Orthotopic Neobladder versus Ileal Conduit Urinary Diversion after Cystectomy – A Quality-of-Life Based Comparison

Abstract

Ann R Coll Surg Engl 2009; 91: 565-569 565Over the last century, there has been an evolution of methods for lower urinary tract reconstruction following cystectomy, from being simple means of diverting urine to techniques allowing normal voiding pattern through the intact native urethra. Various methods for continent urinary diversion have been developed to provide such realistic options from simply diverting urine through a conduit to orthotopic reconstruction. [1][2][3][4][5] These innovations in urinary diversions should allow patients to lead a near-normal lifestyle, eliminating the need for a urostomy. However, orthotopic bladder substitution (OBS) is not offered to a majority of patients undergoing cystectomy as the benefits of OBS over ileal conduit diversion (ICD) on quality-of-life parameters remain indeterminate.Health-related quality of life (HRQoL) is a multifaceted and subjective concept taking into consideration the patient's physical and emotional status, general health, social interaction and mental health. Comparison of QoL parameters in patients who have had cystectomy has been difficult with variable results. [6][7][8][9] This could be explained by the use of different questionnaires comparing a multitude of techniques. We compared HRQoL between patients who underwent OBS or ICD following cystectomy using a bladder cancer specific functional index questionnaire. Patients and MethodsOver a 6.5 year period, 57 consecutive patients who underwent Evolution of pathological guidelines has empowered centres to offer orthotopic substitution (OBS) to patients undergoing radical cystectomy. We compared health-related quality of life (HRQoL) between patients who underwent OBS or ileal conduit urinary diversion (ICD) following radical cystectomy. PATIENTS AND METHODS A total of 57 patients who underwent cystectomy were assessed pre-operatively using Karnofsky performance scale (KPS). Of these, 52 patients (28 OBS and 24 ICD) who responded to a postal questionnaire consisting of SF-36 and a functional index questionnaire were included. RESULTS Median age of patients was 70 years. Pre-operative KPS scores were similar. All eight HRQoL scales were favourable in both groups. OBS patients had significantly better physical functioning. In the cohort, 42% of men with OBS and 25% of diversions could maintain an erection to varying degrees. Of the OBS patients, 85% were continent with two patients reporting reduced QoL with pad usage. Of ICD patients, 63% felt less complete and 42% were embarrassed due to the stoma, with 58% apprehensive of stomal leakage. Of OBS patients, 96% had significant relationships and a more active life-style. CONCLUSIONS In a similar age-group population, there was no significant difference in most QoL indices but body image issues persist in ICD patients. OBS patients had significantly better physical function, continuing to have a more active lifestyle. They attained urethral voiding with good continence. A detailed discussion of long-term functional outcome would engender a realistic ...

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