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Llueca A, Maazouzi Y, Ponce P, Serra A, Garau C, Rodrigo M. Step by step Indiana pouch construction in a previously irradiated patient with a cervical cancer relapse. Int J Surg Case Rep 2019; 66:187-191. [PMID: 31865230 PMCID: PMC6928324 DOI: 10.1016/j.ijscr.2019.11.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/24/2019] [Accepted: 11/28/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Radiation therapy and radical pelvic surgery, either radical cystectomy or pelvic exenteration, is the golden standard treatment for infiltrating bladder carcinoma, as well as advanced or recurrent cervical, vulvar, vaginal and endometrial cancer. However, due to the poor radiation sensitivity of the cervix and vagina, a high-radiation dose is required, leading to early and/or late onset urogenital complications in approximately 50% of the patients. CASE PRESENTATION The following case report describes a 64-year-old native Russian woman presenting a relapse of a vaginal cuff squamous cell carcinoma, who underwent a laterally extended endopelvic resection (LEER) followed by a neobladder reconstruction based on the Indiana pouch (IP) technique. The process is described here step by step. DISCUSSION Indiana pouch urinary diversion was based on thorough research, the reproducibility of the technique, our urologist's experience with the Indiana Pouch, as well the lower rate of complications published in various separate series. CONCLUSION Indiana pouch is a successful continence urinary reservoir with a reproductible technique, however long-term observation is needed.
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Affiliation(s)
- Antoni Llueca
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain; Dept. of Medicine, University Jaume I (UJI), Castellon de la Plana, Spain.
| | - Yasmine Maazouzi
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain
| | - Paula Ponce
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain
| | - Anna Serra
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain; Dept. of Medicine, University Jaume I (UJI), Castellon de la Plana, Spain
| | - Carmen Garau
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain
| | - Miguel Rodrigo
- Multidisciplinary Unit for Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellon, Spain; Dept. of Medicine, University Jaume I (UJI), Castellon de la Plana, Spain
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Isharwal S, Gupta S. Management of End-Stage Radiation Cystitis in the Cancer Survivor. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).
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Urh A, Soliman PT, Schmeler KM, Westin S, Frumovitz M, Nick AM, Fellman B, Urbauer DL, Ramirez PT. Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2013; 129:580-5. [PMID: 23480870 PMCID: PMC3935607 DOI: 10.1016/j.ygyno.2013.02.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/13/2013] [Accepted: 02/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare outcomes of patients undergoing continent or incontinent urinary diversion after pelvic exenteration for gynecologic malignancies. METHODS Data on patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 were collected. A multivariate logistic regression model was used and statistical significance was P<0.05. RESULTS A total of 133 patients were included in this study. The mean age at exenteration was 47.6 (range, 30-73) years in the continent urinary diversion group and 57.2 (range, 27-86) years in the incontinent urinary diversion group (P<0.0001). Forty-six patients (34.6%) had continent urinary diversion, and 87 patients (65.4%) had incontinent urinary diversion. The rates of postoperative complications in patients with continent and incontinent urinary diversion, respectively, were as follows: pyelonephritis, 32.6% versus 37.9% (P=0.58); urinary stone formation, 34.8% versus 2.3% (P<0.001); renal insufficiency, 4.4% versus 14.9% (P=0.09); urostomy stricture, 13.0% versus 1.2% (P=0.007); ureteral (anastomotic) leak, 4.4% versus 6.9% (P=0.71); ureteral (anastomotic) stricture, 13.0% versus 23% (P=0.25); fistula formation, 21.7% versus 19.5% (P=0.82); and reoperation because of complications of urinary diversion, 6.5% versus 2.3% (P=0.34). Among patients with continent urinary diversion, the incidence of incontinence was 28.3%, and 15.2% had difficulty with self-catheterization. CONCLUSION There were no differences in postoperative complications between patients with continent and incontinent conduits except that stone formation was more common in patients with continent conduits.
