Technique For Urinary Diversion Research Articles

Robotic intracorporeal urinary diversion: state of the art.

We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

An improved ileal conduit surgery for bladder cancer with fewer complications

BackgroundRadical cystectomy and urinary diversion remains the standard surgical treatment for patients with muscle-invasive or high-risk or recurrent non-muscle-invasive bladder cancer. Although this approach prolongs patient survival remarkably, there are postoperative complications associated with urinary diversion. This study aimed to assess the efficacy of modified ileal conduit surgery for reducing early and late stoma- and ureteroileal anastomosis-related complications, as compared with conventional ileal conduit urinary diversion.MethodsWe retrospectively evaluated the clinical data of bladder cancer patients treated with radical cystectomy and ileal conduit urinary diversion at Sun Yat-sen University Cancer Center between January 1, 2000 and June 30, 2016. Ileal conduit was created by the conventional or a modified technique. The clinicopathologic features of the conventional and the modified ileal conduit groups were compared using the t test and the Chi square test. Multivariable logistic regression analysis and multivariable Cox regression analysis were performed to determine the odds of developing stoma- and ureteroileal anastomosis-related complications in the two groups.Results145 and 100 patients underwent the modified and conventional ileal conduit surgery, respectively. The two groups were comparable with regard to clinicopathologic features. The rate of stoma-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (0.7% vs. 17.0%, P < 0.001). No late stoma-related complications were seen in the modified ileal conduit group, but were seen in 13 (13.0%) patients in the conventional ileal conduit group. The rate of ureteroileal anastomosis-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (4.8% vs. 15.0%, P = 0.001). In multivariable analyses, the modified ileal conduit group was significantly less likely to develop stoma- (odds ratio [OR] = 0.024, 95% confidence interval [CI] 0.003–0.235; P = 0.001) or ureteroileal anastomosis-related complications (OR = 0.141, 95% CI 0.042–0.476; P = 0.002) than the conventional ileal conduit group.ConclusionsOur modified surgical technique for ileal conduit urinary diversion may be effective for reducing early and late complications related to the stoma and the ureteroileal anastomosis. Prospective randomized clinical trials are needed to confirm our results.

Single-port Robotic Intracorporeal Ileal Conduit Urinary Diversion During Radical Cystectomy Using the SP Surgical System: Step-by-step Technique

To describe the step-by-step technique for robotic intracorporeal ileal conduit urinary diversion (ICUD) following radical cystectomy performed by using the novel da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, CA). Four consecutive patients (2 males and 2 females) were initially counseled for robotic cystectomy with ICUD performed by using the da Vinci SP surgical system. Surgeries were performed by duplicating the steps of the institutional approach for intracorporeal ICUD performed with the multiarms robotic platform. Perioperative outcomes were analyzed. Data were collected under institutional review board approval (IRB 13-780). Single-port robot-assisted radical cystectomy with ICUD was successfully completed in 3 patients (2 males and 1 female). Mean robotic operative time for ICUD was 75 minutes (range 67-90). There was no conversion to standard multiarms robotic approach. One patient needed to be converted to extracorporeal urinary diversion due to severe adhesions of small bowels. No additional ports were placed. Neither transfusions nor intraoperative complications occurred. All patients were discharged on postoperative day 5. One patient reported self-limited nausea and vomiting after discharge (Clavien grade I). In our preliminary experience, ICUD after robot-assisted radical cystectomy is feasible using the da Vinci SP surgical system. Further comparative studies with open and multiarms robotic approaches are warranted.

Dérivation du haut appareil urinaire par une sonde JJ : indications et résultats dans une étude rétrospective et monocentrique

