Describtion
Ileal conduit in the contemporary era
The IC technique is based on the use of a short segment of ileal bowel to allow urine to traverse the abdominal wall and empty through a cutaneous stoma into a dedicated stoma collection device. The first description of the IC urinary diversion must be attributed to Seiffert [5] in 1935. However, the technique was subsequently refined and popularised by Bricker in the 1950s [6]. Further surgical variants, mainly concerning the ileo-ureteral implant, introduced by Wallace [7], Le Duc et al. [8], Saudin and Pettersson [9], and Taguchi (see Lee et al. [10]), did not substantially change the original technique, which remained the reference for urinary diversion against which all other types of post-RC surgical solutions have been compared and judged. On the one hand, it has been stated that the major qualifying points of IC are represented by the relatively simple surgical technique and the low rate of inherent postoperative complications. On the other hand, a visible stoma, the need for lifelong stoma care, and the related limitations in terms of social relationships, lifestyle, and leisure activities are well-recognized disadvantages of this procedure [3]. Whether IC is actually an easy-to-perform intervention with overall limited postoperative complications remains a questionable issue. The overall long-term functional results are far from those expected from an ideal procedure [11], and the presence of a visible or malfunctioning stoma could be related to long-life anxiety and depression [12]. The fact is that dissemination of IC diversion and its acceptance in socially advanced countries remain disparate. According to a recent report by the Urologic Diseases in America Project [13], among 27 494 patients submitted to RC between 2001 and 2005 from the Nationwide Inpatient Sample, 4539 (16.5%) underwent a continent urinary diversion and 22 955 (83.5%) underwent an IC. Interestingly, a significant trend towards the more liberal use of the IC during the last few years has been registered in some US contexts. The monoinstitutional report by Lowrance et al. [14] showed that OBS accounted for 47% of all urinarydiversions in 2000 and for only 21% in 2005. Likewise, the recent study by Manoharan et al. [15] showed that of all patients (mean age: 69 yr) submitted to RC between 1992 and 2007 at a department of urology in Miami, Florida, 56% underwent IC and 41% underwent OBS. The trend is similar in many European contexts. The Swedish Bladder Cancer Register study was completed by including >90% of all patients with newly diagnosed bladder cancer treated with RC between 1997 and 2003, and IC and continent reconstruction were accomplished in 64% and 36% of cases, respectively [16]. Likewise, the German population-based study by Bader et al. [17] showed that IC was selected in up to 64% of overall cases after cystectomy. Similarly, a French national survey published in 2008 by the French Association of Urology confirmed the IC as the most frequent post-RC urinary diversion (84%) [18]. This scenario seems to contrast with that at some reference centres where, in the same period of time, a much higher percentage of patients underwent OBS (Ulm, 66%; Bern, 54%; Mansoura, 39% [19]). It clearly emerges that continent reconstructions are more often completed at academic departments than at county hospitals, demonstrating a substantial provider influence on the choice of post-RC surgical solution. The report published in 2007 by the members of Consensus Conference on Bladder Cancer and the Socie´te´ Internationale d’Urologie, including >7000 patients from 13 urologic departments [3], probably reflects the current distribution in the frequency of urinary diversions at reference centres. In this report, OBS accounted for 47% (30–66%) and IC accounted for 33% (22.6–64%). It is evident that the rate of patients submitted to any kind of diversion varies widely among high-volume institutions, and very little is known about the reason for this variation. The same study showed that surgical solutions different than IC and OBS are used only marginally in most urologic departments: anal diversion (10%), continent cutaneous diversion (8%), and incontinent cutaneous diversion (2%). When analyzing the mentioned studies, and regardless of the characteristics of the urologic centres, IC unquestionably remains the most frequent approach in female patients and in those >75 yr with less favourable TNM classification
Patient preparation
A complete preoperative anaesthesiologic assessment including cardiac testing, renal and hepatic function, and correction of modifiable medical disease such as hypertension, cardiac arrhythmias, and anaemia should be completed in all patient candidates for RC. During the last decade, enhanced recovery protocols with standardised perioperative plans of care or ‘‘fast-track’’ (FT) schedules have also emerged as tools to assist RC patients. Particularly, the FT protocols incorporate innovative aspects such as non-narcotic analgesics, limited bowel preparation, early institution of an oral diet, and drainage management and have been recognised by many clinical studies [20] as a promising approach in RC followed by the use of intestinal segments.
The use of bowel preparation using polyethylene glycol or sodium phosphate oral solution has been recommended and adopted for a long time in patients who are suitable for intestinal surgery to reduce the incidence of postoperative ileus, wound infections, and digestive anastomotic dehiscence [21]. However, when only the small bowel is being used, scant evidence supports bowel preparation. A simple cleaning enema the night before surgery as part of an FT regimen was documented to be a reliable and effective approach in patients who underwent IC diversion [22]. In IC patients, the urologist or stoma therapist should mark the site of the stoma, and the patient should test the appliance and wear the definitive urine collection device for 1 or 2 d before surgery. The stoma therapist may represent a key figure in the perioperative and postoperative management of these patients. Likewise, before surgery, patients should be fully informed about the risks and benefits of IC and surgical alternatives. Sufficient time should be given to patients to realize the impact of everyday aspects related to the urinary diversion selected before obtaining the informed consent. Often, before a final decision has been taken, counselling of the patient and the family is required, with the help of psychologists, oncology nurse specialists, or patients who have previously undergone the chosen procedure
Indications and contraindications to ileal conduit