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Page 2 of 11 Tinoco et al. Mini-invasive Surg 2021;5:28 https://dx.doi.org/10.20517/2574-1225.2021.35

Keywords: Urinary diversion, ileal conduit, orthotopic neobladder, cystectomy, urinary bladder neoplasms,
complication

INTRODUCTION
Radical cystectomy for the treatment of bladder cancer implies a urinary diversion for replacement of the
lower urinary tract, which nowadays can be created in an extracorporeal or minimally invasive totally
intracorporeal way. The ideal urinary reservoir would be a low-pressure system, storing approximately 500
mL of urine, with complete continence, complete voluntary control of voiding, and minimal absorption of
urinary waste products . The variety of urinary diversion types underlines the absence of an ideal one. They
[1]
can be divided into noncontinent and continent diversions. Noncontinent cutaneous diversions include
cutaneous ureterostomies and bowel conduits; continent diversions can be cutaneous, with a catheterizable
pouch, or orthotopic, as the famous neobladder. The most used urinary diversions are the ileal conduit and
the orthotopic neobladder, which will be the focus of this review. Both have specific complications which
will be discussed, as well as their management. They can be created by an extracorporeal open approach or
in a minimally invasive totally intracorporeal way, with similar complications. The complication rates
described in this review are summarized in Table 1. Comparing diversions is beyond the scope of this
review.

METHODS
A search using the keywords “radical cystectomy”, “urinary diversion”, “neobladder”, “ileal conduit”, and
“complications” was conducted on PubMed and Scopus to identify eligible articles. We focused primarily
on randomized clinical trials and systematic reviews/meta-analysis when available, but we mostly included
retrospective studies, case series, and case reports. We also used the “snowball method”, involving tracking
references of the previously chosen articles to identify additional relevant studies. Only articles in English,
Portuguese, and Spanish were reviewed.

GENERAL COMPLICATIONS
Early post-operative complications (90 days)
Surgical morbidity is always dependent on correct reporting of the complications, and radical cystectomy
with urinary diversion rates is an area where this is particularly evident. Studies show a wide range of early
post-operative complication during the first 90 days (20%-80.5%), of both open or robot-assisted radical
[2-5]
cystectomy (RARC) . The lack of standardized complication definitions may be one explanation for this
discrepancy.

Gastrointestinal complications like ileus or small bowel obstruction and infectious complications are the
most frequent [2-4,6] . The “robot-assisted radical cystectomy vs. open radical cystectomy in patients with
bladder cancer” (RAZOR) clinical trial showed no differences between early complication rates for open
(67%) vs. robot-assisted procedures (69%), even when only major complications were considered. All the
urinary diversions in the RAZOR trial were performed extracorporeally, which can influence complication
[6]
results . However, performing the urinary diversion in an extracorporeal or intracorporeal way also carries
similar complication rates, with a trend towards less gastrointestinal complications in the intracorporeal
[7,8]
urinary diversion . Early complications are less related to the type of urinary diversion than late
complications .
[3]
Ileus
Post-operative ileus can have a multitude of definitions, but the most used is “the inability to tolerate solid