Charles Ryan: Hello. I'm joined today by Professor Morgan Roupret who is a Professor of Urology at the Sorbonne University and works at the Pitié Hospital in Paris. Thank you for joining us.
Morgan Roupret: Thank you.
Charles Ryan: We're going to talk about bladder cancers today, your specialty. You have a few things going on this year at EAU. One very interesting topic is the quality of life of patients undergoing urinary diversion after radical cystectomy. So, tell us about the findings and the topic of the debate in that subject.
Morgan Roupret: Yes. That's a very important point because outside the oncological outcome, what we want to provide to the patient is a good medical service. By that I mean, you need to learn to live without a bladder, and when you take it out, the question is how is going to be my quality of life? So there is a choice.
Sometimes we do not have a choice, to be really honest, because they are often contraindications to do a neobladder because a tumor is on the bladder neck or there is an infiltration within the urethra, so for certain I would say criteria, you would say no there is no choice. But when everything is on the table basically you have the choice between the neobladder or the Ileal conduit. And we have to say that it was stated during the congress that in the Western world, I would say 75, 80, up to 80% of the patient they do have to leave after the radical cystectomy Ileal conduit.
Meaning that the vast majority of our patients have an Ileal conduit, and if you consider the points theoretically the patient would choose spontaneously to have a neobladder.
Charles Ryan: Mm-hmm.
Morgan Roupret: No one is claiming to have a stoma, which is on the paper something which is difficult to accept. Because it's another version of your body. But the point is that with the neobladder if it's on the paper, very seriously the rate of continence, and by that I mean daily continence. And the nocturnal continence. Plus the necessity to use clean intermittent catheterization could be an issue. So in the long run, the results of the neobladder are not perfect. There are infections because you use the digestive tube, so there is colonization by the bacteria. You have to overcome the learning curve of the use of clean intermittent catheterization in nearly 25% of the cases, which is not neglectable. And last point is the continence. There are some patients that are complaining about leakage ...
Charles Ryan: Mm-hmm.
Morgan Roupret: And the life with a stoma in the long run, because the median life if this patient is nearly 75, so it's quite easy because you learn how to use it and it's quite convenient. So, it's not as simple as it seems to be on the paper, and the agreement of the people who are sitting there and having the debate, was to say, if your practice you never propose a neobladder. So maybe you are making a mistake and if in your practice, you always propose an Ileal conduit. Then you are making a mistake. So it has to do with personalized medicine in fact. It is just the question of the treatment of the cancer itself but also the quality of life of the patient, and the quality of life is a very subjective multi-criteria component, and it's quite difficult to assess on the long run. So we have to commit ourselves in a deep and meaningful discussion with the patient and the level of knowledge of the patients on this issue is very important.
Charles Ryan: Now I would imagine if only 25% of patients are having neobladders made, there's probably some interoperator dependence, right? Depending on the experience and the technique of the operating urologist. Is that a factor that may figure into the quality of life?
Morgan Roupret: That's, you have a point. That's true. It means also that one of the most complicated surgeries so far in urology remains to remove the bladder. So it's a very demanding surgery and when you are done with this first step of the surgery we have to admit that to perform an Ileal conduit is shorter in length of time in the operating room, than to have a second step as demanding as making a neobladder. So sometimes the choice of the Ileal conduit can be a choice of facility.
Charles Ryan: Mm-hmm.
Morgan Roupret: Meaning that you want to get rid of the surgery. But it cannot be, I would say on an ethical perspective, accepted without putting in perspective the choice of the patient. Contingent upon the fact that the patient has a choice. Because as I told you there are certain contraidications to perform a neobladder.
Charles Ryan: Yeah.
Morgan Roupret: If a patient is too old, it's impossible. But you are right. And there is also the volume. The volume of surgery that you perform in a single institution. In fact, it's common sense. You do properly what you do often. So if you have a tradition, it's like a school of surgery, which has been using the neobladder for many years. It's not an issue.
And there are different subtypes of neobladders also. And there as many neobladders as there are letters in the alphabet. So you have to stick with one single technique. You are not an artist. And you want always to perform the same kind of reservoir.
Charles Ryan: So, what are the properties of a perfectly, or very well-functioning neobladder? How does that patient live?
Morgan Roupret: In fact, there is a bowel movement that is natural. So you want to fight against the spontaneous bowel movement. So what you want to have, you will never get the perfect volume and the perfect balloon. So a neobladder will be never as good as the native bladder. But since, you can gain a volume and bear in mind that it will be an expansion of the neobladder that you have done. Meaning that you should go for a urodynamic assessment 6 months after the surgery that you have provided to the patient.
