Urinary diversions for radical cystectomy: a review of complications and their management

Abstract

Radical cystectomy involves a urinary diversion, the most used being the ileal conduit and the orthotopic neobladder. This review focuses on the complications associated with these procedures, dividing them into general and diversion related complications, as well as their management. We conducted a search on PubMed and Scopus to identify eligible articles on complications of urinary diversions. Randomized controlled trials and systematic reviews with meta-analysis were preferred when available. Early complications occur in the first 90 days after surgery. The most common is post-operative ileus, followed by urinary tract infections and urinary leakage. Most complications occur in the late post-operative setting, being related to the type of urinary diversion. Some of these complications are renal failure, metabolic abnormalities, infections, urolithiasis, and ureteroenteric strictures, each with particular management options. Specific ileal conduit complications are conduit deformities and parastomal hernias. Neobladder patients can have continence problems, like incontinence or urinary retention, but also fistulas and dehiscence. Standardization of complications' definitions and time-dependent reporting are crucial to better understand and manage these complications. Complication rates are similar between open and robot-assisted procedures and between intracorporeal and extracorporeal diversion. Radical cystectomy with urinary diversion is the most difficult surgical procedure in urology with high early and late complication rates. There is an urgent need of standardizing complication reporting to better compare different procedures.

Ileal conduit obstruction secondary to tethering of the small bowel anastomosis to the pubic bone

“…Radical cystectomy and ileal conduit formation are associated with high morbidity. Common short-term complications include postoperative ileus, urinary tract infection and ureteroileal anastomotic leak 7. Other complications include metabolic abnormalities, renal failure, urolithiasis, ureteroenteric strictures and parastomal hernias.…”

“…Other complications include metabolic abnormalities, renal failure, urolithiasis, ureteroenteric strictures and parastomal hernias. The reported long-term complication rate is nearly as high as 80% 7. Of these complications, approximately 29% involve the gastrointestinal system, most commonly the bowel 8.…”

Advances in Urinary Diversion: From Cutaneous Ureterostomy to Orthotopic Neobladder Reconstruction—A Comprehensive Review

“…Considering the stomal stenosis rate superior to 50%, the UCN has limited its application and it is not recommended as a primary choice for palliative diversion considering the better results of percutaneous nephrostomy [20]. Along with stomal stenosis, the most frequent complication is the recurrent UTI which is associated with long-term renal dysfunction and calculi formation [21]. While rare, ureter-aortic fistula represents a fatal complication of UCN [22].…”

NBCA-Lipiodol Mixture Embolization of Persistent Urine Leakage After Orthotopic Neobladder Formation: Techniques and Outcomes

“…Among them, about 5% of patients are known to experience persistent urine leakage (PUL) which usually occurs at the ileourethral anastomosis site ( 8 ). In the recent review of radical cystectomy complications, urethral anastomotic leaks in orthotopic neobladders were reported to reach a rate of 25% in the first 90 days ( 9 ). Although most are minor leakages that can be treated by conservative management, often we encounter uncontrollable PUL in certain patients who inevitably experience deterioration of overall QoL and surgical repair becomes typically difficult ( 10 ).…”