Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 4384 ORIGINAL PAPER No conflict of interest declared. INTRODUCTION The lower urinary tract can be affected by multiple benign conditions that can eventually lead to significant lower uri- nary tract dysfunction (LUTD). These benign conditions can generally be classified into two main categories; neurogenic bladder (NGB) that results from the permanent loss of neu- ronal control over the bladder due to a neurological disor- der such as spinal cord injuries (SCI), multiple sclerosis (MS), Parkinson’s disease (PD) or spina bifida (SB) and non-neuro- genic bladder (non-NGB) that results from structural or func- tional bladder damage rather than loss of neuronal control of the bladder and that can occur with urinary tract fistulas, radiation-induced lower urinary tract damage, refractory urinary incontinence or bladder pain syndrome (BPS) (1-4). Based on the underlying disorder, the presenting symp- toms of these benign conditions can vary widely from continuous urinary leakage to urinary retention, recur- rent urolithiasis, bladder pain, and recurrent urinary tract infections (UTIs). These disorders can ultimately lead to a significant quality of life deterioration and have a detri- mental effect on the upper urinary tract (3-5). The main goal of management of these benign lower uri- nary tract conditions is to protect the upper urinary tract, keep the patients socially dry, eliminate the recurrent urosepsis episodes, and maintain the act of urination whenever possible. This is mainly achieved by conserva- tive and/or minimally invasive measures (5, 6). A well-established procedure in the management of blad- der cancer, urinary diversion is usually considered the last resort for treating these non-malignant lower urinary tract conditions (7-9). External urinary diversions are generally classified into incontinent diversions such as ileal conduit and colonic conduit and continent diver- sions such as Indiana Pouch and continent urinary diver- sion using the ileum (10-13). The primary aim of this study is to report the early and late outcomes of external urinary diversion in patients with refractory non-malignant LUTD. The secondary aim is to evaluate these outcomes independently based on both the underlying condition and the type of external urinary diversion. MATERIALS AND METHODS After approval by University of Cincinnati Institutional Review Objective: To evaluate the early and late out- comes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD). Materials and methods: The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline charac- teristics, surgery indications, operative data, early and late out- comes were collected, analyzed, and compared. Results: A total of 78 patients including 55 patients with neuro- genic bladder (NGB) and 23 patients with non-neurogenic blad- der (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was non- significantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retrac- tion occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively). Conclusions: External urinary diversion can achieve a reason- able level of urological symptoms control in patients with refrac- tory non-malignant LUTD, but with associated adverse out- comes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term. KEY WORDS: Continent Urinary Diversion (CUD); Incontinent Urinary Diversion (IUD); Neurogenic bladder (NGB); Non-neu- rogenic bladder (non-NGB); lower urinary tract dysfunction (LUTD). Submitted 12 November 2022; Accepted 25 November 2022 Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction Mostafa M. Mostafa 1, 2, Ashraf Khallaf 1, Mohamed Kamel 1, Nilesh Patil 1, Ayman Mahdy 1 1 Division of Urology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States; 2 Asiut University Hospitals, Asiut, Egypt. DOI: 10.4081/aiua.2022.4.384 Summary 385Archivio Italiano di Urologia e Andrologia 2022; 94, 4 Continent vs incontinent urinary diversion for non-malignant lower urinary tract dysfunction Board, we started reviewing the charts of all patients who underwent continent and incontinent external urinary diversion procedures for refractory non-malignant LUTD at University of Cincinnati Hospitals in the period between March 2012 and December 2019. All surgeries were per- formed via open surgery by one surgeon (AM) who is well- trained in genitourinary reconstructive surgeries. Inclusion criteria included all patients with refractory non-malignant LUTD who underwent external urinary diversion. Exclusion criteria included patients who were diagnosed with lower urinary tract malignancies and those who did not complete a minimum follow-up of 6 months. We col- lected the demographic and baseline characteristics, sur- gery indications and operative data. Furthermore, we reported early postoperative outcomes that occurred within the first 4 postoperative weeks includ- ing fever, pelvic infection or abscess, wound infection, pneumonia, UTI, paralytic ileus (defined by abdominal pain other than incisional, abdominal distension, failure to pass stool and/or flatus in addition to radiological findings suggestive of obstruction), sepsis, blood loss (defined by hemoglobin drop that required blood transfusion), cardiac complications, and re-operation rate. Late postoperative outcomes that manifested more than 6 months after sur- gery including urological symptom control, stomal compli- cations, anastomotic ureteric strictures, stone formation, wound complications, hydronephrosis with renal function impairment, and need for re-operation were also reported. Urological symptom control was assessed based on the successful resolution of the specific urological symptoms related to patients’ preoperative urological conditions that were the main drive for intervention. Resolution of these symptoms in terms of resolution of hydronephrosis, reduc- tion in urosepsis episodes, alleviation of bladder pain, reduction in urolithiasis, social dryness, and independence was confirmed based on both history taking and clinical examination after a minimum follow-up of 6 months post- operatively. Statistical analysis All statistical analyses were conduct- ed using the SPSS software (SPSS, Inc., Chicago, IL, USA; version 26). Quantitative variables are presented as means ± standard deviation, and qualitative variables are expressed as frequencies with percentages. Results were compared between two groups using Student’s t-test and Mann- Whitney U test for quantitative vari- ables and chi-square test and McNemar’s test for qualitative vari- ables. A p-value of < 0.05 was con- sidered significant. RESULTS After fulfilling the inclusion and exclusion criteria, 78 patients were included in the study. Fifty-five patients (70.51%) had NGB while 23 patients (29.49%) suffered from non-NGB. Most non-NGB patients had radiation-induced urinary tract damage (39.13%, n = 9), followed by refrac- tory overactive bladder (OAB) (21.74%, n = 5), stress uri- nary incontinence (SUI) (17.39%, n = 4), BPS (17.39%, n = 4), and finally traumatic urethral rupture (4.35%, n = 1). Fifty-three patients (67.95%) underwent IUD, while CUD was performed for 25 patients (32.05%). CUD pro- cedures included cutaneous catheterizable ileocystoplasty (19 patients), CUD using ileal catheterizable stoma via Yang-Monte technique (4 patients), and Indiana pouch (2 patients). On the other hand, IUD procedures included cystectomy with ileal conduit (22 patients), ileovesicosto- my (21 patients), and cystectomy with colon conduit (10 patients). The cystectomy was done via a simple supra- trigonal approach without concomitant prostatectomy in males to avoid the associated increased morbidity in those patients with benign conditions. Although ileum is the most commonly used bowel segment for IUD, 10 patients needed a colon conduit in our study to avoid the use of the irradiated devitalized small bowel in those with prior pelvic irradiation and to avoid the need for bowel re-anastmosis in those with a colostomy. Most of the study population were overweight with BMI of 27.77 ± 7.06 and 29.44 ± 7.29 for IUD and CUD groups respectively, female (62.82%) and white (79.49%) with no significant differences between the IUD and CUD groups regarding the demographic and baseline characteristics (Table 1). Based on the underlying condition, there was no signifi- cant difference in early and late postoperative complica- tions and urological symptoms control between NGB and non-NGB patients with p-values of 0.490, 0.563, and 0.160, respectively. Noticeably, fever was exclusively encountered in patients with NGB with p-value of 0.011, while more non-NGB patients had early wound infection (p-value = 0.007). The only significant difference in the late outcomes between the two groups was the incidence Table 1. Demographic and baseline characteristics of the two groups. Variables Incontinent Urinary Continent Urinary P-value Diversion Diversion (IUD) (n = 53) (CUD) (n = 25) • Age in years (mean ± SD) 51.45 ± 15.44 52.04 ± 16.52 0.996 • Follow-up duration in months (mean ± SD) 25 ± 18 26 ± 17 0.951 • Gender 1) Female n (%) 30 (56.60%) 19 (76%) 0.098 2) Male n (%) 23 (43.40%) 6 (24%) • Race 1) White n (%) 39 (73.58%) 23 (92%) 2) Black n (%) 12 (22.64%) 2 (8%) 0.296 3) Hispanic n (%) 1 (1.89%) 0 (0%) 4) Native American n (%) 1 (1.89%) 0 (0%) • BMI (mean ± SD) 27.77 ± 7.06 29.44 ± 7.29 0.370 • Smoking n (%) 11 (20.75%) 3 (12%) 0.347 • Concomitant Comorbidities 1) DM n (%) 11 (20.75%) 4 (16%) 0.619 2) HTN n (%) 25 (47.17%) 9 (36%) 0.353 • Hospital stay (days) 9.89 ± 6.32 8.04 ± 2.62 0.825 • Indications for surgery I) Neurogenic bladder (NGB) n (%) 40 (75.47%) 15 (60%) 0.162 II) Non-neurogenic bladder (non-NGB) n (%) 13 (24.53%) 10 (40%) Archivio Italiano di Urologia e Andrologia 2022; 94, 4 M.M. Mostafa, A. Khallaf, M. Kamel, N. Patil, A. Mahdy 386 of stomal retraction which occurred only in patients with non-NGB (p-value = 0.027) (Table 2). The mean times to stomal complications, anastomotic ureteric strictures, renal and ureteric urolithiasis, wound complications, and hydronephrosis or renal impairment were 23.34 ± 9.54, 14.32 ± 2.13, 13.45 ± 6.74, 12.67 ± 5.64, and 14.56 ± 5.78 months, respectively. The average number of complications per patient was 0.83 for early complications, and 1.03 for late complications. Based on the type of urinary diversion, no significant dif- ference was observed between patients who underwent IUD and those who underwent CUD in terms of early and late postoperative complications and urological symp- toms control with p-values of 0.822, 0.146, and 0.732, respectively. The incidence of stomal leakage and stenosis was signifi- cantly higher in the CUD group than in the IUD group (52% vs 0%, p-value = < 0.001 and 28% vs 3.77%, p- value = 0.002, respectively) (Table 3). Interestingly, none of the patients experienced grade V complications based on modified Clavien-Dindo classifi- cation system. The majority of patients with early complications had grade I and II complications (29.49% and 14.10% of patients, respectively), while most patients with late com- plications suffered from grade IIIa and II complications (21.79% and 15.38%, respectively) (Table 4). DISCUSSION A well-established treatment of bladder cancer, external urinary diversion can also be used for management of benign urinary conditions that cause