Health Outcomes Research

Urinary Diversion in Patients With Spinal Cord

Injury in the United States
Andrew C. Peterson, Lesley H. Curtis, Alisa M. Shea, Kristy M. Borawski,
Kevin A. Schulman, and Charles D. Scales, Jr.
OBJECTIVE To describe the patterns in the use of bladder augmentation and urinary diversion to manage
urologic sequelae among patients with spinal cord injury in the United States.
MATERIALS AND Discharge estimates were derived from the Nationwide Inpatient Sample. All patients underwent
METHODS bladder augmentation or ileal conduit diversion from 1998 to 2005 and had a diagnosis of spinal
cord injury.
RESULTS Ileal loop diversion was performed in an estimated 1919 patients and bladder augmentation in
1132 patients with spinal cord injury from 1998 to 2005. Patients undergoing urinary diversion
tended to be older (mean age 46 vs 34 years; P <.001) and to have Medicare as the primary payer
(55.0% vs 30.8%; P <.001). Patients who underwent urinary diversion appeared to use more
healthcare resources, with a longer length of stay (15 vs 9 days), higher hospital charges ($58,626
vs $37,222), and a greater use of home healthcare services after discharge (all P <.001). Patients
at teaching institutions were more likely to undergo bladder augmentation (42%) than those at
nonteaching institutions (23%; P <.001).
CONCLUSION Bladder augmentation is used in approximately one-third of cases to manage the urologic
complications of spinal cord injury. These patients likely constitute a clinically distinct pop-
ulation that uses fewer healthcare resources. The lower augmentation rates at nonteaching
institutions may indicate an opportunity for quality improvement. UROLOGY 80: 1247e1251,
2012.
2012 Elsevier Inc.

E
stimates suggest that 232,000-316,000 people are
living with spinal cord injuries in the United
States.1 Up to 50 million people worldwide may be
affected by spinal cord injuries or abnormalities, such as
spinal dysraphism.2 Patients with spinal cord injuries are
at risk throughout their lifetimes of a variety of geni-
tourinary problems, including incontinence, infection,
genitourinary tract stones, sexual dysfunction, upper
Financial Disclosure: A. C. Peterson received payment as a consultant/lecturer from
American Medical Systems; L. H. Curtis, none, but has made available on-line
a detailed listing of financial disclosures (http://www.dcri.duke.edu/about-us/conflict-
of-interest/); A. M. Shea, none; K. M. Borawski received payment as a lecturer
from Pfizer; K. A. Schulman, none, but has made available on-line a detailed listing of
financial disclosures (http://www.dcri.duke.edu/about-us/conflict-of-interest/); C. D.
Scales received research funding from Tengion.
Funding Support: This work was supported by a research agreement between Ten-
gion, Inc., and Duke University; C. D. Scales was supported by the Robert Wood
Johnson Foundation Clinical Scholars program and the U.S. Department of Veterans
Affairs.
The views expressed in this article are those of the authors and do not necessarily
represent the official view of the U.S. Department of Veterans Affairs.
From the Department of Surgery and Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina; Department of Surgery,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
Departments of Medicine and Urology, University of California, Los Angeles, School of
Medicine, Los Angeles, California
Reprint requests: Kevin A. Schulman, M.D., Duke Clinical Research Institute, P.O.
Box 17969, Durham, NC 27715. E-mail: kevin.schulman@duke.edu
Submitted: February 29, 2012, accepted (with revisions): June 26, 2012
ª 2012 Elsevier Inc.
All Rights Reserved
urinary tract deterioration, and, ultimately, renal
failure.3-5
The management goals for patients with spinal cord
injuries have traditionally included preservation of the
upper urinary tracts through a program concentrating on
the maintenance of a low-pressure bladder that contrib-
utes to safe storage of urine.6 The secondary goals have
included quality-of-life concerns such as continence, the
prevention of recurrent infections, the prevention of
stones, and ease of maintenance for the patient. All these
goals can be achieved through an aggressive management
program consisting of self-catheterization and pharmaco-
logic relaxation of the bladder, often with anticholinergic
medications. However, when conservative measures are
unable to achieve safe storage of urine or quality-of-life
goals, surgical treatment may be warranted.7 Interven-
tions such as bladder augmentation and urinary diversion
can preserve upper urinary tract function while main-
taining or improving quality of life.8,9
Surgical management of the bladder in patients with
spinal cord injury has included bladder augmentation and
urinary diversion; however, the practice patterns in
a nationally representative sample have been poorly
characterized. Given this context, we sought to describe
the patterns of surgical care and short-term outcomes for
patients with spinal cord injuries in the United States.
0090-4295/12/$36.00 1247
http://dx.doi.org/10.1016/j.urology.2012.06.063
We hypothesized that considerable variation in practice
patterns would exist according to sociodemographic
characteristics and care setting.
MATERIAL AND METHODS
Data Source
We used data from the Nationwide Inpatient Sample (NIS),
a project sponsored by the Agency for Healthcare Research and
Quality. The sampling frame of the NIS includes approximately
90% of all hospital discharges in the United States, and the data
constitute a 20% stratified sample of discharges from approxi-
mately 1000 nonfederal hospitals in >30 states.10 The NIS
includes information about all discharges, regardless of payer
(including Medicare, Medicaid, private insurance, and unin-
sured patients). Discharge abstracts include the primary and
secondary diagnoses and procedures, discharge status, length of
stay, hospital characteristics, patient demographic characteris-
tics, and total charges. The institutional review board of Duke
University Health System determined that the present study was
exempt from the requirement for approval.
Study Population
We identified patients undergoing ileal loop urinary diversion
(International Classification of Diseases, Ninth Revision,
Clinical Modification procedure code 56.51) or bladder
augmentation (code 57.87) who also had a diagnosis code for
spinal cord injury (see Appendix Table). No patients had
a diagnosis code for bladder cancer. We generated national
estimates of procedure use from the 1998 through 2005 cohorts
of the NIS. We included patient demographics (ie, age, race,
and sex) as recorded in the NIS. Approximately 25% of the
observations in the NIS are missing data for patient race. Other
data, such as primary payer, hospital teaching status, and
hospital location, were used as reported by the NIS. The
outcomes, such as length of stay, total charges, and discharge
status, were also analyzed as reported by the NIS.
Statistical Analysis
We used SAS statistical software version 9.1 (SAS Institute,
Cary, NC) to generate national estimates, with an ultimate
cluster variance model to account for the complex survey design
of the NIS. We used NIS sample weights for all analyses. We
used the Rao-Scott chi-square test to compare categorical
outcomes and z tests to compare continuous outcomes. We
assumed a 2-sided hypothesis testing with a ¼ 0.05 for a type I
error rate.
RESULTS
A total of 3051 procedures were performed from 1998 to
2005, including 1919 ileal loop diversions (63%) and
1132 bladder augmentations (37%). We observed several
differences between the patients undergoing bladder
augmentation and those undergoing ileal loop diversion
(Table 1). The patients who underwent ileal loop
diversion were older (46 vs 34 years; P <.001). More than
one-half of the patients undergoing bladder augmentation
were younger than 41 years, but more than one-half of
patients undergoing ileal loop diversion were 41 years.
No racial differences were seen between the 2 groups;
1248
however, this finding must be interpreted with caution,
because data on race were missing for approximately one-
quarter of the patients. The patients undergoing ileal loop
diversion were most likely to have Medicare as the
primary payer, and private insurance was the most
common payer among patients undergoing bladder
augmentation (P <.001).
The patterns of care also differed by hospital charac-
teristics. Most procedures were performed at teaching
institutions. The patients at teaching institutions were
more likely to undergo bladder augmentation (42%) than
those at nonteaching institutions (23%; P <.001).
The in-hospital outcomes differed significantly
between the 2 groups (Table 2). The patients undergoing
ileal loop urinary diversion required more healthcare
resources than did the patients undergoing bladder
augmentation. For example, the length of stay was shorter
and the hospital charges were lower for patients under-
going bladder augmentation. In addition, patients
undergoing ileal loop diversion were more likely to be
discharged to home healthcare than those undergoing
bladder augmentation (37.0% vs 23.6%; P <.001).