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Affiliation(s)
- Anze Urh
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas 77030, United States
| | - Pamela T. Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Shannon Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Alpa M. Nick
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Bryan Fellman
- Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Diana L. Urbauer
- Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
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Covert WM, Westin SN, Soliman PT, Langley GD. The role of mucoregulatory agents after continence-preserving urinary diversion surgery. Am J Health Syst Pharm 2012; 69:483-6. [PMID: 22382478 DOI: 10.2146/ajhp110212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The postsurgical use of N-acetylcysteine, octreotide, and other agents to reduce mucus accumulation after urinary diversion procedures is described. SUMMARY Patients undergoing continence-sparing bladder resection are at risk for infection and stone formation due to mucus accumulation. In addition to N-acetylcysteine, agents studied for mucoregulatory control in such patients include aspirin, urea, ranitidine, and octreotide. N-acetylcysteine has high mucolytic activity in vitro, and positive outcomes with instillations of 20% N-acetylcysteine solution have been reported in some patients. Significant mucus reductions were reported in small numbers of patients treated with oral ranitidine 300 mg daily or instillations of 30 mL of urea 40% solution, while the benefits of aspirin are more questionable. To date, there has been only one randomized controlled trial comparing various agents for mucus reduction after reconstructive bladder surgery; the results indicated no significant benefits with the use of N-acetylcysteine, aspirin, or ranitidine. In one small study (n = 40), the use of subcutaneous octreotide immediately before and for 15 days after surgery was reported to yield significant reductions in mucus production, the need for bladder irrigation to clear blockages, and the mean duration of hospital stays. CONCLUSION Various agents evaluated for mucus control after urinary diversion procedures (oral ranitidine or aspirin, N-acetylcysteine or urea instillations, and subcutaneous octreotide), while reportedly effective for some patients, remain of questionable benefit. More research is needed to define the optimal role of these agents for this indication.
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Affiliation(s)
- Wendy M Covert
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, 77030, USA.
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Abstract
The concept of organ-preserving therapies is a trend in modern oncology, and several tumour types are now treated in this fashion. Trimodality therapy consisting of as thorough a transurethral resection of the bladder tumour as is judged safe, followed by concomitant chemoradiation therapy, is emerging as an attractive alternative for bladder preservation in selected patients with muscle-invasive bladder cancer. Long-term data from multiple institutional and cooperative group studies have shown that this approach is safe and effective and that it provides patients with the opportunity to maintain an intact and functional bladder with a survival rate similar to that for modern radical cystectomy.
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Affiliation(s)
- N J Rene
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC
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Eisenberg MS, Dorin RP, Bartsch G, Cai J, Miranda G, Skinner EC. Early complications of cystectomy after high dose pelvic radiation. J Urol 2010; 184:2264-9. [PMID: 20952024 DOI: 10.1016/j.juro.2010.08.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE Radical cystectomy in patients with a history of pelvic radiation therapy is often a challenging and morbid procedure. We report early complication rates in patients undergoing cystectomy and urinary diversion after high dose pelvic radiation. MATERIALS AND METHODS From 1983 to 2008, 2,629 patients underwent cystectomy with urinary diversion at a single institution. Of these patients 148 received 60 Gy or greater pelvic radiation therapy before surgery. Patient medical records were retrospectively reviewed and any complication within 90 days of surgery was graded using the Clavien-Dindo system. RESULTS Median patient age was 74 years with a median American Society of Anesthesiologists score of 3. Patients received a median of 70 Gy pelvic radiation therapy a median of 2.3 years before surgery. Urinary diversions performed were ileal conduit in 65 patients (43.9%), continent cutaneous pouch in 35 (23.6%) and orthotopic neobladder in 48 (32.4%). A total of 335 early complications were identified. The highest grade complication was 0 in 23% of the patients, grade 1 in 12.2%, grade 2 in 32.4%, grade 3 in 18.9%, grade 4 in 7.4% and grade 5 in 6.1%. Age older than 65 years and American Society of Anesthesiologists score were statistically significant predictors of postoperative complications (p=0.0264 and p=0.0252, respectively). The type of urinary diversion did not significantly affect the grade distribution or number of early complications per patient (p=0.7444 and p=0.1807, respectively). CONCLUSIONS The early complication rate using a standardized reporting system in patients undergoing radical cystectomy after radiation therapy is higher than previously published in nonirradiated subjects. Age and American Society of Anesthesiologists score but not urinary diversion type were associated with early complications in this population.
