Urinary diversion: options, patient selection, and outcomes

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer.