Cutaneous ureterostomy versus ileal conduit as urinary diversion in patients with muscle-invasive bladder cancer undergoing radical cystectomy: A comparative analysis of high-risk cases

Abstract

Introduction:

Radical cystectomy followed by urinary diversion is the standard of care for patients with muscle-invasive bladder cancer (MIBC). Cutaneous ureterostomy has emerged as an alternative to ileal conduit diversion, particularly in high-risk patients. The present study aimed to evaluate the outcomes and complications of cutaneous ureterostomy versus ileal conduit in patients with MIBC.

Methods:

This was a retrospective, descriptive cross-sectional study performed at Shahid Modarres Hospital in Tehran between 2018 and 2021. The study population consisted of patients who underwent radical cystectomy with either ileal conduit or cutaneous ureterostomy. Baseline characteristics, operative data, and postoperative complications were compared between the two groups.

Results:

The results showed that cutaneous ureterostomy was significantly utilized in patients with high creatinine levels, renal failure, and metastatic disease (p < 0.05). Analysis revealed that 30-day, 90-day, and 6-month survival rates, as well as surgical complications, were not significantly different between the two groups. Multivariable regression analysis was performed to adjust for baseline imbalances, indicating that the choice of diversion was not an independent predictor of early mortality, though it was heavily influenced by preoperative frailty. One-year survival, the number of preoperative transfusions, length of hospitalization, and operation duration were significantly higher in the ileal conduit group.

Conclusion:

Cutaneous ureterostomy appears to be a viable and “hypothesis-generating” alternative for elderly and frail patients. It is associated with shorter surgery duration, less blood loss, lower transfusion rates, and shorter hospital stays. Although early mortality rates are comparable, cutaneous ureterostomy may offer a safer profile for high-risk individuals, though long-term comparative studies with multivariable adjustment are warranted.

Keywords

radical cystectomy cutaneous ureterostomy ileal conduit muscle-invasive bladder cancer high-risk patients

Introduction

Bladder cancer (BC) is the fourth most common cancer in men and the ninth most common malignancy overall, accounting for approximately 150,000 deaths worldwide.¹ Urothelial (transitional cell) carcinoma is the most prevalent histological subtype, representing approximately 90% of cases.² A wide array of genetic, anatomical, hormonal, social, and environmental factors contribute to its pathogenesis.³ Established risk factors include male sex, advanced age, ethnicity, exposure to industrial chemicals, pelvic radiation, cyclophosphamide use, chronic bladder irritation, family history, and smoking.⁴

According to the TNM staging system, bladder cancers are categorized into non-muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC), defined by invasion into or beyond the muscularis propria.⁵ While NMIBC has a high recurrence rate, it carries a relatively favorable prognosis with standard care. Conversely, a significant subset of MIBC patients progresses to metastatic disease despite perioperative chemotherapy. Guidelines from the EAU, NCCN, and AUA recommend radical cystectomy (RC) and urinary diversion (UD) as the standard treatment for MIBC and high-risk recurrent NMIBC.^6
–10 Despite diagnostic advancements, approximately 25% of patients present with MIBC at initial diagnosis.¹¹ Without timely intervention, 38% of these patients develop metastasis within 6 months, with 5-year overall survival rates as low as 5% in untreated cases.¹²

Although RC is the gold standard, it is a complex, invasive procedure associated with significant morbidity and mortality, particularly in the elderly and frail population. Recent evidence highlights that while orthotopic diversions are often preferred for younger patients, the choice of diversion in the elderly must be carefully individualized to balance oncological outcomes with the patient’s physiological reserve.¹³ Urinary diversion methods are broadly classified into continent and incontinent types. The ileal conduit (IC) remains the most common incontinent diversion due to its perceived simplicity and established safety profile.¹⁴ However, in high-risk patients, especially those presenting with obstructive uropathy or renal insufficiency, the extensive intestinal manipulation required for IC can lead to severe metabolic and surgical complications.¹⁵

In such high-risk scenarios, cutaneous ureterostomy emerges as a viable, simplified alternative. By avoiding bowel resection and reducing operative time, this method potentially minimizes blood loss and intensive care requirements, thereby improving safety in patients with multiple comorbidities.¹⁶ Given the lack of robust comparative data in this specific high-risk subgroup, the present study aimed to compare the outcomes and complications of cutaneous ureterostomy versus ileal conduit in patients with MIBC undergoing radical cystectomy.

