Construction of orthotopic neobladder was initially limited to men as it was thought to be associated with higher rate of voiding dysfunction and compromised oncologic outcome in women. Although the technique is feasible in women and is not associated with unfavorable oncologic outcome, voiding dysfunction occurs more frequently. Anderson et al. evaluated 49 women with orthotopic neobladder urinary diversion for a mean follow-up period of 3.1 years. They reported nighttime incontinence, daytime incontinence, and emptying failure in 55%, 43%, and 31% of patients, respectively [13]. Furthermore history of concurrent or previous hysterectomy was associated with higher rate of incontinence in their series. In contrast, several other studies have reported daytime and nighttime continence rates of 75–93% and 72–84% in women, respectively. These values are quite high and parallel to those reported from series of men [17–20]. Despite controversies on continence rate, most series have reported higher frequency of emptying failure and need to intermittent catheterization in women compared to men [13, 21]. Posterior prolapse of the neobladder during Valsalva maneuver and subsequent angulation of the urethra have been suggested as the cause of impaired neobladder emptying in women. Lengthening of the urethra in an attempt to improve continence may also increase the likelihood of emptying failure, whereas superior and anterior fixation of the neobladder and using omental or peritoneal flaps to fill the posterior pelvis may secure proper orientation of the neobladder and prevent prolapse. Furthermore, meticulous dissection and preservation of pelvic floor fascia and levator muscles in women may prevent neobladder prolapse. Emptying failure rarely occurs in men. In a series of 655 men, Simon et al. observed incomplete emptying (defined as a residual urine volume >100 mL) in 75 (11.5%) patients. Mechanical obstruction secondary to either benign strictures or local tumor recurrence was the major cause of incomplete emptying in their series [22].

Some investigators have also reported older age and diabetes mellitus as predicting factors for voiding dysfunction in patients with orthotopic neobladder [14]. The use of colonic segments in pouch reconstruction is associated with increased voiding pressures and higher likelihood of incontinence. In addition, non-nerve sparing technique during cystectomy results in compromised sphincter function and higher probability of incontinence [11].

Stomal stenosis may be a consequence of long-term ischemia, skin irritation, and/or facial constriction. Although earlier series have reported a stricture rate of 20–25% and 10–25% in ileal and colon conduits, respectively [25], more recent studies have reported lower rates of conduit stricture. In a study from Mayo Clinic, conduit stricture was reported in less than 3% of 1057 patients after a median follow-up of 9.4 years [26]. However, stomal stenosis and catheterization difficulties occur in a significant proportion of patients with catheterizable stomas [27]. Reported rate of stomal stenosis and difficult catheterization in patients with continent cutaneous diversion varies between 4 and 15% in the literature. Continence mechanism applied in the diversion may also affect the stenosis rate [28]. Stomal stenosis impedes proper urinary drainage and may require open surgical revision. Proper surgical technique and careful attention to the vascularity of the bowel segment as well as proper alignment of the conduit minimize the risk of stenosis. Furthermore, parastomal skin care and the use of a properly fitting external appliance may also reduce the risk of stomal stenosis.

Elongation of the bowel segment used in the creation of conduit or reservoir is another complication associated with urinary diversion and indicates a distal obstruction or failure to adequately catheterize the reservoir (Fig. 8.1). Sometimes it is associated with massive enlargement and may rarely result in a volvulus of the segment. Improper drainage and increased pressure of the segment may lead to deterioration of the renal function; therefore, prompt attention and revision are warranted.

Parastomal hernia is defined as protrusion of peritoneal content through the abdominal wall defect adjacent to the stoma (Fig. 8.2). Parastomal hernia may be associated with discomfort and inappropriate fitting of external appliance and has negative impacts on quality of life. It might also lead to urinary obstruction and/or bowel obstruction, incarceration, strangulation, and perforation.

This is a common complication in patients with conduit diversions, and the incidence varies from 2.3 to more than 60% in different series [29–32]. This variation may be related to different criteria used to define the condition, duration of follow-up, and whether the diagnosis is made clinically or based on radiological evaluations. The diagnosis is usually made clinically; however, radiologic evaluation increases the accuracy of diagnosis. Parastomal hernias are categorized into three different subtypes based on a clinico-radiological classification system proposed by Moreno-Matias et al. [33]. In type 1, the bowel loop forming the stoma is herniated through the wall defect. In type 2, hernia sac contains omentum or abdominal fat, and type 3 refers to herniated bowel loops other than stoma. Using this classification system, Donahue et al. noted that 5(4%), 90 (66%), and 41(30%) patients develop type 1, 2, and 3 parastomal hernia, 2 years after cystectomy and ileal conduit diversion, respectively. In a series from the University of Southern California, with a median follow-up of 57 months, the rate of parastomal hernia was found to be 23% [34]. In a study from Mayo Clinic addressing complications associated with conduit diversion in 1045 patients, parastomal hernia was the most common stoma-related complication occurring in 14% at a median of 2 years [26]. Similarly in a retrospective review of Indiana University cystectomy database, risk of parastomal hernia was 12% and 22% at 1 and 2 years after cystectomy [35].

Intestinal obstruction is one of the most common bowel complications after urinary diversion, and the incidence varies based on the type of segment used for the creation of diversion. There is a 10% risk of bowel obstruction in patients with ileoileal anastomosis, and when a segment of colon is utilized for the diversion, the incidence of obstruction is 5% [49, 50]. Reported incidence of bowel obstruction varies significantly in different series. In a large series of 1057 patients from Mayo Clinic, bowel obstruction was reported to occur in 16% of patients at a median follow-up period of 1.7 years. In another study of 923 patients with follow-up duration of 20 years, bowel obstruction was reported in 3.6% of patients [51]. Bowel obstruction may be a consequence of intestinal stenosis, adhesion bands, internal hernia, or volvulus. Stricture of the intestinal anastomosis may occur either in early postoperative period or during the long-term evaluation. Early-onset strictures usually occur as a consequence of improper technique, whereas late-onset strictures develop due to ischemia (i.e., using irradiated bowel). In addition to the aforesaid benign causes of bowel obstruction, recurrence of cancer and peritoneal carcinomatosis should be considered in patients presenting with bowel obstruction.

Another complication related to the bowel segment is fistula formation. Fistula can develop between the conduit or neobladder/pouch and intestine as well as between the neobladder and vagina or rectum. Some patients may also develop cutaneous urinary or fecal fistulas. These complications generally occur within the first weeks after the surgery and are associated with significant morbidity and mortality. These patients frequently develop sepsis with an associated mortality rate of 2% [52].

In most series incidence of fistula formation after cystectomy and urinary diversion has been reported to be less than 5%, although some series with long-term evaluation have reported that up to 10% of patients with urinary diversion may develop fistulas [26, 53, 54].

Total parenteral nutrition and urinary drainage using large-bore catheters are initial considerations in the management of patients; however, conservative management is not effective in the majority of patients, and they require surgical repair [13, 26, 53]. The probability of cancer recurrence should also be considered at the site of fistula.

Pouch/neobladder perforation is an extremely rare and potentially life-threatening complication in patients with continent diversion. Patients usually present with acute abdominal pain and distention. Rupture may occur as a consequence of traumatic catheterization or blunt trauma to a full urinary reservoir. The rupture usually occurs intraperitoneally [51]; therefore, immediate laparotomy and repair of the reservoir are necessary. Few reports of conservative management also exist in the literature [55, 56].