Second, patients and their families need help to identify their own priorities and tolerance for the disadvantage of each type of diversion. This is an iterative process as they understand the pros and cons and try to prioritize those for themselves. This may require several discussions over time. Providing written materials, encouraging patients to talk to others who have been through the various procedures, and encouraging open family discussions are all helpful. It is also useful to have a trained physician extender who can help answering specific questions and guide the patient through the process.

Finally, it is important that we physicians recognize how much our own bias can influence the decision. Physicians are trained to be persuasive, and it is relatively easy to influence patients’ decisions just based on how the options are presented to them and the inflections of the advice delivered. There are marked differences in the rate of continent diversion at various institutions, even at those with specialists who have extensive experience in continent diversion [33]. Nationally less than 20% of patients undergo continent diversion, compared to 60–75% at some high-volume centers [34]. One center reported a marked decrease in continent diversion over a 5-year timespan, almost certainly reflecting physician bias rather than any radical difference in their patient population [35]. Many urologists today have had little exposure to continent diversion in training or after and may not want to refer the patient out to a center where that option may be offered [36]. There is also a significant financial disincentive for surgeons to perform a procedure that takes extra time when there is not a concomitant increase in reimbursement [37].