Materials and methods

Study design and population

This retrospective, comparative study was conducted on patients who underwent radical cystectomy followed by either ileal conduit (IC) or cutaneous ureterostomy (CU) at the Urology Department of Shahid Modarres Hospital, Tehran, between 2018 and 2021. Out of 500 radical cystectomies performed during this period, 128 patients met the inclusion criteria: 62 underwent ileal conduit and 66 underwent cutaneous ureterostomy. Patients who underwent cutaneous ureterostomy as a secondary or salvage procedure (re-surgery; n = 15) were excluded to maintain the homogeneity of the primary diversion groups.

Data collection

Comprehensive clinical data were extracted from electronic medical records, including demographic characteristics (age, sex), oncological status (metastatic vs non-metastatic), and perioperative parameters (operative time, intraoperative complications, and blood transfusion requirements). Postoperative outcomes included short-term mortality (30-day), postoperative complications, length of hospital stay, and the need for secondary surgical interventions. Long-term follow-up data, including laboratory tests, ultrasonography findings, and patient satisfaction, were also recorded. For patients with incomplete records, missing data regarding survival status, cause of death, and diversion-related issues (e.g. catheter dependency in the CU group) were obtained via direct telephone interviews.

Outcome measures

The primary outcomes were survival rates (30-day, 90-day, 6-month, and 1-year) and the incidence of surgical and medical complications. Secondary outcomes included operative duration, length of hospitalization, and perioperative transfusion rates. Additionally, the association between clinico-pathological features (e.g. hydronephrosis, pathological stage, and positive surgical margins) and 30-day mortality was assessed.

Statistical analysis

Data analysis was performed using SPSS version 22.0. Continuous variables were expressed as mean ± standard deviation (SD) or median (range), while categorical variables were presented as frequencies and percentages. The Chi-square test (or Fisher’s exact test) and independent t-test (or Mann-Whitney U test) were used for group comparisons. To identify independent predictors of mortality and complications, multivariable logistic regression analysis was performed. All associations were reported with 95% confidence intervals (CIs). Two-sided p-values < 0.05 were considered statistically significant.

Results

The baseline characteristics of the patients are shown in Table 1. As indicated in Table 1, most of the baseline characteristics in the two groups were in good agreement with each other. The incidence of renal failure and metastasis in patients who underwent cutaneous ureterostomy was significantly higher than in patients with an ileal conduit (both with p < 0.001). This is due to the fact that cutaneous ureterostomy was the preferred option for most high-risk patients. Additionally, it was found that the cutaneous ureterostomy method was significantly more frequently performed in patients with NX lymph node involvement (p = 0.05).

Table 1.

Basic characteristics of the MIBC patient who underwent ileal conduit or cutaneous ureterostomy following radical cystectomy.

