What is the best urinary diversion after laparoscopic radical cystectomy?

Radical cystectomy today is considered one of the most complex and morbid surgical interventions in urology. The application of a minimally invasive approach to radical cystectomy has grown, and excellence centers have published series in which laparoscopic radical cystectomy (LRC) is associated with lower morbidity and equivalent short–term oncologic results [1]. To date, neobladder substitution has been selected increasingly in high–volume centers, whereas the ileal conduit has been a standard method of urinary diversion after radical cystectomy. Although it is well accepted that radical cystectomy with subsequent urinary diversion is associated with marked complications, there have been limited studies comparing the perioperative and intraoperative findings between the ileal conduit and neobladder [2].

The authors have written an article about the comparison of two urinary diversion methods after laparoscopic radical cystectomy [3]. LRC is a challenging procedure with many benefits if performed in an experienced center. Another issue with LRC involves the decision about which urinary diversion to choose. Although a neobladder seems more acceptable for the patient, it has its own risks during the operation and in the follow–up period. It also takes more time to construct, even in open surgery [2]. This article is the first in the literature to compare these two diversion methods in laparoscopic surgery. A comparison was made of 63 patients: ileal conduit and neobladder in 39 and 24 individuals respectively. The patients were not randomized and it is difficult to say that the number of patients is sufficient to make a healthy comment about the features of the two techniques. The patient demographics, operative time, conversion rate, blood loss, transfusion rate, morphine analgesic requirement, length of hospital stay, complication rates, follow up, and quality of life assessments were compared between the two groups.

They found no difference between age, BMI, smoking history, transurethral resection of bladder tumor pathology result, blood loss, blood transfusion requirement, conversion rates, length of hospital stay, morphine requirement, complications, or follow–up and quality of life. This shows that the two techniques have almost the same features regarding these parameters. It is interesting that there is no difference in the two groups regarding the quality of life parameter. We, in fact, think that neobladder is performed to increase the patient's quality of life. Of course, the authors mention that it is not a randomized study, with a low quantity of patients and low quality of statistical power.

The neobladder procedure took longer to perform than the ileal conduit. It is an expected finding as neobladder construction is more challenging and secondary patients existed in this group.

As a conclusion, the study is valuable, because it is the first one that compares neobladder and ileal conduit diversions after laparoscopic radical cystectomy, but further randomized and larger studies are required to get clearer information about the differences between these two methods.