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Affiliation(s)
- Manuel S Eisenberg
- USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033-9178, USA
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8
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Incorporating pelvic/vaginal reconstruction into radical pelvic surgery. Gynecol Oncol 2009; 115:154-163. [DOI: 10.1016/j.ygyno.2009.05.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 05/26/2009] [Accepted: 05/28/2009] [Indexed: 11/20/2022]
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Bochner BH, Karanikolas N, Barakat RR, Wong D, Chi DS. Ureteroileocecal appendicostomy based urinary reservoir in irradiated and nonirradiated patients. J Urol 2009; 182:2376-80. [PMID: 19762044 DOI: 10.1016/j.juro.2009.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE The ureteroileocecal appendicostomy reservoir is designed to potentially decrease the morbidity of continent diversion, particularly in previously irradiated patients. We report our experience with this reservoir to compare complications in irradiated and nonirradiated patients. MATERIALS AND METHODS The records of 52 consecutive patients who underwent ureteroileocecal appendicostomy diversion between March 2001 and January 2008 were evaluated. Outcomes were analyzed according to whether patients received radiation therapy to the pelvis. Complications were reported as early (within 90 days of surgery) or late. RESULTS Overall 29 patients received radiation therapy. The incidence of early complications requiring operative intervention was 14%, including 2 patients (9%) with and 5 (17%) without radiation (p = 0.68). All except 1 reoperation was done to revise the stoma. Early urinary tract infections developed in 17% of nonirradiated and 28% of irradiated patients (p = 0.51). The most common late complication was stomal stenosis requiring dilation on an outpatient basis, which occurred in 21% of patients, including 4 with (17%) and 7 without (24%) radiation (p = 0.74). Late ureteral complications requiring intervention were reported in 15% of renal units, including 2 of 44 without (5%) and 6 of 56 with (11%) radiation (p = 0.21). CONCLUSIONS Ureteroileocecal appendicostomy is a safe, effective technique for continent cutaneous urinary diversion in heavily irradiated patients. Complication rates did not significantly differ between irradiated and nonirradiated patients, and appear improved compared to those in previous reports.
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Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, Kimmel Center for Prostate and Urologic Cancers, New York, New York 10021, USA.
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Hautmann RE, de Petriconi R, Volkmer BG. Neobladder formation after pelvic irradiation. World J Urol 2008; 27:57-62. [DOI: 10.1007/s00345-008-0346-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 10/18/2008] [Indexed: 11/30/2022] Open
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Milosevic M, Gospodarowicz M, Zietman A, Abbas F, Haustermans K, Moonen L, Rödel C, Schoenberg M, Shipley W. Radiotherapy for Bladder Cancer. Urology 2007; 69:80-92. [PMID: 17280910 DOI: 10.1016/j.urology.2006.05.060] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 05/03/2006] [Indexed: 11/24/2022]
Abstract
The radiotherapy panel met to develop international consensus about the optimal use of radiotherapy, alone or in combination with surgery and chemotherapy, in the radical treatment of patients with bladder cancer. A consensus meeting of experts in the treatment of bladder cancer was convened by the Société Internationale d'Urologie (SIU). The radiotherapy committee, which had international representation from 6 countries, performed a critical review of the English-language literature and developed evidence-based guidelines for the use of radiotherapy in the treatment of patients with bladder cancer. The strength of the evidence supporting each recommendation was ranked according to a 4-point scale. Consensus statements were developed that address (1) the effectiveness of radiotherapy in the treatment of bladder cancer, (2) the most appropriate patients for curative treatment with radiotherapy, (3) the optimal method of delivery of radiotherapy, (4) the best radiation prescription for treating bladder cancer, and (5) optimal management of the patient's condition after radiotherapy has been provided. Radiotherapy is effective treatment for selected patients with bladder cancer; it produces long-term disease control with preservation of normal bladder function. Modern radiotherapy treatment techniques offer the potential to improve cure rates and reduce adverse effects. All patients in whom the condition is newly diagnosed should be assessed in a multidisciplinary setting, where the relative merits of surgery, radiotherapy, and chemotherapy can be considered on an individual basis with the aim of optimizing overall outcomes.
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Affiliation(s)
- Michael Milosevic
- Radiation Medicine Program, Princess Margaret Hospital, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol 2006; 7:837-47. [PMID: 17012046 DOI: 10.1016/s1470-2045(06)70903-2] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pelvic exenteration has been used for 60 years to treat cancers of the lower and middle female genital tract in radiated pelves. The mainstay for treatment success in terms of locoregional control and long-term survival is resection of the pelvic tumour with clear margins (R0). New ablative techniques based on developmentally derived surgical anatomy and laterally extended endopelvic resection have raised the number of R0 resections done, even for tumours that extend to the pelvic side wall, which were traditionally judged a contraindication for exenteration. Although mortality has fallen to less than 5%, treatment-related severe morbidity of pelvic exenteration still exceeds 50%, possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. The benefits of exenteration for patients who have advanced primary disease or recurrent tumours after surgery, versus those who have chemoradiotherapy, are not proven by results of controlled trials, but can be assumed from retrospective data. Comparative findings are missing, and arguments are unconvincing to favour pelvic exenteration over less extensive treatments and best supportive care for palliation of cancer symptoms in most patients.