Parameter		Ileal conduit (N = 62)	Cutaneous ureterostomy (N = 66)	p-value	OR (95%CI)
Sex (male)		57 (91.9)	55 (83.3)	0.18	1.44 (0.71–2.92)
Age (mean ± SD)		65.5 ± 9	66.4 ± 12.6	0.61	0.98 (−2.84 to 4.81)^a
Diabetes mellitus		8 (12.9)	11 (16.7)	0.62	0.74 (0.27–1.98)
Hypertension		17 (27.4)	24 (36.4)	0.34	0.66 (0.31–1.40)
Renal failure		1 (1.6)	16 (24.2)	<0.001	0.05 (0.007–0.40)
Hydronephrosis		28 (45.2)	24 (36.4)	0.36	1.44 (0.71–2.92)
Radiotherapy		9 (14.5)	13 (19.7)	0.48	0.69 (0.27–1.75)
Metastasis		1 (1.6)	18 (27.3)	<0.001	0.04 (0.006–0.33)
Pathology	Adenocarcinoma	0	3 (4.8)	0.21	-
	SCC	0	1 (1.8)
	TCC	60 (98.4)	56 (90.3)
	Other	1 (1.6)	2 (3.2)
T stage	T0	2 (3.2)	4 (7.1)	0.09	-
	T1	6 (9.7)	6 (10.7)
	T2	12 (19.4)	14 (25)
	T3	24 (38.7)	9 (16.1)
	T4	18 (29)	23 (41.1)
N stage	N0	28 (45.2)	17 (30.4)	0.05	-
	N+	19 (30.6)	14 (25)
	NX	15 (24.2)	25 (44.6)
Margin involvement		25 (40.3)	27 (47.4)	0.39	0.27 (0.12–1.27)

Mean difference (95% CI).

The differences in qualitative data between the two groups were evaluated (Table 2). Our data showed that there was no significant difference between the two groups (ileal conduit vs cutaneous ureterostomy) regarding complications during and after surgery, 30-day, 90-day, and 6-month survival, stoma stenosis, or the number of deaths due to cancer.

Table 2.

The differences in qualitative data between MIBC patients who underwent ileal conduit or cutaneous ureterostomy following radical cystectomy.

Parameter		Ileal conduit N (%)	Cutaneous ureterostomy N (%)	p-value	OR (95%CI)
Complications during surgery		4 (6.5)	7 (10.6)	0.53	0.58 (0.16–2.09)
Surgery complications	Fever	4 (6.5)	6 (9.2)	0.74	-
	Ileus	10 (16.1)	13 (20)
	Febrile leak	1 (1.6)	2 (3.2)
	Ureteral stricture	3 (4.8)	1 (1.8)
Medical complications	MI	0	3 (4.5)	0.06	-
	Embolism	3 (4.8)	4 (6.1)
	DVT	0	4 (6.1)
Complications categorized by Clavien-Dindo classification	I	4 (6.5)	6 (9.2)	0.20	-
	II	11 (17.7)	19 (28.8)
	IIIa	0	0
	IIIb	3 (4.8)	1 (1.8)
	IVa	3 (4.8)	7 (10.6)
	IVb	0	0
	V	0	0
30-day survival		60 (96.8)	59 (89.4)	0.16	3.55 (0.71–17.84)
90-day survival		54 (87.1)	56 (84.8)	0.80	1.20 (0.44–3.28)
6-month survival		48 (77.4)	42 (63.3)	0.12	1.95 (0.90–4.26)
1-year survival		35 (56.5)	21 (31.8)	0.007	2.77 (1.35–5.71)
Stoma stenosis		7 (10.6)	4 (6.1)	0.50	0.36 (0.27–1.47)
Stoma discomfort		13 (21.3)	13 (19.7)	0.83	1.10 (0.46–2.61)
Death due to cancer		23 (54.8)	29 (64.4)	0.38	1.49 (0.63–3.54)

Postoperative complications were categorized according to the Clavien-Dindo classification. Although the CU group showed a lower frequency of adverse events, this difference did not reach statistical significance (p = 0.208). The majority of complications in both groups were minor (Grade I–II). Major complications (Grade III–IV) occurred in 9% of the CU group compared to 12.3% of the IC group.

In follow-up studies after discharge, our findings showed that 1-year survival was significantly higher in patients who underwent ileal conduit. As shown in Table 3, the results of the quantitative data analysis showed that the duration of hospitalization after surgery, hemoglobin levels during hospitalization, and duration of surgery were significantly higher in the ileal conduit group. On the other hand, the number of transfusions before surgery, creatinine levels during hospitalization, and the creatinine level and creatinine drop at the time of discharge were significantly higher in patients undergoing cutaneous ureterostomy.

Table 3.

The differences in quantitative data between MIBC patients who underwent ileal conduit or cutaneous ureterostomy following radical cystectomy.