significant LUTD. The management of such conditions is primarily achieved by conservative and/or minimally invasive measures. If these measures fail, surgical interventions are indicated (7, 8, 14, 15). These surgical interventions, however, have a significant impact on patients’ quality of life. In an interesting study by Borghi et al. 2021 (16), they dis- cussed orthotopic urinary diversion as a feasible surgical intervention in refractory non-malignant LUTD and its impact on quality of life and sexual function particularly in females. They reported that although orthotopic neobladder improves physical and mental health in patients with refractory non-malignant LUTD, urinary symptoms were frequently encountered affecting general health and sexual function in females as compared to males (16). The optimal surgery prevents recurrent episodes of symptomatic UTIs or urosepsis, prevents uri- nary stone formation, provides satisfactory continence between voids, and prevents upper urinary tract damage (9, 12, 13). In this study, we analyzed the outcomes of external urinary diversion in refractory non-malignant lower urinary tract conditions aiming to evaluate their effectiveness and complications. Although complications were higher in NGB patients in Table 2. Demographic and baseline characteristics of the two groups. Variables Total (n = 78) Neurogenic bladder Non-neurogenic bladder P-value (n (%) (NGB) (n = 55) (non-NGB) (n = 23) (n (%) (n (%) • Early outcomes within the first 4 postoperative weeks Patients with early complications 42 (53.85%) 31 (56.36%) 11 (47.83%) 0.490 Fever 13 (16.67%) 13 (23.63%) 0 (0%) 0.011 Pelvic infection/abscess 4 (5.13%) 4 (7.27%) 0 (0%) 0.184 Wound infection 11 (14.10%) 4 (7.27%) 7 (30.43%) 0.007 Pneumonia 2 (2.56%) 2 (3.64%) 0 (0%) 0.354 Urinary tract infection (UTI) 4 (5.13%) 4 (7.27%) 0 (0%) 0.184 Ileus 21 (26.92%) 18 (32.73%) 3 (13.04%) 0.074 Sepsis 1 (1.28%) 1 (1.82%) 0 (0%) 0.515 Blood Loss+ Transfusion 4 (5.13%) 4 (7.27%) 0 (0%) 0.184 Cardiac Complications (Arrythmias/NSTEMI) 3 (3.85%) 1 (1.82%) 2 (8.70%) 0.150 Reoperation (Acute Surgical Complications) 2 (2.56%) 2 (3.64%) 0 (0%) 0.354 • Late Outcomes after 6-month follow-up Urological symptoms control 52 (66.67%) 34 (61.82%) 18 (78.26%) 0.160 Resolution of hydronephrosis, social dryness, and independence/patients with voiding dysfunction and/or hydronephrosis 40/57 (70.18%) 32/44 (72.73%) 8/13 (61.54%) 0.438 Reduction in urosepsis episodes/patients with recurrent urosepsis episodes 38/55 (69.09%) 25/34 (73.53%) 13/21 (61.90%) 0.365 Alleviation of bladder pain and reduction in urolithiasis/patients with recurrent urolithiasis and bladder pain 28/45 (62.22%) 20/30 (66.67%) 8/15 (53.33%) 0.384 Patients with late complications 47 (60.26%) 32 (58.18%) 15 (65.22%) 0.563 Stomal complications 1) Stomal leakage 13 (16.67%) 7 (12.73%) 6 (26.09%) 0.149 2) Stomal stenosis 9 (11.54%) 6 (10.91%) 3 (13.04%) 0.788 3) Stomal hernia 10 (12.82%) 6 (10.91%) 4 (17.39%) 0.435 4) Stomal site pain/Bleeding 1 (1.1) 1 (1.82%) 0 (0%) 0.515 5) Stomal retraction 2 (2.56%) 0 (0%) 2 (8.70%) 0.027 Anastomotic Ureteric Stricture 2 (2.56%) 2 (3.64%) 0 (0%) 0.354 Stones (Ureters, Kidneys) 15 (19.23%) 12 (21.82%) 3 (13.04%) 0.370 Wound complications 1) Wound separation/Incisional hernia 7 (8.97%) 3 (5.45%) 4 (17.39%) 0.093 2) Sinus/Fistula formation 3 (3.85%) 2 (3.64%) 1 (4.35%) 0.882 3) Recurrent wound infection/Abscess 2 (2.56%) 1 (1.82%) 1 (4.35%) 0.519 Hydronephrosis/Renal impairment 6 (7.69%) 3 (5.45%) 3 (13.04%) 0.251 Reoperation (Persistent Symptoms) 10 (12.82%) 7 (12.73%) 3 (13.04%) 0.970 387Archivio Italiano di Urologia e Andrologia 2022; 94, 4 Continent vs incontinent urinary diversion for non-malignant lower urinary tract dysfunction the early postoperative period and higher in non-NGB