How does each urinary diversion work?
Both use a piece of your own small bowel; the difference is where the urine comes out. After the bladder is removed (radical cystectomy), the two ureters from the kidneys need a new route.
- Ileal conduit (urostomy). A short piece of small bowel is joined to the ureters and brought out through the abdominal wall as a stoma. Urine flows continuously into a bag on the skin.
- Orthotopic neobladder. A reservoir is made from 40 to 60 cm of small bowel and joined to the urethra. Urine is stored inside the body and passed through the urethra.
- Ureterocutaneostomy. The ureters are brought directly to the skin without using bowel. It is the simplest diversion, and the European Association of Urology (EAU) guideline describes it as preferred in frail patients.
A fourth type, a reservoir emptied through a small skin opening with a catheter, is rarely used today because of its complication rates, according to the same guideline.
Who is suited to a neobladder, and who to an ileal conduit?
A neobladder needs a tumour-free urethra, adequate kidney and liver function, and a patient who is able and willing to train it. When one of these is missing, an ileal conduit is usually the safer choice. The table follows the 2026 EAU guideline.
| Factor | Neobladder possible | Ileal conduit preferred |
|---|---|---|
| Urethra | Free of tumour at the level where it is divided | Invasive tumour in the urethra or at that level: a neobladder is not offered (strong recommendation) |
| Kidney and liver function | Adequate | Severely impaired |
| Lymph nodes | None or limited involvement (N0 to N1) | More extensive involvement (N2 to N3) |
| Previous pelvic radiotherapy | None | High-dose radiotherapy (relative contraindication) |
| Urethra and sphincter | Working sphincter, no complex stricture | Severe sphincter-related incontinence or complex urethral strictures |
| Ability to manage it | Motivated, good hand function, able to learn self-catheterisation | Debilitating neurological or psychiatric illness |
| Life expectancy | Long enough to benefit | Limited |
Age alone does not decide. The guideline notes that 80 is often treated as a threshold, yet there is no exact age that rules a neobladder out.
The guideline also asks that every option that applies to you is discussed before surgery, because an informed choice may reduce regret afterwards.
What is daily life like with each?
With a conduit you look after a stoma. With a neobladder you look after a routine.
Ileal conduit. The stoma has no feeling and no muscle, so urine drains all the time. The bag is emptied several times a day and replaced regularly, and a larger bag is connected at night. The position of the stoma is marked before surgery so that the bag sits well under clothing, and stoma care is taught before you leave hospital. Work, travel, sport and swimming remain possible.
Neobladder. A neobladder does not signal fullness the way a bladder does and does not contract by itself. You empty it by the clock, at night as well in the first period, by relaxing the pelvic floor and pressing gently with the abdomen. The bowel wall keeps producing mucus, which appears in the urine. Leakage is common in the first months and improves with pelvic floor training. Some patients cannot empty completely and pass a thin catheter themselves a few times a day; in women, retention has been reported in 7 to 50% across series.
What do the studies show?
Both diversions work, both carry long-term complications, and the evidence does not show that one gives a clearly better life than the other. The comparison rests on observational studies, because no randomised trial of conduit versus neobladder has been done.
| Question | Finding | Study |
|---|---|---|
| Continence with a neobladder | Dry by day in 85 to 90%, at night in 60 to 80%. Lower in elderly patients. | ICUD-EAU consultation 2012, literature review |
| Long-term problems with a conduit | 66% had a conduit-related complication: kidney changes 27%, stoma 24%, bowel 24%, urinary infection 23%, stones 9%. | Madersbacher 2003: 131 patients alive at 5 years or more |
| Long-term problems with a neobladder | 40.8% overall. At 20 years: hydronephrosis 16.9%, incisional hernia 6.4%, feverish urinary infection 5.7%. One in three needed long-term bicarbonate. | Hautmann 2011: 923 patients |
| Kidney function | Declined in 71% with a conduit and 74% with a continent diversion by 10 years; no significant difference. | Eisenberg 2014: 1,631 patients |
| Quality of life, all patients | Slightly better with a neobladder overall, not statistically significant; significant in the subgroup with ileal neobladders. | Cerruto 2016: meta-analysis of 18 non-randomised studies |
| Quality of life, women | No significant difference between the two. | Xing 2022: meta-analysis, 283 women |
Limits: patients chosen for a neobladder are on average younger and fitter, so differences between the groups partly reflect selection. The two long-term series come from single centres and cover operations from the 1970s to the 2000s.