ObjectivesThe purpose of the study was to report the indications and results of the upper urinary tract diversion with JJ stent at the Urology department of Grand Yoff General Hospital (HOGGY) Patients and methodsThis was a retrospective mono-centric descriptive study from January 1st, 2014 to December 31st, 2015 concerning patients’ files that had a JJ stent as a type of upper urinary tract diversion. ResultsForty-four patient files had been included. The average age of patients was 47.9 years with extremes of 20 and 75years. Women accounted for 68% of cases. The sex-ratio was 0.47. Uretero-hydronephrosis was the main indication of JJ stent rise in 95.5% of patients. It was bilateral in 42, 86% of cases, and complicated with renal failure in 47.73% of patients. Renal colic accounted for 22.73% of indications. The etiologies were dominated by urolithiasis with 29.55% of cases, followed by tumor etiologies with 27.27% of cases including cervical tumors in 18.18% of cases. The procedure was performed without fluoroscopic control (blind) in 54.55% of cases, there were 66.67% case of success. The overall success rate was 65.1%. The renal function of patients with preoperative renal failure improved in 57.15% of cases. Only one patient (2.33% of cases) had a postoperative complication. ConclusionThe JJ stent is an effective, minimally invasive technique for upper urinary tract diversion for renal function preservation. Its realization without fluoroscopic guidance is possible but needs a rigorous selection of patients.

The surgical technique and initial outcomes of Anatolian neobladder: a novel technique of ileal neobladder after radical cystectomy

BackgroundWe describe a detailed novel step-by-step approach for creation of an ileal neobladder and compare the outcomes with standart neobladder.MethodsBetween August 2009 and January 2016, 36 consecutive patients with bladder cancer underwent radical cystectomy and orthotopic urinary diversion with an ileal neobladder. A novel technique of ileal neobladder construction, called the Anatolian neobladder, was designed by a single surgeon (ZT). Demographics and clinical data were collected. Perioperative, oncologic, and functional outcomes were reported. Complications were graded as early or late. These outcomes were compared with patients who underwent standard neobladder during this period in our center.ResultsThe operation was technically successful in all cases. Early postoperative complications occurred in 33.3% of the patients. Daytime continence was achieved successfully in 83.3% of the patients. No patient had severe metabolic acidosis. Six patients (16.6%) died during follow-up, five due to metastatic bladder cancer and one due to a cardiac problem. There was no any statistically significant difference between novel technique and standard neobladder for oncological and functional outcomes.ConclusionsThe Anatolian ileal neobladder is as feasible and safe as standard neobladder technique for urinary diversion in patients with bladder cancer undergoing radical cystectomy.

Transperineal Approach for Intracorporeal Ileal Conduit Urinary Diversion Using a Purpose-built Single-port Robotic System: Step-by-step

To describe a step-by-step technique for single-port transperineal intracorporeal ileal conduit urinary diversion using a purpose-built robotic platform. In one male cadaver, the da Vinci SP1098 surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform intracorporeal ileal conduit urinary diversion by a transperineal approach after radical cystoprostatectomy and bilateral pelvic lymph node dissection. The surgery was completed through a 2.5-cm perineal incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) and a dedicated 25-mm multichannel port accommodating a 12-mm × 10-mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments, and a 6-mm accessory laparoscopic instrument were placed. Moreover, at the planned level of the cutaneostomy, a 12-mm port to accommodate the Endo-GIA was placed. The primary outcomes were the technical feasibility, the operative time, and the record of eventual procedural complications. The intervention was successfully completed without any conversion or need for additional ports. The total operative time was 200 minutes. Operative time for urinary diversion was 90 minutes. We demonstrated the feasibility of single-port transperineal intracorporeal ileal conduit urinary diversion using the SP1098 purpose-built robotic platform. Limitations include the preclinical setting. The applicability in the clinical model is awaited to be tested after the platform will be commercially available.

Ileal Continent Reservoir: A Feasible Option for Bladder Augmentation and Urinary Diversion

To present the results of technique of continent urinary diversion, described by Macedo, that allows the configuration of a tunnel with a flap of the ileal tube at the same segment created for the reservoir. From January 2006 to November 2016, 29 patients were underwent a urinary diversion by Macedo's technique. Patients' demographics, hospitalization time, surgical time, follow up, continence rate, reservoir capacity, and postoperative complications were evaluated. Sixty-nine percent were male and the median age was 16.9 years. The main etiology was meningomyelocele (69.1%). The mean surgical time was 4.2 hours (standard deviation [SD] 0.9 range 2.9-6.3). The median length of hospital stay was 10 days (interquartile range: 11.3 range 5-51). The mean follow up was 3.3 years (SD 2.2 range 0.3-9.8). Procedure in the bladder neck was performed in 12 patients (41.3%). A continence rate of the catheterizable conduit was 82.8%.The reservoir capacity increased from 134.4 to 364.4 ml (P <.0001). The continence rate improved significantly (20 vs 74%, P <.0001). There was no change in glomerular filtration rates in the long term (143.1 vs 147, P = .45). Morbidity rate was 58% (25 complications in 17 patients), 72% occurred within the first 60 days and 60% were classified as Clavien-Dindo I or II. Except for publications from the original author, this is the first series described. The outcomes are similar, adding important data with respect to this technique. They show that the ileal reservoir is feasible, reproducible, and with good results.

