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Keywords: For >30 yr, the ileal conduit (IC) has been considered the ‘‘standard’’ urinary
Complications diversion for bladder cancer patients submitted to radical cystectomy. It is uni-
Continent urinary reservoirs versally recognised as being the most clinically adequate, cost-effective, and
Ileal conduit reliable solution in the long term. During the last two decades, this surgical
Quality of life procedure has been challenged by the dissemination and the excellent clinical
Radical cystectomy outcome of bladder substitutions, which gave the surgeon options in supporting
Stoma the patient’s final choice. Despite this, from a survey of recent literature, IC remains
Surgical anastomosis a widely used urinary diversion in most urologic centres. In particular, it is most
Urinary bladder neoplasms frequent in female patients and in patients >70 yr with high preoperative comor-
Urinary diversion bidities and unfavourable clinical tumour stage.
Enhanced recovery protocols with standardised perioperative plans of care or
‘‘fast-track’’ approaches as well as advances in postoperative patient surveillance
have consistently decreased the overall morbidity related to the IC procedure.
Although technically simpler to perform when compared with continent reser-
voirs, IC has not been associated with lower complications. This can be explained
partly by the more unfavourable clinical characteristics of patients who undergo
the procedure and partly by technical surgical errors. Postoperative complications
strictly related to IC contribute to reduce the postoperative quality of life. These
complications include uretero-ileal anastomotic strictures and stomal, peristomal,
and abdominal wall-related complications. Most prospective studies, however,
found no difference in overall quality of life when comparing different types of
transposed intestinal segment surgery.
# 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, Università ‘‘Vita-Salute’’, Ospedale San Raffaele, Via
Olgettina, 60, 20132 Milano, Italy. Tel. +390226432306; Fax: +390226432969.
E-mail address: colombo.renzo@hsr.it (R. Colombo).
urine, have consistently improved the patient’s postoper- diversions in 2000 and for only 21% in 2005. Likewise, the
ative QoL. recent study by Manoharan et al. [15] showed that of all
For >30 yr, the ileal conduit (IC) has been considered the patients (mean age: 69 yr) submitted to RC between 1992
‘‘standard’’ urinary diversion method for most patients and 2007 at a department of urology in Miami, Florida, 56%
submitted to RC. It is recognised as the most clinically underwent IC and 41% underwent OBS. The trend is similar
adequate, reliable, and cost-effective solution. In the mid- in many European contexts. The Swedish Bladder Cancer
1980 s, the IC was challenged by the introduction of both Register study was completed by including >90% of all
orthotopic bladder substitution (OBS) and cutaneous patients with newly diagnosed bladder cancer treated
continent reservoir concepts [3]. During the last 20 yr, a with RC between 1997 and 2003, and IC and continent
variety of surgical OBS improvements have been introduced reconstruction were accomplished in 64% and 36% of cases,
progressively into clinical practice and proposed more and respectively [16]. Likewise, the German population-based
more often to bladder cancer patients as the best compro- study by Bader et al. [17] showed that IC was selected in up
mise between oncologic radicality and postoperative QoL to 64% of overall cases after cystectomy. Similarly, a French
[4]. This surely advocates for reconsidering the role of IC; national survey published in 2008 by the French Association
therefore, the real question is whether IC should still be of Urology confirmed the IC as the most frequent post-RC
considered the standard urinary diversion procedure urinary diversion (84%) [18].
following RC. This scenario seems to contrast with that at some
reference centres where, in the same period of time, a much
2. Ileal conduit in the contemporary era higher percentage of patients underwent OBS (Ulm, 66%;
Bern, 54%; Mansoura, 39% [19]). It clearly emerges that
The IC technique is based on the use of a short segment of continent reconstructions are more often completed at
ileal bowel to allow urine to traverse the abdominal wall academic departments than at county hospitals, demon-
and empty through a cutaneous stoma into a dedicated strating a substantial provider influence on the choice of
stoma collection device. The first description of the IC post-RC surgical solution.
