Quality of life with urinary diversion

There continues to be debate about how best to replace bladder function following radical cystectomy. All the usual options currently involve the use of transposed intestinal segments, and all have advantages and disadvantages. The impact of each option on quality of life (QoL) is an important consideration.

This review assesses the evidence base that underpins each of the major forms of transposed intestinal segment surgery (ileal conduit diversion, continent urinary diversion, and orthotopic bladder replacement). The meaning, determinants, and measurement of QoL are also explored. We conducted a systematic review searching Medline, PubMed, EMBASE, CINAHL, and the Cochrane Library from 1966 to August 2010. A total of 46 studies (including 8 prospective studies) met the inclusion criteria reporting on 4186 patients. Although the reports suggest a reasonably well-maintained QoL after all transposed intestinal segment surgical options, most were retrospective studies, and the few prospective nonrandomised studies had limitations.

From the available published evidence, it still remains unclear if one form of transposed intestinal segment surgery is superior to another in terms of QoL. In light of this continued uncertainty, there is an urgent need to establish the important determinants of QoL for this cohort; to standardise a set of core important outcomes; and, once and for all, to undertake high-quality prospective (ideally randomised) studies comparing the different surgical options to help guide policy and clinical practice in transposed intestinal segment surgical practice. Until such time, care will continue to be individualised, taking into account patient factors, surgeon factors, centre factors, and health provider factors, unsatisfactory as this may be for patients.