Parameter	Ileal conduit (mean ± SD)	Cutaneous ureterostomy (mean ± SD)	p-value	Mean difference (95% CI)
Transfusion during surgery (times)	(1.90 ± 1.11)	(1.92 ± 1.09)	0.91	0.02 (−0.36 to –0.40)
Transfusion before surgery (times)	(0.41 ± 0.87)	(1.28 ± 1.68)	<0.001	0.86 (0.39 to 1.34)
Transfusion after surgery (times)	(1.12 ± 1.31)	(1.16 ± 1.29)	0.87	0.03 (−0.41 to –0.49)
Hospitalization (times)	(12.98 ± 5.47)	(8.89 ± 5.89)	<0.001	−4.08 (−6.08 to –−2.09)
Hemoglobin at hospitalization (g/dl)	(11.40 ± 2.22)	(10.08 ± 2.35)	0.001	−1.32 (−2.12 to –−0.51)
Hemoglobin at discharge (g/dl)	(10.31 ± 1.29)	(10.20 ± 1.71)	0.68	−0.10 (−0.64 to –0.42)
Creatinine level at hospitalization (mg/dl)	(1.48 ± 0.64)	(2.77 ± 2.94)	0.01	1.28 (0.52 to 2.04)
Creatinine level at discharge (mg/dl)	(1.29 ± 0.39)	(1.63 ± 0.97)	0.01	0.34 (0.007 to 0.60)
Decrease in creatinine level (mg/dl)	(0.19 ± 0.53)	(1.06 ± 2.47)	0.007	1.12 (0.42 to 1.56)
Total survival (days)	(740.22 ± 765.79)	(508.83 ± 654.94)	0.06	−231.39 (−480.16 to −17.38)
Surgery duration (min)	(329.83 ± 81.38)	(229.31 ± 76.78)	<0.001	−100.52 (−128.18 to −72.85)

Furthermore, we evaluated the correlation of patients’ 30-day mortality in each group with factors such as transfusion frequency before, during, and after surgery, hydronephrosis, pathological stage, and positive surgical margins. Analyses showed that there was no correlation between the aforementioned characteristics and 30-day mortality in either group.

To identify independent predictors of 1-year survival, a multivariable logistic regression model was constructed. Initially, all clinically relevant variables, including age, sex, comorbidities (DM, HTN), urinary diversion type (ileal conduit vs cutaneous ureterostomy), and tumor characteristics, were entered into the model (Table 4). To refine the model and minimize the risk of overfitting, a backward elimination process was employed.

Table 4.

Multivariable logistic regression analysis of potential predictors for 1-year survival (dependent variable).

Variable	B	SE	Adjusted OR (95% CI)	p-value
Sex (male)	−0.36	0.75	0.69 (0.15–3.05)	0.62
Age	−0.05	0.02	0.94 (0.9–0.99)	0.02
Diabetes mellitus	0.63	0.64	1.88 (0.52–6.72)	0.33
Hypertension	−0.63	0.50	0.53 (0.2–1.41)	0.20
Hydronephrosis	−0.12	0.46	0.88 (0.35–2.2)	0.79
Radiotherapy	0.15	0.65	1.16 (0.32–4.22)	0.81
Metastasis	0.69	0.79	2 (0.42–9.52)	0.38
Pathology	0.43	0.55	1.54 (0.72–2.45)	0.87
T stage	0.25	0.81	1.29 (0.66–1.89)	0.71
N stage	0.50	0.72	1.65 (0.89–4.04)	0.40
Urinary diversion	−0.93	0.50	0.39 (0.14–1.06)	0.06

Note. The model was refined using backward elimination. Variables except age were removed during the steps as they did not significantly contribute to the model. Reference group: Ileal Conduit. CU: Cutaneous Ureterostomy. Note: Categorical variables with instability (e.g. ESRD, T-stage) were excluded from this table to ensure model convergence.