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Affiliation(s)
- Michael Höckel
- Department of Obstetrics and Gynaecology, University of Leipzig, Philipp-Rosenthal-Str 55, 04103 Leipzig, Germany.
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Chang SS, Alberts GL, Smith JA, Cookson MS. Ileal conduit urinary diversion in patients with previous history of abdominal/pelvic irradiation. World J Urol 2004; 22:272-6. [PMID: 15448995 DOI: 10.1007/s00345-004-0446-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 07/06/2004] [Indexed: 10/26/2022] Open
Abstract
Urinary diversion among patients receiving prior radiation is common. Herein, we present our experience with ileal conduit (IC) diversion in patients with a history of prior abdominal and/or pelvic radiation therapy. We analyzed the charts of 177 patients who underwent IC urinary diversion between 1/1994 and 6/2000, and 36 patients were identified who had previously undergone radiation therapy. Decisions to proceed were based on surgeon preference as determined by intraoperative appearance and viability of the selected bowel segment. Chart review included serum studies, upper tract imaging studies, and complications related to diversion. Durability of diversion was determined by examining the interval between urinary diversion and the need for additional procedures. A total of 30 patients with at least 3 months follow-up were identified. Renal function remained stable in 86% (26/30) with a median follow-up of 21.5 months (range 3-63 months). Hydronephrosis was noted preoperatively in 4 patients (13%) who demonstrated stable upper tracts and serum creatinine in the post-operative period. Three patients (10%) developed unilateral hydronephrosis related to tumor recurrence, with one patient demonstrating a rise in baseline serum creatinine. Hydronephrosis was noted in 5 patients (16%) secondary to development of ureteroenteric stricture. Serum creatinine remained stable in 2 patients without intervention with 2 years follow-up. Intervention for obstruction was necessary in 3 patients at 22, 31, and 61 months following diversion. In one patient, an intraoperative decision to use the colon for urinary diversion was made secondary to appearance of small bowel. Minor complications were noted in 9 patients (30%), while 3 patients (10%) experienced major complications in the immediate post-operative period. Five patients (17%) experienced complications potentially related to the use of ileum for urinary diversion. The use of ileum for urinary diversion among patients with a history of radiation appears technically feasible and a viable treatment alternative. Our data support the use of ileum in the majority of patients as evidence by a low complication rate and a high rate of upper tract preservation. In addition, these data imply that a prior history of abdominal and/or pelvic radiation should not serve as the sole determining factor in the selection of bowel segment utilized during urinary diversion.
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Affiliation(s)
- Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, Tennessee 37232-2765, USA.
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Bochner BH, McCreath WA, Aubey JJ, Levine DA, Barakat RR, Abu-Rustum N, Poynor E, Wong D, Chi DS. Use of an ureteroileocecal appendicostomy urinary reservoir in patients with recurrent pelvic malignancies treated with radiation. Gynecol Oncol 2004; 94:140-6. [PMID: 15262132 DOI: 10.1016/j.ygyno.2004.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Evaluation of a modified right colon urinary reservoir in a heavily radiated patient population undergoing pelvic exenteration. METHODS A retrospective chart review was performed on all patients with recurrent gynecologic, colorectal, and urological tumors who underwent total pelvic or anterior exenteration and urinary diversion from 3/01 to 7/03 using an ureteroileocecal appendicostomy urinary reservoir. RESULTS Fourteen patients were identified over the study interval. The mean age of the patients was 53 years (range, 22-78 years). All patients received external beam, intracavitary, or a combination of both radiation treatment modalities to the pelvis preoperatively. Eight patients received intraoperative radiation therapy (IORT) at a mean dose of 16.25 Gy (range, 12.5-17.5 Gy). The primary sites of disease were as follows: cervix, five; prostate, three; uterus, two; colon/rectum two; and one each for vulva and bladder. Complete stomal continence was achieved in all patients after a median follow-up of 10 months (range, 2-31 months). Two patients experienced a traumatic disruption of the stomal-skin anastomosis in the early postoperative period (postoperative days 7 and 14). One late complication related to the ureterointestinal anastomosis was observed and consisted of an anastomotic stricture managed conservatively. One patient experienced an entero-pouch fistula following re-exploration for an acute postoperative hemorrhage. CONCLUSION The early outcomes using the ureteroileocecal appendicostomy urinary reservoir in heavily radiated patients demonstrate the technical feasibility of this design as both minimal early stoma and ureterointestinal complications may occur. Longer postoperative follow-up will be required to address the late outcomes of this procedure and its ultimate use in this population.
