Improving Patient Decision-Making in Urinary Diversion

Educational Objectives

The goal of this program is to improve management of patients requiring urinary diversion. After hearing and assimilating this program, the clinician will be better able to:

1. Identify patients undergoing urinary diversion who are at increased risk for complications.

Summary

Urinary Diversion Options

Ileal conduit: standard of care for urinary diversion but is associated with complications, eg, parastomal hernia (PSH); factors contributing to PSH — surgical technique, body mass index, nutrition, wound healing, chemotherapy, diabetes, obstructive disease, and chronic steroid usage; PSH rate in patients undergoing an ileal conduit procedure is 20% to 25%; the recurrence rate is ≥50%; patients are advised to control factors to prevent complications

Catheterizable diversions: complications are related to failure of continence mechanisms; the Kock pouch is rarely used because of the regular failure of its continence mechanism; compliance (eg, catheterizing, irrigating) predicts failure rate of pouches; patients may prefer an umbilical stoma for cosmetic reasons, but failure rates may be higher, particularly in patients with obesity

Orthotopic urinary diversions: nocturnal enuresis may affect 30% to 40% of patients; patients without issues during the day may experience severe nighttime incontinence due to loss of pelvic floor tone

Factors influencing diversion selection: renal function, liver function, inflammatory bowel disease, age (relative), and overall compliance; catheterizable — manual dexterity, coordination, hypermotility syndrome (eg, overactive Indiana pouch); orthotopic — preoperative urinary incontinence, pelvic radiation (bowel segment selection), and primary tumor type (stage and location)

Incontinence after diversion: orthotopic diversion is associated with sphincteric incontinence; catheterizable diversion is associated with an incontinent valve mechanism; pouch-related incontinence may affect patients with catheterizable diversion or orthotopic diversion, and should receive an evaluation similar to that of an overactive bladder; management of sphincteric incontinence is challenging because of the tendency to relaxation and Valsalva during voiding, which makes obstruction ill-advised and potentially complicates the management process, particularly in females

Transurethral injections (TUI): Quek et al (2004) found that TUI for treatment of urinary incontinence after orthotopic neobladder reconstruction in patients with severe disease has a less than optimal durable response; the pubovaginal sling approach is complex with a high rate of complications (eg, hypercontinence)

Management of nocturnal enuresis: includes behavioral interventions or imipramine (typically used in pediatric patients); use of an artificial urinary sphincter with daytime de-activation and nighttime activation for male patients with severe incontinence is recommended; providers should be aware of the risk for bowel obstruction

Decision regret: a study by Check et al (2020) found that patients who were informed about bladder reconstruction options experienced less regret independent of the method that was selected

Patient Insights to Improve Experience

Klein et al (2021): semi-structured interviews were conducted with patients 6 to 12 mo after radical cystectomy; no patients expressed decision regret; patients undergoing continent diversion were highly motivated and utilized additional information sources (eg, the Bladder Cancer Network); patients with appliances or catheters had difficulties adjusting after placement; 77% of patients felt they had adequate information, but some expressed surprise at postoperative complications; peer-to-peer support was desired by most patients

Readings

Check DK, Leo MC, Banegas MP, et al. Decision regret related to urinary diversion choice among patients treated with cystectomy. J Urol. 2020;203(1):159-163. doi:10.1097/JU.0000000000000512; Gillern S, Bleier JI. Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials. Clin Colon Rectal Surg. 2014;27(4):162-171. doi:10.1055/s-0034-1394090 doi:10.4111/icu.2016.57.4.240; Klein GT, Ajay D, Volk RJ, et al. Living with urinary diversions: patient insights to improve the perioperative experience. Urology. 2021;152:190-194. doi:10.1016/j.urology.2021.01.009; Moon A, Vasdev N, Thorpe AC. Continent urinary diversion. Indian J Urol. 2013;29(4):303-309. doi:10.4103/0970-1591.120111.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Westney has been a consultant and on the Data Monitoring Board for Laborie, and a consultant for Boston Scientific. Dr. Westney's spouse has been an employee of Boston Scientific. Dr. Westney presents information related to off-label or investigational use of a therapy, product, or device. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Westney was recorded at the 42nd Annual Ralph E. Hopkins Urology Seminar, held February 1-4, 2023, in Jackson Hole, WY, and presented by Medical Education Resources and Carden Jennings Publishing. For information on upcoming CME activities from this presenter, please visit Jacksonholeseminars.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

UR461703

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.