COMMENT
The present study is the first nationally representative
analysis of patients with spinal cord injury who under-
went bladder augmentation or urinary diversion,
presumably to manage urologic sequelae of their injury.
Bladder augmentation was used in approximately one-
third of cases. We observed important differences in the
patient characteristics and outcomes between the 2
cohorts. The patients undergoing bladder augmentation
were younger and more likely to be privately insured. A
comparison of hospital outcomes suggested that patients
undergoing bladder augmentation used fewer healthcare
resources during recovery, including shorter hospital stays,
lower charges, and a lower proportion of patients dis-
charged to home healthcare services. These differences
suggest that the 2 groups represent clinically distinct
patient cohorts.
A number of explanations could account for the segre-
gation of patients with spinal cord injury among surgical
interventions. Surgical intervention might be necessary
when anticholinergic therapy and clean intermittent
catheterization regimens fail in the treatment of neuro-
genic bladder secondary to spinal cord injury. Bladder
augmentation with small or large bowel can increase the
storage volume, improve bladder compliance, reduce the
risk of progression to renal failure, and improve conti-
nence.11-14 Management considerations for bladder
augmentation include the need to continue clean inter-
mittent catheterization, the formation of bladder calculi
from secreted mucus, and the need for a major recon-
structive surgical procedure.13,15 Thus, younger (and
presumably healthier) patients may preferentially undergo
bladder augmentation, a conclusion consistent with our
findings. Because of the need for continued intermittent
UROLOGY 80 (6), 2012
Table 1. Baseline characteristics
Characteristic Ileal Loop Urinary Diversion (n ¼ 1919) Bladder Augmentation (n ¼ 3403) P Value
Age (y) 46  0.6 34  0.9 <.001
Age group (n) <.001
0-20 y —* 176 (15.6)
21-40 y 581 (30.3) 559 (49.3)
41-60 y 1050 (54.7) 321 (28.4)
>60 y 257 (13.4) 45 (4.0)
Missing —* —*
Femaley 857 (44.6) 549 (48.5) .33
Racey .14
Black 241 (12.5) 103 (9.1)
Hispanic —* 73 (6.4)
White 1072 (55.9) 572 (50.6)
Missing/other 531 (27.7) 383 (33.8)
Primary payery <.001
Medicaid 365 (19.0) 287 (25.4)
Medicare 1055 (55.0) 349 (30.8)
Private insurance 432 (22.5) 403 (35.6)
Missing/other 67 (3.5) 93 (8.2)
U.S. geographic regiony .59
Midwest or north central 627 (32.7) 384 (33.9)
Northeast 196 (10.2) 149 (13.2)
South 741 (38.6) 373 (32.9)
West 355 (18.5) 226 (20.0)
Hospital teaching statusy <.001
Nonteaching 621 (32.4) 182 (16.0)
Teaching 1293 (67.4) 950 (83.9)
Hospital locationy .007
Rural 135 (7.0) —*
Urban 1779 (92.7) 1103 (97.4)
Data presented as mean  standard error or numbers, with percentages in parentheses, unless otherwise noted.
* Too few discharges or relative standard error for this estimate >0.30; therefore, estimates are unreliable, according to Nationwide
Inpatient Sample criteria.
y
Data presented as numbers, with weighted percentages in parentheses.

Table 2. In-hospital outcomes stratified by type of urinary diversion

Ileal Loop Urinary Diversion Bladder Augmentation
(n ¼ 1919) (n ¼ 1132) P Value
Mean length of stay  SE (d) 15  1.0 9  0.3 <.001
Mean charges per discharge  SD ($) $58,626 $37,222 <.001
In-hospital mortality —* —* .85
Discharge to home healthcare 709 (37.0) 267 (23.6) <.001
Data presented as numbers, with weighted percentages in parentheses, unless otherwise noted.
* Too few discharges for reliable interpretation, according to Nationwide Inpatient Sample criteria.

