Orthotopic urinary diversions after radical cystectomy for bladder cancer: lessons learned last decade

Orthotopic urinary diversion (OUD), or neobladder, is believed to be the gold standard for surgical bladder reconstruction following radical cystectomy though it is performed far less often than ileal conduits. As both a continent and intracavitary diversion, OUDs offer unique advantages for patients. Their utilization has decreased overall though, especially with the advent of robotic surgery. In this review, we will cover patient selection for OUD, functional outcomes (i.e., continence, sexual activity, quality of life [QoL]), and robotic orthotopic diversions.

OUDs have seen a proportionally greater decline in utilization compared with ileal conduits as the number of robotic radical cystectomies being performed with intracorporeal diversions increases. Multiple robotic series have demonstrated less perioperative blood loss and shorter hospital stays when compared with the open approach though operative times are longer, the learning curve is steeper, and overall costs may be higher in some settings. Perioperative safety and short-term oncological outcomes appear comparable. Since robotic OUDs are relatively new, functional outcomes are not yet well established. Patient satisfaction with urinary diversion is associated with informed decision-making tailored to the patient. A thorough understanding of expected short- and long-term functional outcomes and the care required to maintain an OUD improves QoL and satisfaction with diversion choice.

Given the potential advantages of OUD, its decreasing use is a remarkable trend. Shared decision-making and a patient-centered approach should be used when selecting the type of urinary diversion.