urinary diversion must be attributed to Seiffert [5] in 1935. The report published in 2007 by the members of
However, the technique was subsequently refined and Consensus Conference on Bladder Cancer and the Société
popularised by Bricker in the 1950s [6]. Further surgical Internationale d’Urologie, including >7000 patients from 13
variants, mainly concerning the ileo-ureteral implant, urologic departments [3], probably reflects the current
introduced by Wallace [7], Le Duc et al. [8], Saudin and distribution in the frequency of urinary diversions at
Pettersson [9], and Taguchi (see Lee et al. [10]), did not reference centres. In this report, OBS accounted for 47%
substantially change the original technique, which (30–66%) and IC accounted for 33% (22.6–64%). It is evident
remained the reference for urinary diversion against which that the rate of patients submitted to any kind of diversion
all other types of post-RC surgical solutions have been varies widely among high-volume institutions, and very
compared and judged. little is known about the reason for this variation. The same
On the one hand, it has been stated that the major study showed that surgical solutions different than IC and
qualifying points of IC are represented by the relatively OBS are used only marginally in most urologic departments:
simple surgical technique and the low rate of inherent anal diversion (10%), continent cutaneous diversion (8%),
postoperative complications. On the other hand, a visible and incontinent cutaneous diversion (2%). When analyzing
stoma, the need for lifelong stoma care, and the related the mentioned studies, and regardless of the characteristics
limitations in terms of social relationships, lifestyle, and of the urologic centres, IC unquestionably remains the most
leisure activities are well-recognized disadvantages of this frequent approach in female patients and in those >75 yr
procedure [3]. Whether IC is actually an easy-to-perform with less favourable TNM classification.
intervention with overall limited postoperative complica-
tions remains a questionable issue. The overall long-term 3. Patient preparation
functional results are far from those expected from an ideal
procedure [11], and the presence of a visible or malfunc- A complete preoperative anaesthesiologic assessment
tioning stoma could be related to long-life anxiety and including cardiac testing, renal and hepatic function, and
depression [12]. The fact is that dissemination of IC correction of modifiable medical disease such as hyperten-
diversion and its acceptance in socially advanced countries sion, cardiac arrhythmias, and anaemia should be complet-
remain disparate. ed in all patient candidates for RC.
According to a recent report by the Urologic Diseases in During the last decade, enhanced recovery protocols
America Project [13], among 27 494 patients submitted to with standardised perioperative plans of care or ‘‘fast-track’’
RC between 2001 and 2005 from the Nationwide Inpatient (FT) schedules have also emerged as tools to assist RC
Sample, 4539 (16.5%) underwent a continent urinary patients. Particularly, the FT protocols incorporate innova-
diversion and 22 955 (83.5%) underwent an IC. Interesting- tive aspects such as non-narcotic analgesics, limited bowel
ly, a significant trend towards the more liberal use of the IC preparation, early institution of an oral diet, and drainage
during the last few years has been registered in some US management and have been recognised by many clinical
contexts. The monoinstitutional report by Lowrance et al. studies [20] as a promising approach in RC followed by the
[14] showed that OBS accounted for 47% of all urinary use of intestinal segments.
738 EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744
The use of bowel preparation using polyethylene glycol the type of urinary diversion [24]; however, as recently
or sodium phosphate oral solution has been recommended shown in an overview by Froehner et al. [25], the IC is the
and adopted for a long time in patients who are suitable for urinary diversion of choice (>70%) in daily clinical practice
intestinal surgery to reduce the incidence of postoperative for elderly patients (>70 yr). In the same setting and even
ileus, wound infections, and digestive anastomotic dehis- more for patients >75 yr of age with severe comorbidities or
cence [21]. However, when only the small bowel is being with incurable disease requiring cystectomy mainly for
used, scant evidence supports bowel preparation. A simple symptom control, IC competes with cutaneous ureteros-
cleaning enema the night before surgery as part of an FT tomy, decreasing both surgical trauma and complication
regimen was documented to be a reliable and effective rates.