patients on the long-term, the differences were generally non-significant and can possibly be attributed to the dif- ference in numbers of patients between the two groups (55 patients with NGB versus 23 patients with non- NGB). In contrast to our study, Cohn et al., 2014 (7) reported fewer overall complications in patients with NGB than with other non-neuro- genic conditions. During the early postoperative period, we reported paralytic ileus as the most common complication, with an overall inci- dence of 26.92%, and the rate was non-significantly higher in patients with NGB than those with non- NGB which can be attributed to the fact that NGB patients usually have a baseline neurogenic bowel mak- ing them vulnerable to paralytic ileus. Fever, pelvic infections with or without abscesses, pneumonia, and UTI were reported only in patients with NGB, a finding explained by higher rates of UTIs, stone formation and lung complica- tions in NGB population in general. However, the overall long term complication rate (60.26%) was comparable to that reported by Erfan et al., 2015 in patients who underwent urinary diversion after radical cystectomy for bladder cancer (60%) (17). Surprisingly, although considered major procedure, urinary diversion is not usually associated with major blood loss with prop- er handling of the bowel and its mesentery. The overall rate of postoperative blood loss that required transfusion Table 4. Modified Clavien-Dindo classification of complications. Variables Total (n = 78) Incontinent Urinary Continent Urinary P-value (n (%) Diversion (IUD) Diversion (CUD) (n = 53) (n = 25) • Early outcomes within the first 4 postoperative weeks Procedures with early complications, n (%) 42 (53.85%) 29 (54.72%) 13 (52%) 0.822 I, n (%) 23 (29.49%) 17 (32.08%) 6 (24%) 0.465 II, n (%) 11 (14.10%) 5 (9.43%) 6 (24%) 0.084 IIIa, n (%) 2 (2.56%) 2 (3.77%) 0 (0%) 0.325 IIIb, n (%) 2 (2.56%) 2 (3.77%) 0 (0%) 0.325 IV, n (%) 4 (5.13%) 3 (5.66%) 1 (4%) 0.756 V, n (%) 0 (0%) 0 (0%) 0 (0%) --- • Complications after 6-month follow-up Procedures with late complications, n (%) 47 (60.26%) 29 (54.72%) 18 (72%) 0.146 I, n (%) 8 (10.26%) 5 (9.43%) 3 (12%) 0.727 II, n (%) 12 (15.38%) 6 (11.32%) 6 (24%) 0.147 IIIa, n (%) 17 (21.79%) 10 (18.87%) 7 (28%) 0.362 IIIb, n (%) 10 (12.82%) 8 (15.09%) 2 (8%) 0.382 IV, n (%) 0 (0%) 0 (0%) 0 (0%) --- V, n (%) 0 (0%) 0 (0%) 0 (0%) --- Table 3. Early and late outcomes based on the type of urinary diversion. Variables Total (n = 78) Incontinent Urinary Continent Urinary P-value (n (%) Diversion (IUD) Diversion (CUD) (n = 53) (n = 25) • Early outcomes within the first 4 postoperative weeks Patients with early complications 42 (53.85%) 29 (54.72%) 13 (52%) 0.822 Fever 13 (16.67%) 10 (18.87%) 3 (12%) 0.448 Pelvic infection/abscess 4 (5.13%) 4 (7.55%) 0 (0%) 0.158 Wound infection 11 (14.10%) 6 (11.32%) 5 (20%) 0.304 Pneumonia 2 (2.56%) 1 (1.89%) 1 (4%) 0.582 Urinary tract infection (UTI) 4 (5.13%) 3 (5.66%) 1 (4%) 0.756 Paralytic ileus 21 (26.92%) 16 (30.19%) 5 (20%) 0.344 Sepsis 1 (1.28%) 1 (1.89%) 0 (0%) 0.489 Blood Loss+ Transfusion 4 (5.13%) 4 (7.55%) 0 (0%) 0.158 Cardiac Complications (Arrythmias/NSTEMI) 3 (3.85%) 2 (3.77%) 1 (4%) 0.961 Reoperation (Acute Surgical Complications) 2 (2.56%) 2 (3.77%) 0 (0%) 0.325 • Late Outcomes after 6-month follow-up Urological symptoms control 52 (66.67%) 36 (67.92%) 16 (64%) 0.732 Resolution of hydronephrosis, social dryness, and independence/patients with voiding dysfunction and hydronephrosis 40/57 (70.18%) 25/40 (62.5%) 15/17 (88.24%) 0.052 Reduction in urosepsis episodes/patients with recurrent urosepsis episodes 38/55 (69.09%) 24/34 (70.59%) 14/21 (66.67%) 0.760 Alleviation of bladder pain and reduction in urolithiasis/patients with recurrent urolithiasis and bladder pain 28/45 (62.22%) 16/26 (61.53%) 12/19 (63.16%) 0.912 Patients with late complications 47 (60.26%) 29 (54.72%) 18 (72%) 0.146 Stomal complications 1) Stomal leakage 13 (16.67%) 0 (0%) 13 (52%) <0.001 2) Stomal stenosis 9 (11.54%) 2 (3.77%) 7 (28%) 0.002 3) Stomal hernia 10 (12.82%) 6 (11.32%) 4 (16%) 0.564 4) Stomal site pain/ Bleeding 1 (1.28%) 0 (0%) 1 (4%) 0.143 5) Stomal retraction 2 (2.56%) 1 (1.89%) 1 (4%) 0.582 Anastomotic ureteric stricture 2 (2.56%) 2 (3.77%) 0 (0%) 0.325 Stones (Ureters, Kidneys) 15 (19.23%) 13 (24.53%) 2 (8%) 0.084 Wound complications 1) Wound separation/ Incisional hernia 7 (8.97%) 6 (11.32%) 1 (4%) 0.291 2) Sinus/Fistula formation 3 (3.85%) 3 (5.66%) 0 (0%) 0.225 3) Recurrent wound infection/Abscess 2 (2.56%) 1 (1.89%) 1 (4%) 0.582 Hydronephrosis/Renal impairment 6 (7.69%) 6 (11.32%) 0 (0%) 0.080 Reoperation (Persistent Symptoms) 10 (12.82%) 8 (15.09%) 2 (8%) 0.382 Archivio Italiano di Urologia e Andrologia 2022; 94, 4 M.M. Mostafa, A. Khallaf, M. Kamel, N. Patil, A. Mahdy 388 in our study was low (5.13%) and only reported in patients with NGB unlike the higher rate of perioperative blood transfusion (28%) reported by Osborn et al., 2014 (18) following cystectomy with urinary diversion for benign conditions and Schiavina et al., 2013 (19) who reported 6.5% transfusion rate after radical cystectomy with urinary diversion for bladder cancer. Although adequately studied following malignancies, the outcomes of external urinary diversions following benign urinary conditions have not been sufficiently addressed. Compared to our study, Osborn et al., 2014 (18) reported a slightly lower rate of postoperative ileus, pneumonia, blood loss requiring transfusion, and stoma complica- tions in patients who underwent cystectomy with urinary diversion for benign conditions. Cohn et al., 2014 (7) reported a higher rate of urinary symptom resolution (73%) in 26 patients who underwent cystectomy with urinary diversion for refractory benign conditions. However, they reported a higher rate of infections and wound complications (35% and 23% respectively) than in our study. In contrast to our study results, Andersen AV et al., 2012 (20) reported a moderate rate of complica- tions after bladder augmentation and/or cystectomy with urinary diversion for 41 patients with BPS while attribut- ing this rate mainly to stomal and intestinal issues. Another study done by Al Hussein Al Awamlh B et al., 2015 (21) investigated the quality of life in 29 patients with refractory benign conditions who underwent cystec- tomy with urinary diversion, and reported a significant rate of early postoperative complications of 65.5% which they attributed to pelvic pain, infections, and gut distur- bances. Additionally, the cumulative physical health domain and cumulative mental health domain used to assess the quality-of-life revealed worsening in 26% and 21% of patients respectively. There was considerable resolution of urological symp- toms in 66.67% of patients, and the rate of improvement was non-significantly higher in non-NGB patients than in NGB patients. These findings were supported by several studies such as Cohn et al., 2014 (7) and E. Brown et al., 2015 (6) who reported that cystectomy and urinary diversion procedures were successful management options for benign lower urinary conditions. Relevant to that, the re-operation rate for uncontrolled symptoms and/or acute surgical complications including wound complications and stomal complications such as stomal retraction, recurrent stomal stenosis, and stomal leakage was 12.82% and 2.56%, respectively with non-significant difference between NGB and non-NGB groups. Generally, incontinent diversions were associated with higher rates of early postoperative complications, while continent diversions were