The
choice of urinary diversion type after radical cystectomy is based on an
individualized assessment integrating patient preferences, functional status,
life expectancy, and oncologic control. In clinical practice, ileal conduit
(IC) represents the most frequently used option [7]. Ileal conduit is generally
associated with better body image perception and improved social interactions,
but it remains technically more demanding and may be associated with a higher
reoperation rate [8]. Cutaneous ureterostomy (CU), the simplest technique,
constitutes a relevant alternative in frail patients (ASA score ? 3), as it
avoids the use of an intestinal segment, thereby reducing metabolic and
surgical complications. It is particularly indicated in patients requiring anticoagulation,
presenting with inflammatory bowel disease, or with a history of multiple
abdominal surgeries [1,9]. Regarding morbidity, Kilciler et al. reported no
increased risk of complications or reoperation with CU compared to IC,
suggesting that CU constitutes a safe alternative [13]. However, other studies
have reported divergent results [14,15], highlighting the heterogeneity of
study populations and selection criteria. Concerning blood loss,
our results show comparable hemoglobin variations between groups (p = 0.128),
in agreement with the work of Kilciler and Sainin [1,13], as well as with Moeen
et al., who found no significant difference in transfusion requirements between
continent and incontinent diversions [2]. Experience in a high-volume center
may contribute to reduced transfusion requirements. Preservation
of renal function is a major concern. Some studies suggest an increased risk of
renal impairment after CU due to recurrent pyelonephritis episodes or
hydronephrosis secondary to stomal stenosis [1,9]. However, a comparative study
including four types of diversion showed no significant difference in terms of
renal function, although recurrent pyelonephritis and chemotherapy may play a
deleterious role [16]. In our cohort, the increase in creatinine was
significant in the IC group (p = 0.004), while the variations observed in the
CU groups were more moderate. These results could be explained by direct and
continuous urinary drainage in CU, whereas the ileal conduit may be exposed to
reflux phenomena, anastomotic stenosis, or reservoir dysfunction. Quality
of life after urinary diversion depends on multiple factors, including age,
comorbidities, type of diversion, occurrence of complications, patient
expectations, and surgical expertise. It is recommended that these procedures
be performed in high-volume centers [2].
Few
studies have simultaneously compared both modalities (CU, IC) [2,17,18]. In our
study, assessment was based on the SF-36 [3] and Barthel index [4]
questionnaires, which constitutes an original approach in this population.
Literature data are contrasting. Erber et al., using the EORTC QLQ-C30 and
BLM30 questionnaires, reported an advantage of IC in terms of physical function
and global health status [19-20]. Other work suggests that IC might offer
benefits in elderly patients on certain functional parameters, provided there
are no long-term complications [21]. Conversely, Elbadry et al., using the
FACT-BL questionnaire, observed higher overall scores in IC patients associated
with better body image and better urinary control [22]. A meta-analysis of 21 studies
including 2,285 patients showed globally comparable results, with a slight
advantage for IC in young patients in good general condition [23]. In our
study, only the "emotional function" and "fatigue"
dimensions differed significantly. IC patients presented better emotional
scores, probably related to more favorable body perception. In contrast, CU
patients reported more fatigue, possibly related to initial frailty,
comorbidities, and constraints associated with stoma equipment, particularly at
night. These findings are consistent with the observations of Thulin et al.,
who reported impaired sleep and quality of life in some IC patients due to
incontinence [24], highlighting the multifactorial complexity of these
assessments. Some studies suggest that neither age, nor postoperative
complications, nor BMI significantly influence long-term quality of life [25].
Our results confirm that, despite some specific differences, overall quality of
life scores remain comparable between modalities. However, our study has
several limitations: relatively short follow-up duration, single-center design,
limited sample size in the IC group, and incomplete questionnaire response
rate. Furthermore, assessments were performed at different postoperative time
points, which may introduce variability. In conclusion, although many
quality-of-life dimensions are similar between the two techniques, ileal
conduit appears associated with better emotional function, while cutaneous
ureterostomy is associated with more pronounced fatigue. IC seems more suitable
for young patients in good general condition, whereas CU constitutes a relevant
option for elderly high-risk patients. The decision must remain individualized,
integrating comorbidities, surgeon experience, and detailed patient information,
with quality-of-life questionnaires serving as an essential decision-making aid
tool.