approach in patients who underwent IC diversion [22]. In IC Although OBS has been successfully performed in female
patients, the urologist or stoma therapist should mark the patients [26], at present, IC remains the most frequent
site of the stoma, and the patient should test the appliance urinary diversion in females. Mean older age at time of
and wear the definitive urine collection device for 1 or 2 d bladder cancer diagnosis and high rates of both urinary
before surgery. The stoma therapist may represent a key incontinence and hypercontinence reported in some
figure in the perioperative and postoperative management experiences, together with a relative increase of postopera-
of these patients. Likewise, before surgery, patients should tive complications after OBS, play roles in preferring IC in
be fully informed about the risks and benefits of IC and the female population [3].
surgical alternatives. Sufficient time should be given to
patients to realize the impact of everyday aspects related to 5. Surgical technique step by step and practical
the urinary diversion selected before obtaining the in- suggestions
formed consent. Often, before a final decision has been
taken, counselling of the patient and the family is required, RC with pelvic lymphadenectomy should be completed by
with the help of psychologists, oncology nurse specialists, or respecting well-defined surgical steps, as summarized by
patients who have previously undergone the chosen Stein and Skinner [27] and by Bhojwani and Mellon [28].
procedure.
5.1. Choice and preparation of the ileal segment
4. Indications and contraindications to ileal
conduit A segment of 12–18 cm of ileum proximally to the
ileo-caecal valve is measured and generally tagged by
Since the introduction of continent urinary reservoirs into sutures. Preserve intact at least 15 cm of terminal ileum to
clinical practice, the paradigm for choosing a urinary avoid metabolic disturbances related to salt absorption.
diversion after RC has substantially changed. Currently, only Care must be taken to adapt the length of isolated ileal
one QoL study suggests that bladder substitutions score segment to the physical conformation of the patient (eg,
higher than IC [23]. To date, however, we should consider OBS longer for obese patients). Do not use a too short an ileal
as the first option for all RC patients and identify those for segment to avoid stretching and tension of the cutaneous
whom an orthotopic reconstruction might not be the ideal stoma. Likewise, avoid the use of a redundant segment to
solution. In this way, rather than the standard, IC may be prevent residual urine volume and urinary infections of
considered the most frequent alternative solution in all cases both conduit and renal units. In patients who have
that are unsuitable for orthotopic substitutions. An absolute undergone prior radiation, carefully select a segment of
contraindication to continent urinary diversion of any type is ileum unaffected by radiation.
compromised renal function due to long-standing obstruc- The mesentery of the iliac segment selected is incised
tion or chronic renal failure, particularly when serum and prepared in a sequential manner using Kelly clamps and
creatinine levels exceed 150–200 mol/l. Severe hepatic 3-0 free ties. Large feeding vessels must be avoided during
dysfunctions represent a well-known contraindication to this process to prevent vascular damage of both ileal
OBS. Likewise, patients with compromised intestinal func- segment and digestive anastomosis. Haemostatic surgery
tion should be oriented to an incontinent diversion. In devices such as bipolar scissors, harmonic scalpels, or
addition, OBS is contraindicated in cases of anal sphincter stapling devices may be of help, as may transillumination by
mechanism deficiency or when urethrectomy is required. An using a satellite lamp at right angles to the bowel.
impaired intellectual ability and the lack of manual dexterity The mesentery needs to be delicately dissected near the
may be considered as relative contraindications for bladder tagged sutures to allow a GIA stapler or noncrushing clamps
reconstruction because some patients may not be able to void to be placed. The bowel segment is divided, and the end of
with adequate use of abdominal straining, to manage the ileal segment that will be exteriorized is marked.
programmed night-time awakenings, and to perform self- Proximal and distal ends of ileum are then anastomosed.
intermittent catheterisation when needed. History of pelvic The digestive anastomosis may be completed by using
irradiation, urethral stricture, neurologic disease, and will- staplers or by handmade standard sutures either side to side
ingness for regular follow-up are additional reasons for or end to end. Verify that the lumen of the completed
preferring an IC to OBS [3,24]. intestinal anastomosis is sufficiently wide, avoid any
In properly selected cases, high-volume centres report traction on the suture, and prefer the peristaltic direction.
