What are the advantages and disadvantages of ileal (ileal conduit) vs colonic (colonic conduit) conduits for urinary diversion after radical cystectomy (RC), including refluxing and anti-refluxing techniques?

Ileal vs Colonic Conduit for Urinary Diversion After Radical Cystectomy

The ileal conduit is the standard and preferred urinary diversion method after radical cystectomy, offering the fastest operative time, lowest complication rates, and most reliable long-term outcomes, particularly for elderly patients and those with comorbidities. 1, 2, 3, 4

Ileal Conduit: The Gold Standard

Advantages

• Lowest reoperation rates compared to all other urinary diversions, making it the safest long-term option 3, 4
• Fastest and technically easiest procedure to perform, reducing operative time and anesthetic exposure 4
• Least decline in renal function over time compared to other diversions, with universal but minimal GFR decline 3
• Most appropriate for elderly patients (the majority of bladder cancer patients), those with limited manual dexterity, poor motivation, anatomical restrictions, or compromised renal function 3, 4
• Excellent quality of life outcomes with high patient acceptability, especially in elderly populations 3
• No requirement for self-catheterization or intensive patient rehabilitation 4

Disadvantages

• External stoma required with need for external collection appliance, affecting body image 1, 2
• Peristomal complications occur in 15-65% of patients, including parastomal hernia, stoma prolapse, stenosis, retraction, and peristomal skin changes (irritant dermatitis, candidiasis, allergic reactions) 5
• Ureteroileal anastomotic strictures occur in approximately 16% with traditional Wallace technique, though newer modifications can reduce this rate significantly 6, 7
• Requires lifelong stoma care and appliance management 5

Technical Considerations

• Preoperative stoma marking by an enterostomal therapist is essential to optimize stoma site and reduce postoperative complications 1, 2
• Modified techniques (such as retrosigmoid ileal conduit) can reduce ureteroileal stricture rates to near zero compared to 16% with traditional Wallace technique 6
• Ureteral stenting at the time of surgery improves upper tract drainage, enhances bowel recovery, and reduces metabolic acidosis 1

Colonic Conduit: Limited Role

When to Consider

Colonic conduits are rarely indicated and should only be considered when:

• The ileum is unavailable or unsuitable (prior radiation, inflammatory bowel disease affecting ileum, short bowel syndrome)
• Previous extensive small bowel surgery precludes ileal use

Disadvantages Compared to Ileal Conduit

• Higher metabolic complications due to greater absorptive surface area of colon
• Increased risk of electrolyte abnormalities, particularly hyperchloremic metabolic acidosis
• More mucus production leading to increased risk of conduit obstruction
• Technically more challenging with longer operative time
• No survival or quality of life advantage over ileal conduit

Refluxing vs Anti-Refluxing Techniques

Refluxing Anastomosis (Standard Approach)

Advantages

• Simpler and faster to perform technically 6, 7
• Lower stricture rates because no tunneling or complex anastomosis required 6
• Easier to revise if complications occur
• No evidence of increased pyelonephritis or renal deterioration compared to anti-reflux techniques in long-term studies 3

Disadvantages

• Theoretical risk of ascending infection, though not clinically significant in practice 3
• Potential for reflux of bacteria to upper tracts

Anti-Refluxing Anastomosis

Advantages

• Prevents reflux of urine and bacteria to upper tracts theoretically
• May reduce pyelonephritis risk in theory (not proven clinically)

Disadvantages

• Significantly higher stricture rates due to tunneling and tension on anastomosis 6
• More technically demanding with longer operative time
• Increased risk of obstruction from edema or ischemia at tunneled segment
• No proven clinical benefit in preventing renal deterioration or infection 3
• Difficult to access ureter retrograde for future interventions 7

Clinical Algorithm for Selection

For >95% of patients undergoing radical cystectomy:

1. Offer ileal conduit as first-line urinary diversion 1, 2, 3, 4
2. Use refluxing anastomosis (Wallace or Bricker technique) to minimize stricture risk 6, 7
3. Consider modified techniques (retrosigmoid approach) to further reduce stricture rates 6

Reserve colonic conduit only for:

• Patients with unavailable or diseased ileum
• Prior extensive small bowel resection
• Radiation-damaged ileum

Avoid anti-refluxing techniques unless specific research protocol, as they increase stricture rates without proven clinical benefit 6, 7, 3

Critical Pitfalls to Avoid

• Do not perform anti-refluxing anastomosis routinely—the increased stricture rate (16% vs 0% in some series) outweighs any theoretical benefit 6
• Do not skip preoperative stoma marking—this significantly reduces postoperative stoma complications 1, 2
• Do not remove ureteral stents too early—keep for 5-10 days to optimize drainage and reduce complications 1
• Do not assume colonic conduit is equivalent—it offers no advantages and has higher metabolic complications
• Do not underestimate peristomal complications—they occur in up to 65% of patients and require ongoing surveillance 5