Urinary diversion in high-risk elderly patients: Modified cutaneous ureterostomy or ileal conduit?

doi:10.1016/j.urology.2005.03.031

Urology

Volume 66, Issue 2, August 2005, Pages 299-304

https://doi.org/10.1016/j.urology.2005.03.031 Get rights and content

Abstract

Objectives

To evaluate the efficacy and safety of the type of urinary diversion during radical cystectomy in high-risk elderly patients by comparing a modified cutaneous ureterostomy with the ileal conduit urinary diversion.

Methods

Of 481 patients who underwent radical cystectomy between 1993 and 2002, 54 individuals older than 75 years with an American Society of Anesthesiologists score of 3e, 4, or 4e were characterized as high risk. These patients were grouped according to those who underwent a modified cutaneous ureterostomy (group 1, 29 patients) and those who underwent ileal conduit urinary diversion (group 2, 25 patients). Student’s t and Fisher’s exact tests were used for statistical analysis.

Results

The patients in group 2 had a longer operative time (P <0.001), an increased need for blood transfusion (P = 0.025), an increased need for intensive care monitoring (P = 0.032), and a longer mean hospitalization time (P <0.001) than the patients in group 1. In group 2, we recorded statistically greater rates of intraoperative complications (P = 0.035), early medical and surgical complications (P = 0.031 and P = 0.012, respectively), and late surgical complications (P = 0.004). The intraoperative, early, and late surgical complication rate was 13.7%, 24.1%, and 17.2% in group 1 and 40%, 60%, and 56% in group 2, respectively. One patient in group 2 died in the early postoperative period.

Conclusions

Cutaneous ureterostomy represents a simplified alternative for urinary diversion in high-risk elderly patients. It can be performed quickly, with few early and late postoperative complications compared with the ileal conduit operation.

Section snippets

Material and methods

Between 1993 and 2002, 481 patients with bladder cancer underwent radical cystectomy and urinary diversion at our institution by the same group of surgeons (C.D. and A.S.). Muscle-invasive disease (clinical Stage T2 or worse), multifocal high-grade tumor, and carcinoma in situ refractory to intravesical immunotherapy were the main indications for radical cystectomy. The TNM classification system was used for staging. ¹⁵ All candidates, even in an emergency case, were assessed preoperatively in

Results

No statistically significant difference was found between the two groups regarding the definitive pathologic tumor stage (Table I). The mean follow-up for both groups was 5.7 years (range 1.1 to 10.2). Both groups had patients with similar comorbidities. Cardiovascular disorders were the most common comorbidity (16 patients in group 1 and 13 patients in group 2, P = 1.000), followed by chronic obstructive airway disease (9 and 5 patients, respectively; P = 0.535), diabetes mellitus (6 patients

Comment

Radical cystectomy is considered a definite treatment of invasive bladder cancer. 2, 4 Owing to progress in surgical technique, anesthesia, and intensive care monitoring, it has been applied successfully in elderly patients, achieving mortality and morbidity rates similar to those reported in younger patients. 2, 7, 9 The indications for cystectomy and the selection of urinary reconstruction are not dependent on the patient’s age, provided that rigorous preoperative assessment and anesthetic

Conclusions

We suggest that in high-risk elderly patients with invasive bladder cancer, urologists should consider the performance of a modified cutaneous ureterostomy more frequently.

References (20)

H. Nishiyama et al.
Clinical outcome of a large-scale multi-institutional retrospective study for locally advanced bladder cancera survey including 1131 patients treated during 1990–2000 in Japan
Eur Urol
(2004)
B.K. Hollenbeck et al.
Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older
Urology
(2004)
D.P. Wood et al.
Radical cystectomy for carcinoma of the bladder in the elderly patient
J Urol
(1987)
S.S. Chang et al.
Radical cystectomy is safe in elderly patients at high risk
J Urol
(2001)
M. Soulié et al.
A multicenter study of the morbidity of radical cystectomy in select elderly patients with bladder cancer
J Urol
(2002)
D.C. Miller et al.
The impact of co-morbid disease on cancer control and survival following radical cystectomy
J Urol
(2003)
M. Peyromaure et al.
Surgical management of infiltrating bladder cancer in elderly patients
Eur Urol
(2004)
G.P. Kearney et al.
Cutaneous ureterostomy in adults
Urology
(1992)
M.F. Botteman et al.
The health economics of bladder cancera comprehensive review of the published literature
Pharmacoeconomics
(2003)
J.P. Stein et al.
Radical cystectomy in the treatment of invasive bladder cancerlong term results in 1054 patients
J Clin Oncol
(2001)

There are more references available in the full text version of this article.