The operation itself is the larger risk. In a series of 1,142 radical cystectomies analysed with strict reporting, 64% of patients had a complication within 90 days and 13% had a high-grade one. Most complications were minor.
What does a neobladder offer, and what does it ask of you?
It offers a body without a stoma and asks for months of training and lifelong attention.
What it offers
- No stoma and no bag. Urine is passed through the urethra.
- Good daytime control for most. Daytime continence in 85 to 90% in published series.
- Body image. There is no stoma on the abdomen, although measured quality of life is not clearly better than with a conduit.
What it asks
- Training. Emptying by the clock, pelvic floor exercises and patience in the first months.
- Night-time leakage. Night-time continence is reached in 60 to 80%, so some leakage at night persists for a share of patients.
- Self-catheterisation for some. Retention was reported in 7 to 50% of women across series.
- Metabolic follow-up. In the series of 923 patients, 307 needed long-term bicarbonate to correct acid balance.
- It may not be possible. If tumour is found at the urethral margin during surgery, the plan changes to a conduit.
Does robotic surgery change the choice?
No. The choice between a conduit and a neobladder is made on the same grounds whether the operation is robotic or open. After the bladder has been removed with the robot, either diversion can be built through a small incision (extracorporeal) or entirely inside the abdomen (intracorporeal). At this practice, Prof. Ateş builds the diversion through a small incision.
That is the method used in the randomised RAZOR trial of 350 patients, in which two-year progression-free survival was 72.3% after robotic and 71.6% after open cystectomy: cancer control was equivalent.
Two other randomised trials built the diversion inside the body, so their figures cannot be carried over directly to the extracorporeal method. In iROC (338 patients), robotic cystectomy was followed by fewer blood clots (1.9% versus 8.3%) and fewer wound complications (5.6% versus 16%) than open surgery. In a smaller trial of 116 patients, the probability of regaining daytime and night-time continence with a neobladder was similar after robotic and open surgery, fewer pads were needed at night after open surgery, and body image was better after robotic surgery.
Nine different robotic neobladder techniques have been described, and a 2024 systematic review found no evidence that favours one of them. Comparisons of the intracorporeal and extracorporeal methods have not settled which is better, and the EAU guideline concludes that the experience of the surgeon and the hospital matters more than the technique.
What does recovery look like, and what changes if you travel for surgery?
Recovery takes weeks with either diversion, and a neobladder adds a training period. Thin stents in the ureters are usually removed at 2 to 3 weeks. With a neobladder, the catheter stays until a check for leaks at about week 3, and voiding training starts after that. Full daily activity returns at around 6 to 8 weeks.
For patients from abroad, no fixed number of days is given in advance for this operation. The length of stay depends on the type of diversion, the course of the operation and how recovery goes, and it is planned individually. Before you travel, arrange at home a urologist for follow-up and, with a conduit, access to a stoma nurse.
Follow-up continues for life with both diversions: kidney function, the upper urinary tract on imaging, blood salts and acid balance, and vitamin B12. In a study of 1,631 patients followed for a median of 10.5 years, kidney function declined in most patients, and the type of diversion was not an independent cause. Narrowing where the ureters join the bowel, and kidney infections, were. More on the cancer treatment itself is on the bladder cancer page.
Which questions should you ask your surgeon?
Ask which options are open to you, and why.
- Is my urethra free of tumour, and has that been checked?
- Are my kidney and liver function good enough for a neobladder?
- Which diversion do you recommend for me, and what makes the other one less suitable?
- How many cystectomies with each type of diversion do you perform?
- If a neobladder turns out not to be possible during surgery, what will you do instead?
- Who will teach me stoma care or neobladder training, and who follows me at home?
This article gives general information and does not replace an assessment of your own scans and results. Treatment is decided individually.