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Affiliation(s)
- Bernard H Bochner
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Salom EM, Mendez LE, Schey D, Lambrou N, Kassira N, Gómez-Marn O, Averette H, Peñalver M. Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years. Am J Obstet Gynecol 2004; 190:994-1003. [PMID: 15118628 DOI: 10.1016/j.ajog.2004.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A patient with a recurrent central pelvic malignancy after radiation will require urinary diversion as part of the reconstructive phase of the pelvic exenteration. The aim of our study was to assess the result of our 15-year experience with a continent ileocolonic urinary reservoir, which is known as the Miami pouch. STUDY DESIGN Since 1988, all patients who received a continent ileocolonic urinary reservoir in the Division of Gynecologic Oncology, University of Miami School of Medicine, were included in the study. Parameters that were evaluated during the study period include functional outcomes, early and late perioperative complications, and their treatment. RESULTS A total of 90 patients were identified from February 1988 to December 2002. Seventy-eight patients (87%) had a recurrent central pelvic malignancy, and 82 patients (91%) received radiation before the Miami pouch procedure. The non-reservoir-related morbidities were fever (76%), wound complication (30%), pelvic collection (12%), ileus/small bowel obstruction (12%), and postoperative death (11%). The most common reservoir-related complications were urinary infection (40%), ureteral stricture (20%), and difficulty with self-catheterization (18%). In our study, the overall complication rate that was related directly to the Miami pouch was 53%. Conservative treatment resolved>80% of these cases. The rate of urinary continence that was achieved in our patients was 93% during our 15-year experience with the Miami pouch. CONCLUSION The Miami pouch is a good alternative for continent urinary diversion during exenteration or radiation-induced damage. The rate of major complications that require aggressive surgical intervention is acceptable. Most postoperative complications (80%) can be corrected with the use of conservative techniques that are associated with fewer deaths than reoperation and thus should be used first. The technique is simple and effective in women who are at high risk, who have undergone previous radiation therapy, and who have a high rate of functional success and is a profound advantage for a woman's psychosocial well-being.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Colon/surgery
- Female
- Florida/epidemiology
- Genital Neoplasms, Female/epidemiology
- Genital Neoplasms, Female/etiology
- Genital Neoplasms, Female/mortality
- Genital Neoplasms, Female/pathology
- Genital Neoplasms, Female/radiotherapy
- Genital Neoplasms, Female/surgery
- Humans
- Ileum/surgery
- Medical Records
- Middle Aged
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Outcome Assessment, Health Care
- Postoperative Complications
- Retrospective Studies
- Urinary Incontinence
- Urinary Reservoirs, Continent/statistics & numerical data
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Affiliation(s)
- Emery M Salom
- University of Miami, School of Medicine, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, 33136, USA.
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16
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Houvenaeghel G, Moutardier V, Karsenty G, Bladou F, Lelong B, Buttarelli M, Delpero JR. Major complications of urinary diversion after pelvic exenteration for gynecologic malignancies: a 23-year mono-institutional experience in 124 patients. Gynecol Oncol 2004; 92:680-3. [PMID: 14766266 DOI: 10.1016/j.ygyno.2003.11.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2003] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the postoperative outcome of patients undergoing urinary diversion at the time of pelvic exenteration. METHODS Between January 1980 and December 2002, 232 pelvic exenterations for gynecologic malignancies were performed in our hospital. One hundred and twenty-four included a urinary diversion. There were locally advanced or recurrent cancers including 101 cervical, 11 endometrial, 5 vagina, 2 ovarian malignancies and 5 pelvic sarcoma. RESULTS Ninety patients (72.5%) had a history of previous irradiation. Exenterations were 69 anterior and 55 total. Urinary diversion included 14 bilateral ureterostomies, 62 trans-intestinal diversion and 48 continent diversion using distal ileum and right colon. Pelvic filling was performed in 56 patients (45%). Low colorectal anastomosis was performed in 42 of 48 supralevator pelvic exenteration (87.5%). Postoperative mortality rate was 8% (10/124). Overall 12-week postoperative morbidity rate was 52% (65/124) and appears to be significantly higher in irradiated patients and after total exenteration. In trans-intestinal noncontinent group, eight patients were reoperated for a complication directly related to urinary diversion procedure. No reoperation for such a complication was performed in the continent urinary diversion group. CONCLUSIONS Ileocolic continent pouch seems to be the safer urinary diversion procedure after exenteration for gynecological malignancies especially in irradiated patients and after total exenteration.