catheterization, patients with limited manual dexterity
secondary to a greater level of spinal cord injury (eg,
cervical cord injury) might preferentially undergo ileal
loop diversion to simplify management of urinary output.
Ileal loop urinary diversion continues to have a role in
the treatment of patients with neurogenic bladder
secondary to spinal cord injury.16,17 Management
considerations for urinary diversion procedures include
the need to continually wear a urinary device, but this is
likely more straightforward than intermittent catheteri-
zation for patients and caregivers. The choice to proceed
with bladder augmentation rather than incontinent
urinary diversion is often left to the experience and
recommendation of the surgeon; however, functional
status and caregiver support are likely major determinants
of the surgeon’s recommendation.
Patients with higher-level spinal cord injuries generally
have greater functional limitations and would presumably
require more intensive healthcare resource use in the
postoperative period. For example, patients with cervical
spinal cord injury might require more physical therapy,
might have a slower return of bowel function (leading
to longer hospital stays), and need more intensive respi-
ratory monitoring or perioperative therapy. Our findings
of longer lengths of stay, higher hospital charges, and
increased use of home healthcare at discharge are
consistent with this interpretation. These differences in
outcomes support our hypothesis that patients who
undergo urinary diversion represent a distinct clinical
cohort.
We observed no statistically significant differences by
race or sex in the proportion of patients undergoing

UROLOGY 80 (6), 2012 1249

urinary diversion or bladder augmentation, although
approximately 25% of discharges were missing data on
race. Our finding of similar rates of bladder augmentation
among male and female patients contrasts with a previous
study of patients with spina bifida. Among patients with
neurogenic bladder secondary to spina bifida, female
patients were more likely to undergo urinary diversion.18
The reasons for this difference are unclear but might
relate to the ease of learning to catheterize the urethra in
women compared with younger female patients. In
addition, female patients with spina bifida might undergo
fewer augmentation procedures because of a diminished
continence mechanism compared with male patients with
spina bifida. Patients at teaching hospitals were almost
twice as likely to undergo bladder augmentation as those
at nonteaching hospitals. This difference might represent
a referral bias of patients more appropriate for bladder
augmentation to expert centers. Alternatively, practi-
tioner expertise or management philosophy might differ
between teaching and nonteaching hospitals. More data
are required to explore whether this observation repre-
sents optimal practice or an opportunity to maximize
quality of care through additional referrals.
Our study had several limitations. The level of spinal
cord injury is likely the primary determinant of procedure
selection; however, we were unable to reliably determine
the level of injury from these administrative claims data.
Few patients had diagnosis codes for the level of spinal
cord injury. It is likely that when urinary diversion or
augmentation procedures are being performed, surgeons
do not identify the level of injury as a secondary diagnosis.
The use of claims data might have also resulted in clas-
sification error. Other urinary diversion procedures, such
as ileovesicostomy or continent cutaneous diversions,
might have been missed or included in the wrong group.
Although we could not exclude the possibility that local
coding practices could result in the inclusion of patients
with spina bifida in the present study, we used an entirely
different algorithm than was previously used to study
urinary diversion in patients with spina bifida.18 These
data represent hospital discharges only; thus, we were
unable to follow-up patients over time or gather infor-
mation on their history before the procedure, such as
length of time since their injury or previous surgical
interventions. Therefore, some proportion of ileal loop
diversions might have represented failed previous bladder
augmentations. Clinical data, such as information
regarding renal function, were also lacking. Since 2005,
botulinum toxin has been approved by the Food and Drug
Administration for the treatment of neurogenic bladder;
thus, these practice patterns could change as a result of
this advance. Finally, we lacked data on longer term
outcomes after hospital discharge. Despite these limita-
tions, our use of a well-established, nationally represen-
tative data set designed to permit meaningful analysis of
relatively rare procedures, such as bladder augmentation,
suggests areas for additional study and potential optimi-
zation of care for patients with spinal cord injury.