In the final step of the regression, age remained the only significant independent predictor of 1-year survival (OR = 0.953, 95% CI: 0.919–0.989, p = 0.010). This indicates that for every 1-year increase in age, the odds of 1-year survival decreased by approximately 5%. While the type of urinary diversion showed a trend toward significance in the initial model (OR = 0.394, p = 0.066), it did not remain an independent predictor in the final refined model. These findings suggest that the survival disparity observed in the univariate analysis was primarily driven by the advanced age of patients in the cutaneous ureterostomy group rather than the surgical technique itself.

Discussion

Bladder cancer (BC) ranks as the 10th most common malignancy worldwide. According to the EAU, NCCN, and AUA/ASCO/ASTRO/SUO guidelines, radical cystectomy (RC) remains the gold-standard treatment, significantly improving survival rates.¹² Research indicates that in-hospital mortality following RC is generally lower than 30-day mortality, which, in turn, is two to three times lower than the 90-day mortality rate.^17
–19 While current guidelines recommend both RC and urinary diversion via an ileal conduit (IC) as standard care for muscle-invasive bladder cancer (MIBC), this study sought to evaluate whether cutaneous ureterostomy (CU) could serve as a strategic alternative to reduce morbidity and mortality in these patients.

Although clinical data on MIBC patients undergoing RC with CU are relatively scarce, existing evidence suggests that CU may significantly reduce perioperative risks. This technique minimizes operative duration and eliminates complications related to bowel manipulation, thereby potentially improving outcomes in patients with multiple comorbidities.^20
–23 It is crucial to recognize that not every MIBC patient is a suitable candidate for RC, nor does every RC patient have an indication for an ileal conduit. Indeed, urinary diversion via an ileal conduit is associated with a substantial proportion of postoperative complications,²⁰ and mortality rates remain high across many surgical centers.^20
–23 Consequently, tailored treatment decisions are essential, as meticulous management can significantly enhance life expectancy in high-risk individuals.

Incontinent urinary diversion offers a feasible and technically simpler approach to reestablishing urinary excretion post-RC, particularly for elderly patients. Among available options, the ileal conduit and cutaneous ureterostomy provide effective and optimal choices for selected patients.²⁴ Given the lack of head-to-head comparative studies, the present study evaluated these two methods. Our findings indicated that while demographic characteristics were well-matched, patients with higher baseline creatinine, renal failure, and metastasis were significantly more likely to be selected for CU. No significant differences were observed regarding 30-day, 90-day, and 6-month survival, or in surgical complications. However, while univariate analysis showed higher 1-year survival in the IC group, the CU group benefited from significantly shorter hospital stays and operative durations. Specifically, our study found the operative time for CU to be approximately 100 min shorter, which is consistent with other reports showing a reduction of about 80 min²⁵ although some studies, such as Knap et al., reported a shorter duration for the ileal conduit without statistical significance.

Regarding blood loss, previous research suggests that patients undergoing CU lose approximately 23% less blood than those undergoing IC, leading to lower transfusion requirements.^21,25 In contrast, our study found comparable intra-operative transfusion rates, though pre-operative transfusions were significantly higher in the CU group—a reflection of the higher baseline frailty and clinical complexity of these patients. Furthermore, our results showed that the decrease in creatinine levels was more pronounced in the cutaneous ureterostomy group, likely due to the superior ultra-drainage provided by this method, making it a potentially better choice for patients with renal impairment.

A pivotal finding of our study emerged from the multivariable analysis, which clarified the relationship between the type of urinary diversion and patient survival. While univariate analysis initially suggested a survival advantage for the ileal conduit (IC) group, this effect was not sustained after adjusting for potential confounders. Our final regression model identified advanced age as the sole independent predictor of 1-year survival (OR = 0.953, 95% CI: 0.919–0.989, p = 0.010), rather than the surgical technique itself. This indicates that for every 1-year increase in age, the odds of 1-year survival decreased by approximately 5%.

