Outcomes of RC have been improving for the last 30 years to become the most common therapeutic strategy for muscle-invasive bladder cancer, with an overall high proportion of 5 years of disease-free survival . Several techniques may be options for urinary diversion after RC, such as IC and TUC .
One of the essential considerations in reducing the incidence of mortality and morbidity in patients who undergo RC in bladder cancer is the choice of urine diversion technique [9, 14]. Unfortunately, there is still often a clinical dilemma in determining the best urine diversion technique until now. Thus, the clinician's decision to select the urinary diversion procedure depends on the operator's preferences.
Recently, as far as we know, only a few studies have reported about RC in bladder cancer with a primary focus on the type of urinary diversion [4, 13, 15, 16]. Although IC urinary diversion is more popular than TUC , both procedures follow the same method in using an external bag to collect urine, which can reduce the level of confidence in social interactions .
Any form of urinary diversion has advantages and disadvantages. Urinary TUC diversion is simpler because it does not include an intestinal section as a urine source, although this procedure is more associated with long-term stoma stenosis [4, 9], and often requires lifelong replacement of the ureteric stent . IC urinary diversion has a high rate of complications related to intestinal segments but does not routinely use ureteric stents . In a previous study, the high incidence of bowel-related complications in IC groups supported not to select IC urinary diversion for patient’s elderly and poor performance status [4, 17, 18].
The incidence of intraoperative bleeding and postoperative complications was high in this study. The majority of postoperative complications occurred in the IC group. It should be emphasized that the immediate postoperative complications associated with intestine anastomotic greatly affected the postoperative outcome in the IC groups. Both groups had the same late incidence of postoperative complications: the TUC group was associated with stoma stenosis, thus requiring regular stenting, while the IC groups also have a high incidence of metabolic changes.
Interestingly, all of these patients no required treatment related to metabolic changes. The incidence of postoperative complications is highly dependent on the duration of follow-up. This is seen in a study that indicates complications will rise to 90% after 15 years .
Metabolic changes were the most frequent complication encountered in this study. We found that the incidence of metabolic changes was related to the type of urinary diversion. This result was consistent with the previous one presented in the literature. . Metabolic urinary diversion changes can occur when using the intestinal segment as a urine reservoir .
One study conducted by Longo in elderly patients with ASA score > 2 who underwent radical cystectomy with TUC urinary diversion showed that they experienced shorter operative time, low complications rates, little intensive care monitoring, and less length of stay when compared with IC techniques (P < 0.05) . Additionally, some studies also mention cutaneous ureterostomy procedures can be an option in patients with complex comorbidities. Naturally, the ability to minimize operative time and intraoperative bleeding can reduce early postoperative complications [4, 12, 15]. This statement is similar to the findings in our study. We found that the time of operation was shorter (207 min vs 358 min; P = 0.000) and required less blood transfusion (45.4% vs 56.7%; P = 0.424) in patients undergoing RC with TUC urinary diversion.
The length of stay in our study was shorter in the TUC group than the IC urinary diversion group (8.5 days vs. 13.7 days; P = 0.002). Many studies have found a similar result. One study conducted by Deliveliotis in 2005 found that the length of stay in patients undergoing TUC was significantly lower compared with IC urinary diversion with 8.6 and 16.0 days, respectively (P < 0.05) .
Several studies suggest that IC urinary diversion has similar results regarding patient satisfaction than other procedures [22, 23]. To date, there has been no research explicitly comparing the satisfaction findings after RC between IC and TUC urinary diversion. In this study, we found that the IC urinary diversion has a better psychological status than TUC. This improvement in psychological scores meant that the IC group had less tense, irritable, lonely, anxious, and depression associated with urinary diversion.
To our knowledge, there are no studies that evaluated the direct hospital-related care cost after performing RC with urinary diversion. We believe, with a reduction in length of stay, the costs will also be reduced. While primarily focused on clinical outcomes, this new concept underlying the TUC urinary diversion also features a significant interplay with health economic considerations. In the future, the perspective on the urinary diversion techniques will rely on additional data collection on the impact of urinary diversion on the patient cost after being hospitalized. Furthermore, patients with an IC urinary diversion experience with no complication of stoma stenotic. In contrast with patients who underwent TUC, 22.7% of cases have stoma stenosis with OR 1.29 (95% CI, 1.03–1.62; p = 0.006). Also, there will be additional costs involved if the patient requires regular stenting for post-TUC stoma stenotic.
One study conducted by Nieuwenhuijzen also found the same result that the IC urinary diversion had fewer late complications of stoma stenosis . These findings showed that, despite the longer length of stay in the IC groups, this procedure has an advantage in long-term effects. In our opinion, TUC urinary diversion is the simplest procedure with a shorter operative time and also less length of stay. Nevertheless, one disadvantage of TUC was the long-term effects of stoma stenosis.
Our study has several limitations due to the retrospective design and small sample size. However, the data's reliability can be maintained to avoid bias since only one person has done the data collection for a long period. Future studies with high-quality prospective multicenter and randomized control trials are needed to evaluate and confirm TUC urinary diversion's effectiveness compared to IC procedures.
While there are some limitations, for all Indonesian patients, this preliminary study has another strength, which helped preserve the homogeneity of the patients' race. A large number of studies available suggest that the post-RC urinary diversion selection requires different racial and regional approaches.