Orthotopic bladder substitution for bladder cancer patients undergoing radical cystectomy: A call to action

In this issue of the CUAJ, Nayak et al¹ retrospectively analyzed urinary function outcomes of 158 patients who received orthotopic neobladder urinary diversion after radical cystectomy for bladder cancer at The Ottawa Hospital between 2006 and 2014. The authors found that significant daytime and nighttime urinary incontinence [UI] was common in the early postoperative period, but improved over the first postoperative year. Specifically, the rates of significant daytime and nighttime UI at one year were 8.6% and 20%, respectively.

The authors are to be congratulated for this timely analysis, as this study adds to the growing evidence base supporting excellent urinary function outcomes following orthotopic bladder substitution in bladder cancer patients. For example, in an analysis of 188 orthotopic neobladder patients who completed validated questionnaires from the University of Southern California, the investigators reported a 12-month daytime urinary continence rate of 92% and 12-month nighttime urinary continence rate of approximately 50%.² Similarly, in a pooled analysis of 2238 patients who received orthotopic bladder substitution, 13% reported daytime UI, whereas 50% endorsed nighttime UI.³

Despite these encouraging functional data, enthusiasm for orthotopic bladder substitution in bladder cancer must be tempered by the dearth of high-quality evidence available to support its superiority over other types of urinary diversion.⁴ Existing data are limited by use of non-validated questionnaires, varying definitions of UI, and differing data collection techniques.⁴ Confirmation of the efficacy and superiority of orthotopic bladder substitution will require well-designed, prospective studies using validated patient-reported outcome data. The Canadian Bladder Cancer Information System (CBCIS) project is currently prospectively collecting data that may serve to enhance this evidence base. At present, however, optimization of orthotopic neobladder use and compliance with consensus guideline-recommended care⁵ may be best achieved through centralization to multidisciplinary bladder cancer teams.