Ileal conduit vs orthotopic neobladder: Which one offers the best health-related quality of life in patients undergoing radical cystectomy? A systematic review of literature and meta-analysis

Orthotopic neobladder (ONB) and ileal conduit (IC) are the most commonly practiced techniques of urinary diversion (UD) after radical cystectomy (RC) in bladder cancer patients. Data in the literature is still discordant regarding which UD technique offers the best HR-QoL. The objective was to compare HR-QoL in patients undergoing ONB and IC after RC, through a systematic review of the literature and meta-analysis. We performed a literature search of PubMed, ScienceDirect, CochraneLibrary and ClinicalTrials.Gov in September 2017 according to the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes. The studies were evaluated according to the "Oxford Center for Evidence-Based Medicine" criteria. The outcome measures evaluated were subdomains' scores of Bladder Cancer Index BCI: urinary function (UF), urinary bother (UB), bowel function (BF), bowel bother (BB), sexual function (SF) and sexual bother (SB). Continuous outcomes were compared using weighted means differences, with 95% confidence intervals. The presence of publication bias was examined by funnel plots. Four studies met the inclusion criteria. The pooled results demonstrated better UF and UB scores in IC patients: differences were -18.17 (95% CI: -27.49, -8.84, P=0.0001) and -3.72 (95% CI: -6.66, -0.79, P=0.01) respectively. There was no significant difference between IC and ONB patients in terms of BF and BB. SF was significantly better in ONB patients: the difference was 12.7 (95% CI, 6.32, 19.08, P<0.0001). However no significant difference was observed regarding SB. This meta-analysis of non-randomized studies demonstrated a better HR-QoL in urinary outcomes in IC patients compared with ONB patients.

Updates on Robotic Intracorporeal Urinary Diversions.

More than a century of development has led to contemporary urinary diversion. It is paramount that robotic intracorporeal diversions uphold the principles defined by open surgery. In this review, we discuss the fundamental open surgical principles that have led to contemporary techniques of urinary diversion. We then outline the technical aspects of several recently described robotic intracorporeal urinary diversions in the context of these surgical principles. Several potential benefits of intracorporeal urinary diversion are being investigated-such as a reduction in gastrointestinal complications, ureteral strictures, and wound complications. Finally, we highlight the important aspects of establishing an intracorporeal urinary diversion program integrated with an Enhanced Recovery after Surgery (ERAS) program. We have included the perioperative outcomes of 100 consecutive cases of intracorporeal urinary diversion with an Enhanced Recovery after Surgery (ERAS) protocol. In this series, 49% were continent diversions. Patients had a median length of stay of 5days, with 37% staying 4days or less. High-grade complications and readmissions were noted in 22 and 20% of patients, respectively. The benefits of intracorporeal urinary diversion appear promising, and there is continued need for high-quality randomized controlled trials to define its role in patients undergoing radical cystectomy.

Radical cystectomy: from open to laparoscopic to robotic surgery

In recent years, the techniques of radical cystectomy and urinary diversion are continually improving , the surgical safety and efficacy are continually increasing. From open to laparoscopic to robotic, surgical techniques are progressing, but it is not yet possible to replace each other. With the development of equipment, laparoscopic radical cystectomy(LRC) and robotic-assisted laparoscopic radical cystectomy (RARC)can further improve the perioperative efficacy, the basic principles of open surgery can be copied, their perioperative oncologic outcomes are not inferior to open surgery. RALRC seems to have more advantages in pelvic lymph node dissection, long-term oncologic outcomes of the three techniques are similar, and open surgery seems to have more advantages in advanced tumors. Intracorporeal construction of the urinary diversion is still the mainstream, extracorporeal is likely to be the future direction. Laparoscopy is still the most suitable minimally invasive technique of radical cystectomy according to our national conditions. Key words: Radical cystectomy(RC); Open radical cystectomy(ORC); Laparoscopy radical cystectomy(LRC); Robotic-assisted laparoscopic radical cystectomy(RARC)