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Affiliation(s)
- G Houvenaeghel
- Department of Surgery, Institut Paoli-Calmettes, 13009 Marseille, France
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WAMMACK ROBERT, WRICKE CHRISTINE, HOHENFELLNER RUDOLF. Long-Term Results of Ileocecal Continent Urinary Diversion in Patients Treated With and Without Previous Pelvic Irradiation. J Urol 2002. [DOI: 10.1016/s0022-5347(05)65083-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- ROBERT WAMMACK
- From the Departments of Urology, University of Mainz School of Medicine, Mainz, Germany, and University Hospital of Vienna, Vienna, Austria
| | - CHRISTINE WRICKE
- From the Departments of Urology, University of Mainz School of Medicine, Mainz, Germany, and University Hospital of Vienna, Vienna, Austria
| | - RUDOLF HOHENFELLNER
- From the Departments of Urology, University of Mainz School of Medicine, Mainz, Germany, and University Hospital of Vienna, Vienna, Austria
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Long-Term Results of Ileocecal Continent Urinary Diversion in Patients Treated With and Without Previous Pelvic Irradiation. J Urol 2002. [DOI: 10.1097/00005392-200205000-00026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ramirez PT, Modesitt SC, Morris M, Edwards CL, Bevers MW, Wharton JT, Wolf JK. Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies. Gynecol Oncol 2002; 85:285-91. [PMID: 11972389 DOI: 10.1006/gyno.2002.6594] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to review our experience with continent urinary diversions in patients with gynecologic malignancies and evaluate the presentation and management of early and late complications. METHODS A retrospective chart review was performed of all patients who underwent a continent urinary diversion on the Gynecologic Oncology Service at The University of Texas M. D. Anderson Cancer Center during the period January 1988 to March 2001. We analyzed our data to evaluate potential risk factors for complications. Renal status, conduit integrity, and overall patient outcomes were also studied. RESULTS We identified 40 patients who underwent a continent urinary diversion using an ileocolonic segment (Miami pouch technique). All patients had a history of gynecologic malignancies. The median age at the time of the procedure was 50 years (range 24 to 76 years), and the median weight was 69.6 kg (range 47 to 125 kg). A total of 39 patients (98%) had a history of radiotherapy. Continent urinary diversion was performed as part of an anterior pelvic exenteration in 12 patients (30%), in conjunction with a total pelvic exenteration in 18 patients (45%), and as the main procedure in 10 patients (25%). The median estimated blood loss was 2100 ml (range 200 to 8500 ml). The median length of hospitalization was 19.5 days (range 7 to 56 days). A total of 24 patients (60.0%) had a postoperative complications unrelated to the reservoir. Complications directly related to the continent urinary diversion were seen in 26 (65.0%) of 40 patients. None of the patients in this study group developed chronic renal failure, and there were no perioperative deaths. At last evaluation, 36 (90%) of 40 patients reported normal continent conduit function. CONCLUSIONS Continent urinary diversion using an ileocolonic segment is a reasonable alternative to the ileal and transverse colon conduit in bladder reconstruction in patients undergoing radical pelvic surgery. The routine use of postoperative total parenteral nutrition, the chronic use of antibiotics after discharge from the hospital, and the routine use of imaging studies remain controversial. In this group of patients, the majority of complications may be successfully managed conservatively.
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Affiliation(s)
- Pedro T Ramirez
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Husain A, Curtin J, Brown C, Chi D, Hoskins W, Poynor E, Alektiar K, Barakat R. Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies. Gynecol Oncol 2000; 78:208-11. [PMID: 10926804 DOI: 10.1006/gyno.2000.5864] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies. METHODS We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. RESULTS Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catheterization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients). CONCLUSIONS Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.
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Affiliation(s)
- A Husain
- Gynecology Service, Department of Surgery, Sloan-Kettering Cancer Center, New York, New York 10021, USA
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SHEN-GUNTHER JANE, MANNEL ROBERTS, WALKER JOANL, JOHNSON GARYA. Construction of the Ileocolonic Continent Urinary Reservoir: Operative Technique at the University of Oklahoma. J Gynecol Surg 1997. [DOI: 10.1089/gyn.1997.13.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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