similar complication rates in elderly patients regardless of Reinforce the staple lines with 3-0 sutures. Remember to
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744 739
[()TD$FIG] [()TD$FIG]
Fig. 1 – (a) Internal transmesentery ileal hernia and (b) internal ileal hernia
through the conduit and the peritoneum of the abdominal lateral wall. to avoid ischemic reactions or strictures at the ileo-ureteral
anastomosis.
accurately close the mesentery window of the ileo-ileal 5.3. Ileo-ureteral anastomosis
anastomosis with 3-0 absorbable sutures to prevent an
internal transmesentery ileal hernia (Fig. 1a). After sending the ureteral stumps for a frozen-section
Ultimately, the isolated ileal segment should be lying [()TD$FIG]histology (to exclude any residual tumour), the ureters are
below the digestive anastomosis (Fig. 2). The distal closed
end of the ileal segment is excised and opened to allow
copious irrigation of its lumen with saline solution. The ileal
loop is oriented to allow peristalsis to proceed in the
antegrade direction towards the cutaneous stoma.
Table 1 – Frequently reported early and late complications surgical revision is often needed for a definitive treatment
following radical cystectomy and ileal conduit
[39]. The type of uretero-ileal anastomosis (Bricker vs
Early Late Wallace) does not affect stricture incidence [40,41].
Meticulous handling and preparation of the distal ureter
Bowel related Stoma related
Intestinal anastomosis related Abdominal wall related are essential to minimise the risk of urine leak and
Ureteral-ileal anastomosis leakage Conduit stenosis postoperative strictures [42]. Tunnelling antireflux tech-
Enteric fistula Uretero-enteric anastomosis niques are not useful [3] for IC reservoirs and have been
stricture
described to carry a higher risk of stenosis in a randomised
Bowel obstruction Hydronefrosis
Prolonged ileus Kidney failure trial [43]. Clinical studies reporting long-term follow-up
Conduit necrosis Metabolic changes showed that up to 50% of patients submitted to uretero-
intestinal refluxing anastomosis will develop upper urinary
tract alterations, but only in 12% of cases do the renal
changes become clinically significant [11].
Some complications are strictly related to IC and have
been distinguished between early (<90 d) and late (>90 d) 7.2.2. Stomal, peristomal, and abdominal wall-related
[4] (Table 1). complications
These complications are extremely frequent (15–65%)
7.1. Early complications [44,45] in IC patients and contribute significantly to reduce
the overall QoL of the patients. The most frequent skin
7.1.1. Related to the uretero-ileal anastomosis disorders are typically caused by chemical injury (irritant
Leakage of the uretero-ileal anastomosis is one of the most contact, dermatitis pseudoverrucous lesions, alkaline en-
challenging adverse events, accounting for up to 7% of cases crustation), mechanical injury (pressure ulcer, stripping
[24]. This complication is more frequently related to injury, mucocutaneous separation), infection (candidiasis,
inadequate surgical technique, such as tension at the folliculitis), and immunologic disorders (allergic contact
anastomosis, devascularisation and rotation of the ureters, dermatitis) [46]. The role of the stoma therapist in both
or defective suture rather than to the kind of uretero-ileal prevention and management of these complications is
anastomosis performed (ie, Bricker vs Wallace; Fig. 4) [38]. essential.
A conservative approach during the early postoperative Parastomal hernia, prolapse, stenosis, and retraction of the
period concerning nutrition, diversion, drainage, and stoma have been reported in up to 31% of cases [44–46] and
treatment of any sepsis is generally sufficient. In the long represent a frequent cause for reoperation after IC.