Postoperative C-reactive protein concentration and clinical outcome: comparison of open cystectomy to robot-assisted laparoscopic cystectomy with extracorporeal or intracorporeal urinary diversion in a prospective study

Objective: This study aimed to compare clinical outcome and postoperative systemic inflammatory response using C-reactive protein (CRP) levels, to quantify the degree of tissue injury in open mini-laparotomy cystectomy (OMC) versus robot-assisted laparoscopic cystectomy with extracorporeal (RALC-EUD) or intracorporeal urinary diversion (RALC-IUD).Materials and methods: From September 2012 to September 2015, 309 patients diagnosed with bladder cancer underwent radical cystectomy with urinary diversion. Of these, 175 patients were eligible for the study and underwent OMC (n = 125), RALC-EUD (n = 12) or RALC-IUD (n = 38). Blood samples were obtained preoperatively and postoperatively on days 1–7. Clinical and perioperative parameters, including demographics, comorbidity, tumour stage and postoperative outcomes, were collected from medical records.Results: Age, American Society of Anesthesiologists score and Charlson score were significantly higher in OMC than in the robotic groups (p = 0.020, 0.012 and 0.008, respectively). Other demographic data showed no significant group differences. Estimated blood loss and blood transfusion volume were higher in OMC (p < 0.001) and operative time was longer in the robotic groups (p < 0.001); no difference was found between RALC groups. Postoperative CRP levels changed over time (p < 0.001) and RALC-IUD appeared to have significantly higher CRP levels on postoperative days 3–7 compared to OMC and RALC-EUD (p < 0.031), but OMC CRP levels were higher than RALC-EUD.Conclusions: In this study, robotic techniques seem less traumatic overall than open surgery, as OMC had higher postoperative CRP levels than RALC-EUD. The higher CRP levels in RALC-IUD may be more reflective of the urinary diversion technique than the true tissue trauma.

The Orthotropic Neobladder; How to Make It Easy?

Radical cystectomy and urinary diversion is the standard treatment for patients with muscle invasive bladder cancer. Urinary diversion after radical cystectomy requires skill and expertise. Multiple techniques of urinary diversion are present. However, the orthotropic neobladder (OBS) may be better in terms of quality of life. For the sake of simplicity, neobladder reconstruction is better divided into the following stages; Stage I: Patient selection and preparation Stage II: Radical cystectomy and lymphadenectomy Stage III: Neobladder reconstruction Stage IV: Uretero- and Urethro-enteric anastomosis Stage V : Postoperative management Stage VI: Management of complications

The Long-Term Follow-Up and Complications Associated with Urinary Diversion in the Cancer Survivor

Over 60 % of patients can experience some type of long-term complication after radical cystectomy and urinary diversion (UD). However, assessment of late complications is challenging due to limited long-term available data for follow-up, different surgical techniques of UD, and selection bias towards diversion type. The aim of this article was to perform a systematic review and classify long-term complications from UD after radical cystectomy for bladder cancer. Renal insufficiency is the most commonly reported high grade adverse event, followed by ureteroenteric anastomotic strictures and bowel complications. Urinary infections are very common and challenging to assess given the presence of colonization and vague symptoms that can be associated to this diagnosis and pyelonephritis if presence of flank pain. Common complications by diversion type include stones, stomal stenosis, or parastomal hernia for urinary conduit and continent cutaneous urinary diversions, as well as urinary incontinence for orthotopic neobladder. Long-term complications are common after radical cystectomy and urinary diversion. Follow-up should be implemented for life to survey for complications. Improving access to these patients and communication with their local practitioners or local urologists when referred back to specialized urology clinic is fundamental to manage these long-term complications.

Treatment of bladder cancer in the elderly.

