Continent bladder substitution has substantially developed since its introduction nearly three decades ago. Although the ideal bladder substitute is yet to be developed, it has been well established that all patients undergoing radical cystectomy should be considered at least potential candidates for orthotopic urinary diversion . Notably, in many bladder cancer referral centres, including ours, orthotopic substitution has replaced ileal conduit as the primary form of reconstruction [2-4]. However, this dissemination has not been noticed at the community level.
The authors  provide a real-life snapshot of the current trends of urinary diversion on the nationwide level. Using the nationwide inpatient sample, they report significant underutilisation of continent urinary diversion after radical cystectomy; 92% of patients undergoing radical cystectomy received incontinent reconstruction. Nonetheless, they noticed a modest trend towards increased continent diversion in the later years of the study; however, the percentage is still far from expected.
Moreover, the study reinforces previous findings of significant demographic disparities in receiving continent diversion. These disparities have become a persistent theme and have also been demonstrated in resource utilisation, oncological outcomes and access to minimally invasive surgery . Is it surgeons' bias or patients' choice? This issue is far from resolved. Undoubtedly, these disparities are to be addressed in healthcare policy planning, more research is also needed to investigate factors influencing the surgeon's decision-making process.