This distinction is clinically significant and suggests that the lower survival rates observed in the cutaneous ureterostomy (CU) group are a reflection of “confounding by indication” or selection bias. Specifically, CU was predominantly offered to significantly older and frailer patients who already possessed a higher baseline risk of mortality. When these factors were accounted for through a stepwise backward elimination process—a method we employed to minimize the risk of overfitting and ensure the robustness of our model—the choice of diversion (CU vs IC) did not independently jeopardize survival outcomes.

Our results align with the growing body of evidence suggesting that for elderly patients with multiple comorbidities, the priority should be the minimization of surgical stress. The significantly shorter operative time and reduced blood loss associated with CU provide a crucial physiological advantage for high-risk individuals. By avoiding bowel-related complications and reducing the overall surgical burden, CU serves as a safe and pragmatic alternative to the more invasive ileal conduit in the “frailest” patient populations. However, we acknowledge that the trend toward significance for urinary diversion type in our initial model (p = 0.066) suggests that larger, prospective studies are still needed to further delineate these associations and establish precise clinical criteria for diversion selection.

Despite these insights, our research has limitations, including its retrospective design and potential selection biases. Future prospective, multicenter studies with randomized designs and standardized complication grading (e.g. Clavien-Dindo) are warranted. Moreover, subsequent research should focus on evaluating quality of life and establishing precise clinical criteria for selecting diversion techniques based on individual risk profiles post-radical cystectomy. In conclusion, cutaneous ureterostomy represents a safe, efficient, and competitive alternative to ileal conduit for elderly and high-risk patients. Its perioperative advantages—including shorter operative time, reduced hospitalization, and rapid creatinine decline—make it a reasonable choice when minimizing surgical stress is clinically paramount.

Conclusion

In conclusion, cutaneous ureterostomy serves as a safe and efficient alternative for elderly and frailer patients requiring urinary diversion. Our study demonstrates that this technique offers significant perioperative advantages, including shorter operative time, reduced blood loss, and shorter hospital stays. Crucially, multivariable analysis revealed that the observed differences in 1-year survival were driven by advanced age and baseline comorbidities rather than the surgical technique itself. Given that complications and mortality rates remain comparable to ileal conduit after adjusting for confounders, cutaneous ureterostomy should be considered a viable, less invasive option for high-risk patients.

Footnotes

ORCID iD

Fereydoon Shirani

Ethical considerations

An ethical code approved the preparation of this paper and project (IR.SBMU.MSP.REC.1400.448.) Shahid Beheshti University of Medical of science.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that supports the findings of this study are available in the article.

References

Afsharmoghadam

Haghighatian

Mazdak

, et al. Concentration-dependent effects of curcumin on 5-fluorouracil efficacy in bladder cancer cells. Asian Pac J Cancer Prev 2017; 18(12): 3225–3230. 10.22034/APJCP.2017.18.12.3225.

Bellmunt

Orsola

Leow

, et al. Bladder cancer: ESMO practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 (Suppl 3): iii40–iii48. 10.1093/annonc/mdu223.

Aghaalikhani

Rashtchizadeh

Shadpour

, et al. Cancer stem cells as a therapeutic target in bladder cancer. J Cell Physiol 2019; 234(4): 3197–3206. 10.1002/jcp.26916.

Wong

MCS

Fung

FDH

Leung

, et al. The global epidemiology of bladder cancer: a joinpoint regression analysis of its incidence and mortality trends and projection. Sci Rep 2018; 8(1): 1129–1212. 10.1038/s41598-018-19199-z.

Matulewicz

Steinberg

GD.

Non-muscle-invasive bladder cancer: overview and contemporary treatment landscape of neoadjuvant chemoablative therapies. Rev Urol 2020; 22(2): 43–51.

Bray

Ferlay

Soerjomataram

, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68(6): 394–424. 10.3322/caac.21492.

Chang

Bochner

Chou

, et al. Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO guideline. J Urol 2017; 198(3): 552–559. 10.1016/j.juro.2017.04.086.

Faba

Tyson

Artibani

, et al. Update of the ICUD-SIU international consultation on bladder cancer 2018: urinary diversion. World J Urol 2019; 37(1): 85–93. 10.1007/s00345-018-2484-3.