And you can see the difference between the size of the reservoir that you are going to provide to the patients, and the expansion of the reservoir itself. Meaning that the neobladder is not a definitive reservoir. It's not a static reservoir. It's something that is going to be dynamic, is going to move. And there is from day 1 of surgery until 6 months, it's going to expand a little bit, and to change.
Charles Ryan: What's the volume of a neobladder the day after surgery?
Morgan Roupret: I would say between 100 and 200 millimeters. And you can go up to 400, 600 millimeters so you can see ...
Charles Ryan: That's over 6 months time?
Morgan Roupret: Yeah.
And the other point is the reflux in the urinary tract, because there is a natural barrier with the bladder that you have to protect the renal function. And so there is no reflux spontaneously. So the patient has to keep in mind that if he has a neobladder, there will be high pressure, volume, that can reflux in the upper tract. So if he wants to keep his renal function as good as possible, then he needs to empty the neobladder as much as possible.
Which is difficult because when your bladder is naturally fulfilled you have a message which is sent to your autonomic system and says to your brain you need to go.
Charles Ryan: Mm-hmm.
Morgan Roupret: To void. Which is not the case with a neobladder. So you need also to learn the new kind of messages that you would receive from your body. And that's something that can be very subjective.
Charles Ryan: Are there messages? Do patients have different sensations from a full bladder?
Morgan Roupret: Yeah I've had many patients in my experience who called me and says, listen to me, Professor, I don't feel well. I'm going to the emergency unit because I have digestive trouble. I may have diarrhea and so on. But I was telling the patient, of course, you need to check. But I have the feeling that your bladder is full, and you don't know it.
So, there were some people that were not feeling well, dizziness, hypotension and so on. So, there are some symptoms that are likely to be in link with the disturbance of the autonomic nervous system. And that let you know that you are in fact facing acute urinary retention on your neobladder.
As soon as they know these symptoms, that have nothing to do with the regular urinary retention, they know when they need to use the catheterization and so on.
Charles Ryan: I see.
Morgan Roupret: So they have to learn to live with the neobladder, which is not that simple.
Charles Ryan: So, what about the perfectly functioning Ileal conduit? I would imagine it's a lot simpler process, right?
Morgan Roupret: Yeah, it's better for the renal function. Because there is no possibility of retention. So, it's not to be ... the problem is of course not the continence urinary function, it's incontinence. Meaning that you are going to have a flow of urine all day long, within the stoma. But if it's done properly and if you respect the particularity of the patient, for instance, it seems to be obvious, but you ask him if he's right-handed, or left-handed because you will put the stoma on the right side or the left side.
If the patient is obese for instance, you will avoid as much as possible to put the stoma at a place where there is no way that the support is going to stick with the skin. So, there are also complications with an Ileal conduit, but the patient, after a few weeks is likely to manage and to handle the situation. And the fact is that for the urinary function and the renal function, it's much more easy to handle because there is no way there is a reflux.
Charles Ryan: So, when you study quality of life, you're no doubt matching patients by age and comorbid illness. But really what you have is two technologies. One is really developed for younger, healthier, thinner patients perhaps. That would be the continent diversions, the neobladder. And then older, more comorbid patients who perhaps have a higher likelihood of obesity, would have the Ileal conduit.
Morgan Roupret: Yeah.
Charles Ryan: And so, when you do a comparison you have to match those age and other factors, right?
Morgan Roupret: Yeah, of course.
There are many variables and you have to stay cautious when you speak of quality of life. You can use a validated questionnaires that has nothing to do with bladder cancer, but there are plenty of questionnaires or surveys that you can spread to your patient, but I need to emphasize the fact that we know very well our patient. It's quite rare that we face muscle invasive bladder cancer from the beginning. This patient we have been treating them for many months or many years, so when the time of the cystectomy happens, we know what to expect. And outside being cured for the disease itself, of course, the request is not always the same. According also to the people who are surrounding the criteria. So social insertion and so on. So there are many criteria that you will not find in the scientific literature that are important to take into account.
Charles Ryan: Well this is a really interesting topic and obviously really important for patients. Not only in terms of cancer control, which it sounds like everybody knows is important, but really the quality of life for what could be many years after cystectomy. So congratulations on this work and really a pleasure talking to you about this.
Morgan Roupret: Thank you.