As the population ages and life expectancy increases in the human population, more individuals will be diagnosed with bladder cancer (BC). The definition of who is elderly is likely to change in the future from the commonly used cut-off of ≥75 years of age. Physiological rather than chronological age is key. BC care in the elderly is likely to become a very common problem in daily practice. Concerns have been raised that senior BC patients are not given treatments that could cure their disease. Clinicians lack quantitative and reliable estimates of competing mortality risks when considering treatments for BC. Majority of patients diagnosed with BC are elderly, making treatment decisions complex with their increasing number of comorbidities. A multidisciplinary approach to these patients may be a way to incorporate discussion from various disciplines regarding treatment options available. Here we review various treatment options for elderly patients with muscle invasive BC and nonmuscle invasive BC. We include differences in treatments from robotic versus open radical cystectomy, various urinary diversion techniques, chemotherapy, radiation therapy and combination treatments. In clinical practice, treatment decisions for elderly patients should be done on a case-by-case basis, tailored to each patient with their specific histories and comorbidities considered. Some healthy elderly patients may be better candidates for extensive curative treatments than their younger counterparts. This implies that these important, life-altering decisions cannot be solely based on age as many other factors can affect patient survival outcomes.

Pictorial review of orthotopic neobladder reconstruction: indication, normal postsurgical anatomy, and complications.

Radical cystectomy with urinary diversion is a common urological procedure performed for the treatment of bladder cancer. Numerous surgical procedures have been developed for urinary diversion. Over the past decade, orthotopic neobladder reconstruction has been used frequently for urinary diversion because of its advantageousness in providing patients with a good quality of life compared with other urinary diversion technique. Knowledge of the indication, surgical procedure, and postsurgical anatomy of orthotopic neobladder reconstruction is essential. While the technique has many advantages, multiple postsurgical complications may occur after reconstruction, including urine leakage, bowel obstruction and fluid collection (lymphocele, urinoma, hematoma, and abscess), neobladder rupture, vesicoureteral reflux, hydronephrosis, urinary tract infection, urinary calculi, abdominal incisional hernia, bowel obstruction, intraneobladder tumor, and tumor recurrence. Radiological imaging including multiple modalities such as intravenous urography, cystography, CT, and MRI plays an important role in the postoperative evaluation of patients with orthotopic neobladder reconstruction and is an accurate method for evaluating complications. In addition, knowledge of appearances on multimodal imaging helps clinicians to select the modality required to achieve an accurate diagnosis of each complication and avoid misdiagnosis.

Alvimopan in an Enhanced Recovery Program Following Radical Cystectomy.

Background: Radical cystectomy (RC) carries a high complication rate, including post-operative ileus. Alvimopan is an FDA approved peripherally acting μ-opioid receptor antagonist that has shown favorable results for improved recovery of gastro-intestinal function resulting in decreased hospital length of stay. Many enhanced recovery pathways (ERP) have been published demonstrating improved outcomes with decreased hospital stay and morbidity. Objective: We evaluated the addition of alvimopan to an ERP in patients undergoing RC. Methods: Patients undergoing RC at our institution during the implementation phase of alvimopan to our established ERP were retrospectively reviewed. Effect of alvimopan as it related to the use of nasogastric tubes, time to initiation of regular diet, and length of hospital stay was assessed using Chi-squared and Student’s T-tests. Linear regression was performed for univariate analysis and binary logistic regression was performed as a multivariate assessment of the effect of alvimopan. Results: Between July 2011 and January 2013, 80 patients were identified who underwent RC under the ERP (34 alvimopan and 46 standard care). Age, sex, neoadjuvant chemotherapy, surgical technique (open vs. robotic), and type of urinary diversion were not different between groups. Alvimopan was associated with a reduction in mean time to regular diet (5.3 vs 4.1 days, p < 0.01) and a reduction in mean length of hospital stay (6.9 vs 5.7 days, p = 0.01). After controlling for other variables, alvimopan usage predicted for shorter time to regular diet and total hospital stay. Conclusions: Alvimopan may help to improve time to regular diet and decrease hospital stay in patients on an enhanced recovery pathway.