associated with more late post- operative complications, although the differences were non-significant. Many studies previously investigated the outcomes of bladder reconstruction and urinary diversion surgeries (12, 22, 23). One of the most well-structured studies was conducted by Cody et al., 2012 (12) who con- cluded that, based on a pool of five studies, there was no significant difference in the outcomes among continent diversion, incontinent diversion, and bladder augmenta- tion. On the other hand, Clark et al., 2005 (22) demon- strated higher rate of complications in patients with con- tinent diversion than in patients who underwent ileal conduit. Study strengths We investigated the outcomes of external urinary diver- sion exclusively in patients with refractory non-malignant LUTD. Additionally, we highlighted the distinctive out- comes based on both the underlying condition and the type of external urinary diversion. The included cases in our study were performed by one surgeon who is well trained in urinary reconstructive sur- geries eliminating bias related to technical issues. Study limitations Besides being a single-center single-surgeon experience, this is a retrospective study that represented a heteroge- neous group of population including NGB and non-NGB. Additionally, the underlying pathology usually deter- mines the type of surgery; therefore, the urinary diver- sions are indicated for more complicated cases which can skew the patient population in our study. A standardized questionnaire was not used in the follow- up to report patient’s satisfaction regarding the urological symptoms; However, this was related to the multiple social and demographic factors that could limit those patients’ ability to return accurately filled questionnaires. CONCLUSIONS External continent and incontinent urinary diversion can be utilized as the last resort for patient with refractory non-malignant LUTD. These procedures can achieve a reasonable level of urological symptoms control, but with associated adverse outcomes. The most commonly reported complication during the early postoperative period is paralytic ileus, while stomal complications and recurrent urolithiasis are the most frequently encoun- tered complications on the long-term. Fever is more like- ly to be encountered in patients with NGB, while early wound infection and late stomal retraction are more asso- ciated with non-NGB. Stomal leakage and stenosis are more encountered with CUD. Although the differences were non-significant, complications tend to be higher with IUD and in NGB patients during the early postoper- ative period and higher with CUD and in non-NGB patients on the long-term. REFERENCES 1. Pozza G, Iafrate M, Mancini M, et al. 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J Urol. 1987; 138:1386-9. Correspondence Mostafa M. Mostafa, MD (Corresponding Author) mostafaabdelaziz91@gmail.com Research Fellow of Urology, Division of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way,Cincinnati, OH 45267 Assistant Lecturer of Urology, Asiut University Hospitals, Asiut, Egypt, Ashraf Khallaf, MD ashraf.m.khallaf2@gmail.com Visiting Scholar of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267 Mohamed Kamel, MD kamelme@ucmail.uc.edu Professor of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way,Cincinnati, OH 45267 Nilesh Patil, MD patilnh@ucmail.uc.edu Associate Professor of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267 Ayman Mahdy, MD, PhD, MBA mahdyan@uc.edu Chief of Urology, Professor of Urology, R. Bruce and Barbara Bracken Endowed Chair in Surgical Urology, Director of Voiding Dysfunction and Female Urology, Medical Director of Urology, the West Chester Hospital, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0589, Cincinnati, OH 45267