Temporal trends and clinical determinants of urinary diversion after radical cystectomy

Objectives To evaluate the temporal trends in types of urinary diversion (UD) used after radical cystectomy (RC) in a large, multicentre, international cohort over the past two decades. Materials and Methods We analysed 6469 patients who underwent RC between 2004 and 2024 at 23 international tertiary referral centres. Trends in UD type (cutaneous ureterostomy [UCS], ileal conduit [IC], and neobladder) were assessed using estimated annual percentage change (EAPC). Multivariable analysis (MVA) models identified preoperative predictors of UD type. EAPC was applied to evaluate temporal changes in the patient characteristics associated with UD type. Results Overall, 882 (14%), 3611 (56%) and 1976 patients (31%) underwent UCS, IC, and neobladder procedures, respectively. IC remained the most common UD, without significant temporal change (P = 0.1). UCS use increased from 2% to 22% (EAPC 9.9%; P < 0.001), while neobladder use declined from 41% to 19% (EAPC -2%; P = 0.009). MVA showed that older age, comorbidities, and advanced disease were associated with higher rates of UCS and lower rates of neobladder use (all P < 0.005). Neoadjuvant chemotherapy (NAC) was inversely linked to UCS, while robot-assisted RC and male sex favoured neobladder use (all P < 0.005). EAPC showed rising proportions of male patients (EAPC 6.7%), patients aged >70 years (1.2%), patients with a Charlson Comorbidity Index >= 3 (8.3%), patients who received NAC (10.4%) and patients with cT2-cN0 disease (0.5%; all P < 0.05). Conclusion Over two decades, a marked increase in UCS use has been observed, alongside a decline in neobladder reconstruction. These trends coincided with a shift toward older, more comorbid patients undergoing RC. Evolving patient profiles and surgical practices underscore the need for tailored UD strategies and optimised peri-operative management.