Urinary Diversion in the Elderly

The elderly or older population segment has a heterogenous definition in the literature with the majority including patients aged between 60 and 80 years. Several studies have proven that a cystectomy can be performed safely in the elderly population. We sought out to review the literature identifying the specific complications and the considerations requiring attention when performing a urinary diversion on an elderly patient. A review of literature performed using PubMed revealed paucity of citations specifically looking at different urinary diversion techniques and the specific complications related in an elderly population. However, we extrapolated additional data from articles that studied cystectomy surgical cohorts with identifiable age stratification. Particular complications and areas deserving of additional attention included gastrointestinal, renal, uretero-enteric anastomotic technique, metabolic disorders, quality of life, and voiding dysfunction. Detailed history and proper counseling of the patient and family are central to the selection of the appropriate urinary diversion technique and help maintain realistic patient expectations with a higher satisfaction rate. It is of paramount importance when considering continent urinary diversions to address the feasibility of adhering to a higher level of maintenance and the patient’s ability to withstand diversion-related complications.

A Simplified Approach to Intracorporeal Robot-Assisted Laparoscopic Ileal Conduit Formation

Introduction: During robot-assisted radical cystectomy, urinary diversions are often performed extracorporeally. However, an optimized minimally invasive technique is possible with total intracorporeal urinary diversion. In this video, we provide a step-by-step demonstration of a simplified approach to the intracorporeal robot-assisted laparoscopic ileal conduit with the Wallace and Bricker anastomosis. Methods: A total intracorporeal ileal conduit formation was performed using the da Vinci robotic surgical system. During ureteral dissection and tunneling, the sigmoid colon was retracted using a dual-blade retractor. A 15-cm segment of ileum ~20 cm from the ileocecal valve was used for the conduit. A 60-mm endoscopic stapler was used to staple, transect, and restore the continuity of bowel segments. Both the Bricker and Wallace ureteroileal anastomoses were performed using a 4-0 monofilament absorbable suture on an RB-1 needle in a continuous manner. Results: This technique of robot-assisted total intracorporeal ileal conduit urinary diversion was performed in 11 patients. No patients developed uretero-enteric or entero-enteric anastomotic leak. One patient required re-operation for bowel obstruction. When performed along with robotic assisted cystectomy and lymphadenectomy, mean total operative time was 445 minutes and mean hospital stay was 7 days. Conclusion: Robotic total intracorporeal ileal conduit urinary diversion offers a truly minimally invasive technique that can be performed for a variety of indications, regardless of the need for specimen extraction. While following similar steps to the traditional Bricker or Wallace anastomosis, the robotic intracorporeal approach utilizes precise control of surgical instruments and allows for a meticulous dissection with minimal blood loss. For patients undergoing radical cystectomy, females bore no abdominal incisions other than port sites since the specimen is removed through the vagina. In males, the incision can be limited to ~5 cm and placed either periumbilical or Pfannenstiel. The authors declare that no competing financial interests exist. Runtime of video: 5 mins

Robot-assisted Radical Cystectomy and Urinary Diversion: Technical Recommendations from the Pasadena Consensus Panel

BackgroundThe technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes. ObjectiveTo review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes. Design, setting, and participantsThe Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3–4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received. Surgical procedureThe consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described. Outcome measurements and statistical analysisPreoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented. Results and limitationsPreoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. ConclusionsRefinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound. Patient summaryWe summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.

Urinary Diversion: Historical Aspect and Patient's Satisfaction

During the last decades, the techniques of urinary diversion have evolved from simple diverting techniques through a conduit to the orthotopic neobladder reconstruction aiming to provide an improved quality of life for patients undergoing radical cystectomy for muscle-invasive bladder cancer. The outcome after cystectomy and continent urinary diversion is not only dependent on surgical technique but restrictive preoperative patient selection and expert perioperative patient management is of equal importance. Urinary diversion techniques are usually limited by two main factors; patient or medical criteria, or both. Important patient criteria are patient's preference, age and co morbidity, body mass index (BMI) and motivation. Medical criteria for choice of the type of urinary diversion are renal function, upper urinary tract status, underlying primary disease, indication for cystectomy and limitations concerning the gastrointestinal tract. Complications after urinary diversion are generally due to the surgical technique, the underlying disease process and its treatment, patient's, co-morbidities and the follow-up period. Patient counseling for better satisfaction about the type and technique of urinary diversion should be tailored to determine the safest method for cancer control, with the least complications along both the short and the long terms, and the easiest comfortable adjustment for a better patients' lifestyle, to obtain the best patients' quality of life. Health-related quality of life (HRQoL) measures should include the patient's physical fitness, the underlying symptoms, global judgment of health, psychological and social well-being, cognitive function, and personal constructs.