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Two doctors discussing bladder surgery options

Bladder Cancer Updates from European Association of Urology Conference

At the recent European Association of Urology Conference (EAU 2019) held in Barcelona, Spain, a number of updates were presented with interesting findings for the bladder cancer community. Three topics in particular raised questions about approaches to treatment.

For many conditions, there is no right answer when addressing treatment approaches. Physicians agree that each patient must be treated individually, taking into account personal preferences, physical condition, and an understanding of existing options. They suggest that there is a lot to explain to patients, and for them to achieve a more complete understanding of their condition involves a great deal of explanation and discussion. When describing specific case studies, it was also clear that surgeon-specific experience and preferences play an important role in patient decision-making.

Ileal conduit or neobladder: which is a better choice for most patients?

One session discussed surgical reconstructive approaches. A clinical case study presentation addressed a patient who required a radical cystectomy (total removal of a cancerous bladder) with pelvic lymph node dissection. Panelists agreed the bladder removal was the appropriate standard of care. But, they debated next steps, the reconstructive merits of incontinent cutaneous (ileal conduit) versus orthotopic continent (neobladder) diversion. They took different positions on the best way to restore urinary function.

Ileal conduit pros and cons

The ileal conduit urinary diversion was the first alternative discussed. The presenters agreed that for most cases, it is the most appropriate reconstructive technique. It involves removing a small piece of the intestinal tract (and then reconnecting so it works properly), using the small piece placed at the skin surface to create a stoma. Ureters are then attached to the other end of the segment of intestine. Urine passes through the newly formed ileal conduit and the stoma into an external collecting pouch. The pouch has an outlet allowing urine to be emptied into a toilet without removing it from your stoma. ( It is generally a shorter operation, involving less post-operative care, and can get patients back to their baseline more quickly. An objection to this approach was that conduits are filled with complications to the stoma: stenosis, retraction, and parastomal hernias.

Neobladder pros and cons

The alternate proposal was for neobladder reconstruction. With this approach, patients store urine inside the body. Surgeons again take a small piece of the intestine to create a pouch that is connected both to the ureter and the urethra. Presenters expressed concern that patients have to learn how to catheterize, irrigate, and void to regain urinary control. This requires a significant commitment that raises compliance concerns.

Goals for patients with bladder cancer are to be disease-free, retaining continence and potency. Determining the right procedure requires patient and physician considerations including stage and spread of disease, general patient health, age, and other comorbidities.1

Decreasing patient pain and anxiety in cystoscopy

The subject of another presentation was ‘peak-end theory’, a principle in psychology whereby patients judge their experiences based upon the memory of how they felt at its peak (the most intense time) and the end, rather than the sum total experience or the average of how they felt across the whole experience. The theory that patients may associate pain, anxiety, and embarrassment with the cystoscopy procedure caused researchers to question whether if the end of the cystoscopic procedure was improved, individual perception of pain and anxiety might improve as well.

Analyzing anxiety levels in a new study

In Canada, a study was launched to break a randomized group of patients having an outpatient flexible cystoscopy for the first time, into 2 groups. One group received the standard treatment, and one group had the cystoscope left in the bladder for an additional two minutes (after the standard cystoscopy was complete) without further manipulation.
Researchers noted that upon administering questionnaires after the procedure there was no difference in medical outcome and pain scores both overall and when analyzed by gender. But in analyzing anxiety levels, when subtyped by gender, men experienced an improvement in anxiety with this newer, and longer technique.

Assessing if this approach is reasonable

This raises questions about the appropriateness of modifying a procedure to reduce anxiety without medical necessity. Issues of adding two minutes of cystoscopy time per patient would negatively influence workflow, clinic time, and scope turnover, especially in locations where clinic time, cystoscopes, physicians are highly in need. Further investigation will have to evaluate if this approach is reasonable.2

Quality of life after bladder surgery

Another discussion at the conference considered quality of life differences after having the bladder-preserving technique Trimodal Therapy, versus having a radical cystectomy.

The case for radical cystectomy was presented based on several studies which demonstrated that over the course of the first year, patients typically recover baseline functioning (number of steps they can take, sitting-to-standing-ability, etc.). An opposing perspective suggested those who undergo bladder preservation techniques have good long-term urinary function and a return to potency when having sex. A 2018 study suggested improvement in the quality of life over time for those who have the trimodal therapy.

There will always be risks and benefits to preserving the native bladder as compared to removing it and performing reconstruction. Doctors will continue to evaluate medical comorbidities, particular quality of life each patient needs, and appropriate cancer controls when considering and recommending surgical options when treating bladder cancer.3

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Cahn, DB. EAU 2019: Case-Based Debate: Ileal Conduit or Continent Diversion: Which is a Better Choice for Most Patients? Available at: Accessed 3.26.19.
  2. Cahn, DB. EAU 2019: A Randomized Controlled Trial of Modified Cystoscopy Technique to Decrease Patient’s Pain and Anxiety. Available at: Accessed 3.26.19.
  3. Cahn, DB. EAU 2019: Who Lives Better? Quality of Life after Bladder Preserving Trimodal Therapy Versus Radical Cystectomy. Available at: Accessed 3.26.19.