Flaig

Spiess

Agarwal

, et al. NCCN guidelines insights: bladder cancer, version 5.2018. J Natl Compr Cancer Netw 2018; 16(9): 1041–1053. 10.6004/jnccn.2018.0072.

10.

Alfred Witjes

Lebret

Compérat

, et al. Updated 2016 EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 2017; 71(3): 462–475. 10.1016/j.eururo.2016.06.020.

11.

Smith

Deal

Woods

, et al. Muscle-invasive bladder cancer: evaluating treatment and survival in the National Cancer Data Base. BJU Int 2014; 114(5): 719–726. 10.1111/bju.12601.

12.

Martini

Sfakianos

Renström-Koskela

, et al. The natural history of untreated muscle-invasive bladder cancer. BJU Int 2020; 125(2): 270–275. 10.1111/bju.14872.

13.

Bizzarri

Recupero

Orsolini

, et al. Elderly and bladder cancer: the role of radical cystectomy and orthotopic urinary diversion, Urologia 2017; 84(3): 141–146. 10.5301/uro.5000224,

14.

Gore

Setodji

, et al. Urinary diversion and morbidity after radical cystectomy for bladder cancer. Cancer 2010; 116(2): 331–339. 10.1002/cncr.24763.

15.

Gupta

Goel

Singh

, et al. Oncological and functional outcome of radical cystectomy in patients with bladder cancer and obstructive uropathy. World J Urol 2013; 31(2): 333–339. https://doi.org/10.1007/s00345-012-0941-z

16.

Korkes

Palou

High mortality rates after radical cystectomy: we must have acceptable protocols and consider the rationale of cutaneous ureterostomy for high-risk patients. Int Braz J Urol 2019; 45: 1090–1093. 10.1590/S1677-5538.IBJU.2019.06.03.

17.

Afshar

Goodfellow

Jackson-Spence

, et al. Centralisation of radical cystectomies for bladder cancer in England, a decade on from the 'improving outcomes guidance': the case for super centralisation. BJU Int 2018; 121(2): 217–224. 10.1111/bju.13929.

18.

Corradi

Galvão

GJC

Oliveira

, et al. Radical cystectomy with pelvic lymphadenectomy: pathologic, operative and morbidity outcomes in a Brazilian cohort. Int Braz J Urol 2016; 42(3): 431–437. 10.1590/S1677-5538.IBJU.2015.0380.

19.

Waingankar

Mallin

Egleston

, et al. Trends in regionalization of care and mortality for patients treated with radical cystectomy. Med Care 2019; 57(9): 728–733. 10.1097/MLR.0000000000001143.

20.

Burkhard

Wuethrich

PY.

Cutaneous ureterostomy: 'back to the future. BJU Int 2016; 118(4): 493–494. https://doi.org/10.1111/bju.13532

21.

Longo

Imbimbo

Fusco

, et al. Complications and quality of life in elderly patients with several comorbidities undergoing cutaneous ureterostomy with single stoma or ileal conduit after radical cystectomy. BJU Int 2016; 118(4): 521–526. 10.1111/bju.13462.

22.

Meng

Wang

Fan

, et al. [Impact of different surgical methods of radical cystectomy on the perioperative complications in patients over 75 years]. Beijing da xue xue bao. Yi xue ban= J Peking Univ Health sci 2016; 48(4): 632–637.

23.

Nogueira

Reis

Machado

, et al. Cutaneous ureterostomy with definitive ureteral stent as urinary diversion option in unfit patients after radical cystectomy. Acta Cir Bras 2013; 28 (Suppl 1): 43–47. 10.1590/s0102-86502013001300009.

24.

Nieuwenhuijzen

de Vries

Bex

, et al. Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions. Eur Urol 2008; 53(4): 834–842. 10.1016/j.eururo.2007.09.008.

25.

Deliveliotis

Papatsoris

Chrisofos

, et al. Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit? Urology 2005; 66(2): 299–304. 10.1016/j.urology.2005.03.031.