Urinary diversion after radical cystectomy.

At most centers with experience in urinary diversion, an orthotopic urinary reservoir is the diversion of choice after radical cystectomy for bladder cancer. The paradigm has shifted in the past 10 years from actively looking for reasons to do an orthotopic diversion to carefully considering why a patient cannot undergo reconstruction to their native urethra. In our institution, any patient who is to undergo a radical cystectomy for bladder cancer is a potential candidate for orthotopic diversion provided they do not have chronic renal insufficiency. In addition, they must have a negative urethral margin on frozen section at the time of cystectomy, and have the mental and physical capacity to understand what is required to manage the reservoir after surgery. Proper patient selection is the key to success. Notably, chronologic age is not an absolute contraindication to orthotopic diversion. Instead, careful consideration of the patient's comorbid conditions should guide eligibility. In addition, locally advanced disease is not a contraindication to an orthotopic diversion. To have the flexibility to manage whatever situation presents itself intraoperatively, the surgeon performing a urinary diversion after radical cystectomy must be facile with several diversion techniques. At the very least, the surgeon must be comfortable with one type of each major form of urinary diversion, a conduit (incontinent) diversion, a continent cutaneous diversion, and an orthotopic diversion. As a result, radical cystectomy and urinary diversion should be performed at centers with significant experience in all three types of diversions.