1250
CONCLUSION
Urinary diversion is used more frequently than bladder
augmentation to manage urologic sequelae of spinal cord
injury in the United States. Patients undergoing bladder
augmentation likely represent a distinct clinical pop-
ulation that is younger, more likely to be privately
insured, and that uses fewer healthcare resources after
surgical intervention. Differences in procedure use at
teaching and nonteaching hospitals could represent an
opportunity for quality improvement. Additional inves-
tigation with more detailed data would refine our
understanding of the practice patterns and their impli-
cations for the quality of care in the management of
urologic sequelae of spinal cord injury.
References
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Facts and Figures at a Glance. Birmingham, AL: University of
Alabama at Birmingham; 2011.
2. Stoffel JT, McGuire EJ. Treating the adult neurogenic bladder.
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9. Madersbacher S, Schmidt J, Eberle JM, et al. Long-term outcome of
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http://www.hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2005.
jsp. Accessed December 15, 2011.
11. Quek ML, Ginsberg DA. Long-term urodynamics followup of
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12. McInerney PD, DeSouza N, Thomas PJ, et al. The role of urody-
namic studies in the evaluation of patients with augmentation
cystoplasties. Br J Urol. 1995;76:475-478.
13. Khoury JM, Timmons SL, Corbel L, et al. Complications of
enterocystoplasty. Urology. 1992;40:9-14.
14. Herschorn S, Hewitt RJ. Patient perspective of long-term outcome
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UROLOGY 80 (6), 2012
 APPENDIX
SUPPLEMENTARY DATA
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.urology.2012.
06.063
EDITORIAL COMMENT
It is not uncommon for urologists to encounter patients with
spinal cord injury whose neurogenic bladder dysfunction has not
responded to “conservative” management with medications and
catheterization. This is a very heterogeneous group of patients
with variable degrees of functional impairment (eg, paraplegia,
quadriplegia), urologic abnormalities (eg, detrusor overactivity,
diminished bladder compliance, hydronephrosis, renal damage,
urethral dysfunction), and comorbidities (eg, obesity, previous
abdominal surgeries, decubitus ulcers, neurogenic bowel
dysfunction). All these factors must be taken into account when
determining which (if any) surgical treatment is appropriate to
address the neurogenic bladder dysfunction. One common deci-
sion is whether to reconstruct the lower urinary tract (typically
with augmentation cystoplasty) or to perform supravesical
diversion (typically using an ileal conduit). The authors examined
the Nationwide Inpatient Sample database to identify patients
with spinal cord injury who had undergone bladder augmentation
or urinary diversion from 1998 to 2005. They conclude that
patients undergoing augmentation cystoplasty tended to be
younger and healthier than those undergoing ileal conduit, which
was not surprising. It is notable that approximately 15% of the
UROLOGY 80 (6), 2012
augmentation surgeries were performed in children (aged 0-20
years), and the number of ileal conduit procedures in children was
very low. I would suspect that most of these surgeries were per-
formed by pediatric urologists, likely at teaching institutions.
Presumably, patients with limited upper extremity function
(higher spinal cord injury levels) would be more likely to
undergo diversion; however, the authors were unable to examine
this because of data limitations. Similarly, we do not have data
about comorbidities (eg, decubitus ulcers, urethral erosions, renal
failure), which likely would have favored the performance of
urinary diversion. The finding that diversion patients used more
resources, had longer postoperative hospitalizations, and
a greater use of home healthcare services suggests that diversion
surgeries were (appropriately) performed in sicker patients.
More augmentations were performed at teaching hospitals
than at nonteaching hospitals. The authors state that this might
be an opportunity for quality improvement; however, without
additional clinical information, it is really impossible to know. It
seems at least equally likely that urologists at nonteaching
hospitals might choose to perform diversions themselves
(because these are commonly performed for the treatment of
bladder cancer) and would choose to refer the reconstructive
cases to teaching hospitals.
J. Quentin Clemens, M.D., F.A.C.S., M.S.C.I., Division of
Neurourology and Pelvic Reconstructive Surgery,
Department of Urology, University of Michigan Medical
Center, Ann Arbor, Michigan
http://dx.doi.org/10.1016/j.urology.2012.06.074
UROLOGY 80: 1251, 2012.
2012 Elsevier Inc.
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