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European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines
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We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).
To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.
A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.
Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ–preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.
This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.
The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.
Cutaneous Ureterostomy Following Radical Cystectomy for Bladder Cancer: A Contemporary Series
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To report peri-operative outcomes of a contemporary series of bladder cancer patients undergoing radical cystectomy (RC) with cutaneous ureterostomy (CU) urinary diversion at a tertiary referral center.
We retrospectively identified patients who underwent RC with CU at Mayo Clinic between 2016 and 2021. Clinicopathologic and perioperative characteristics were analyzed using standard descriptive statistics.
A total of 31 patients underwent RC with CU at our institution. Median age was 72 years and 21 were male. This was highly comorbid cohort (83% had an American Society of Anesthesiologists [ASA] Physical Status Classification System ≥3; median Charlson Comorbidity index = 8). Median time to flatus, tolerating regular diet, and length of stay were 3 (interquartile range [IQR] 3-3), 3 (IQR 3-4), and 4 days (IQR 4-7), respectively. A total of 14 patients experienced a high-grade complication (Clavien-Dindo ≥3) within 30 days of surgery, and 8 were readmitted. The most common 30-day complication was sepsis, which affected 13% (4/31) of patients. At 90 days postsurgery, the readmission rate was 32% (10/31), most commonly for sepsis. Three patients required reoperation within 90 days, including one patient who required CU revision due to stomal ischemia. One patient died within this time frame from causes unrelated to bladder cancer.
In a comorbid, relatively elderly bladder cancer cohort undergoing RC, the use of CU was associated with expeditious surgery and postoperative recovery. CU represents an option for urinary diversion in high-risk patients undergoing RC. Higher rate of postoperative ureteral obstruction can be pre-emptively addressed with chronic stent placement.
Perioperative and Oncologic Outcomes Associated with Simultaneous Radical Cystectomy and Nephroureterectomy
2023, Urology
Citation Excerpt :
Cutaneous ureterostomy (CU) was the most common form of urinary diversion performed in which bowel work was not required. CU represents an attractive form of urinary diversion in RCNU patients due to shorter operative time, less blood loss, lower transfusion rates, and shorter hospital LOS.18,19 Additionally, patients undergoing CU have been found to experience similar health-related quality of life to their counterparts undergoing ileal conduit diversion, and potentially lower intraoperative and early post-operative complication rates.20,21
To compare the perioperative and oncologic outcomes associated with RCNU to a matched cohort undergoing RC alone. Simultaneous radical cystectomy and nephroureterectomy (RCNU) for synchronous upper tract and bladder urothelial carcinoma is an uncommon procedure. Sparse literature exists comparing outcomes in patients treated with radical cystectomy (RC) alone versus RCNU.
Adults treated with RCNU for urothelial carcinoma of the bladder (UCB) and upper tract urothelial carcinoma (UTUC) between 1980 and 2020 were identified. Patients were matched 2:1 to patients undergoing RC alone for UCB based on age (+/- 5 years), gender, BMI (+/- 5), Charlson Comorbidity Index, pathologic staging (stage ≤pT2 vs >pT2), and receipt of neoadjuvant chemotherapy. Outcomes included overall survival (OS), recurrence free survival (RFS), cancer specific survival (CSS), 30-day complications, length of stay (LOS), operative time, and estimated blood loss (EBL).
A total of 39 patients undergoing RCNU were identified and matched to 74 patients undergoing RC. There were no significant differences in LOS, EBL, or 30-day complication rates. Operative time was significantly longer in the RC cohort. OS (HR 0.58, CI 0.35-0.97, P = .036) was significantly better for patients undergoing RC alone, while no significant difference was noted in RFS (HR 0.65, 0.34-1.24) and CSS (HR 0.58, CI 0.31-1.08, P = .08).
Patients undergoing RCNU had significantly lower OS compared to a matched group of patients undergoing RC alone. Perioperative outcomes between the groups did not differ significantly. This data can inform patient counseling for treatment of this rare disease state.
Multimodality Imaging Findings Postcystectomy: Postoperative Anatomy, Surgical Complications, and Surveillance Imaging
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Citation Excerpt :
On imaging, the ileal conduit will be found in the right iliac fossa and will be seen as a fluid-filled loop of bowel with evidence of small bowel folds and extend to the skin surface as a stoma (Fig. 1). Patients who suffer from inflammatory bowel disease or who have a serious comorbidity which prevents utilisation of bowel as a reservoir can undergo a cutaneous ureterostomy.4 The ureters are anastomosed directly to the anterior abdominal wall either singly or anastomosed together to form a continuously draining stomas.
Various surgical techniques exist for urinary diversion post cystectomy and each have different imaging features. This diverse range of surgical procedures can make imaging interpretation difficult and so familiarity with the postoperative anatomy is essential. Multiple imaging modalities and techniques are available for the radiologist's assessment including fluoroscopic studies, computed tomography, magnetic resonance, and radionuclide imaging. Knowledge of when each of these modalities is indicated and the typical imaging appearances is essential for early identification of postoperative complications and detection of tumor recurrence. This information enables the radiologist to make an accurate and early diagnosis and subsequently guide the management pathway for these patients.
Chronic kidney disease and Charlson comorbidity index predict complications after robot-assisted radical cystectomy: A single-center study in Japan
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Comparison of long-term outcomes between ileal conduit and transuretero-cutaneostomy urinary diversion after radical cystectomy: a systematic review and meta-analysis
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Adult urologyUrinary diversion in high-risk elderly patients: Modified cutaneous ureterostomy or ileal conduit?

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

Eur Urol

Urology

J Urol

J Urol

J Urol

J Urol

Eur Urol

Urology

The health economics of bladder cancera comprehensive review of the published literature

Pharmacoeconomics

Radical cystectomy in the treatment of invasive bladder cancerlong term results in 1054 patients

J Clin Oncol

Adult urology
Urinary diversion in high-risk elderly patients: Modified cutaneous ureterostomy or ileal conduit?