term, leakage can determine fibrosis of the anastomosis, Hernias may occur in the wound or adjacent to stomas
leading to upper urinary tract complications. and may require surgical revision, often without disrup-
ting the whole conduit or reservoir. Parastomal hernia is
7.1.2. Bowel-related early complications an incisional hernia secondary to a fascial defect
Paralytic ileus is described in up to 22% of cases and surrounding the conduit. It has been described as
represents one of the most important determinants of the 10–15% of cases; however, the true rate of this
length of hospitalisation [38]. Type of preoperative bowel complication remains undefined because most patients
preparation, fasting prior to surgery, postoperative pain are asymptomatic or prefer not to treat the condition
control, and inadequate surgical procedure are well-defined [46]. Contributing factors include obesity [47], malnutri-
conditioning factors for ileus. Small bowel obstruction may tion, chronic cough, and use of steroids. Although most
be treated with nasogastric tube, intravenous fluids, and parastomal hernias can be managed conservatively,
bowel rest; however, sometimes a surgical intervention can approximately 30% of patients require surgical interven-
be required when an internal hernia is suspected or tion due to obstruction, pain, and bleeding. The use of
documented (Fig. 1). meshes to reinforce weakened fascial planes around
Intestinal anastomosis leakage is a potentially catastroph- stomas and relocation of the stoma to the contralateral
ic complication if not recognized early and accounts for an side should be considered [48].
increase in the mortality rate [35]. A significant difference Stoma prolapse is relatively rare in IC (1.5–8% of cases)
between stapled and hand-sewn ileostomy closures could [49] and is substantially attributable to impaired vascular-
not be found in literature [37]; however, this complication isation of the ileal segment combined with chronic
is frequently related to surgical errors. infection. Nonsurgical management includes the use of a
prolapse belt, although this carries the risk of stoma
7.2. Late complications necrosis. Stoma stenosis is related quite exclusively to the
use of ileum for cutaneous diversion. It has been described
7.2.1. Uretero-ileal anastomotic strictures and deterioration of renal as 2.5–8.5% of cases at a median of 10 yr after surgery
function [50,51] and is associated with loss of peristalsis, thickening
Benign strictures have been described in about 7–14% of of the walls, and narrowing of the skin. Stenosis at the skin
cases and commonly occur during the first 2 yr after surgery level can be managed by dilating the stoma; however,
[35]. Endoscopic and percutaneous management proce- surgical revision may be necessary after the obstruction is
dures are viable treatment options; however, an open relieved and sepsis is resolved.
EUROPEAN UROLOGY SUPPLEMENTS 9 (2010) 736–744 743
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cation rate, and the satisfactory postoperative QoL. [15] Manoharan M, Ayyathurai R, Solowy MS. Radical cystectomy for
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elderly patients and for those with compromised renal
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function, with severe comorbidities, or who are unfit to
cystectomy for bladder cancer: a population based study in Sweden.
manage continent reservoirs. The test of time has demon-
Scand J Urol Nephrol 2010;44:69–75.
strated that the long-term reliability of this procedure [17] Bader P, Westermann D, Frohneberg D. Urinary diversions: which
strictly depends on a rigorous surgical technique. one is right for which patient? Urologe A 2009;48:127–36.
[18] Mottet N, Castagnola C, Rischmann P, et al. Quality of life after
Conflicts of interest cystectomy: French national survey conducted by the French As-
sociation of Urology (AFU), the French Federation of Stoma Patients
(FSF) and the French Association of Enterostomy Patients (AFET) in
The authors have nothing to disclose.
patients with ileal conduit urinary diversion or orthotopic neo-
bladder. Prog Urol 2008;18:292–8.
Funding support [19] Somani BK, Nabi G, Wong S, et al. How close are we to knowing
whether orthotopic bladder replacement surgery is the new gold
None. standard?—evidence from a systematic review update. Urology
2009;74:1331–9.
[20] Olbert PJ, Baumann L, Hegele A, Schrader AJ, Hofmann R. Fast-track
Acknowledgements
concepts in the perioperative management of patients undergoing
radical cystectomy and urinary diversion: review of the literature
The authors would like to thank Ms. L. Wood and Mr. J. and research results. Urologe A 2009;48:137–42.
Mannell for the linguistic revision of the manuscript and Mr. [21] Tabibi A, Simforoosh N, Basiri A, Ezzatnejad M, Abdi H, Farrokhi F.
Nicola Spreafico for the figures. Bowel preparation versus no preparation before ileal urinary di-
version. Urology 2007;70:654–8.
[22] Maffezzini M, Campodonico F, Canepa G, Gerbi G, Parodi D. Current
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