Follow-up of double-barreled wet colostomy after pelvic exenteration at a single institution

Double-Barrel Urocolostomy After Pelvic Exenteration: Short-Term Morbidity and Patient-Reported Quality of Life

BACKGROUND

Total pelvic exenteration is a radical surgical procedure for advanced pelvic malignancies. Traditionally, an ileal conduit is created on the right abdominal wall for urinary diversion and an end-colostomy on the left abdominal wall for fecal diversion. However, this approach is associated with increased morbidity and a negative impact on quality of life (QoL). A unilateral double-barrel urocolostomy (DBUC) offers an alternative using the sigmoid colon for urinary drainage. This can potentially reduce complications, improve QoL, and preserve the right vertical rectus abdominis muscle (VRAM) flap for pelvic reconstruction. This study aimed to evaluate the impact of the DBUC on 90-day morbidity and QoL of patients undergoing pelvic exenteration for locally advanced colorectal and anal cancer.

METHODS

Data were prospectively collected from all patients who underwent pelvic exenteration with DBUC reconstruction for colorectal and anal cancer at our tertiary care center between January 2020 and May 2023.

RESULTS

This study enrolled 20 patients. Postoperative complications were observed in 19 patients, including seven major complications. Two complications were directly attributable to the DBUC. Patients reported favorable QoL outcomes in terms of global health, functional ability, and symptom management, with expected limitations in physical performance due to extensive abdominal surgery. At 1 year after surgery, all the patients preferred the DBUC over separate bilateral ostomies.

CONCLUSION

The DBUC procedure has demonstrated safety and efficacy in terms of short-term morbidity and favorable patient-reported QoL, making it an attractive alternative to dual ostomies for patients undergoing pelvic exenteration, particularly when VRAM reconstruction is considered.

A single centre experience on the formation of double barrelled uro-colostomy in pelvic exenteration surgery: a cohort study

BACKGROUND

Double barrelled uro-colostomy (DBUC) is an alternative to traditional ileal conduit (IC) and separate colostomy in patients requiring simultaneous urinary and faecal diversion for reconstruction in pelvic exenteration surgery (PES).

METHODS

This cohort study evaluated short- and long-term morbidity and mortality associated with DBUC formation in 20 consecutive adult patients undergoing PES in an Australian Complex Pelvic Surgical Unit. Data were obtained from a prospective database.

RESULTS

Mean age 59 years (range 27-76 years). PES was performed for malignant disease in 18 patients (curative intent in 17). Mean operative duration 11.8 h (range 7-17 h). Mean follow-up duration 29.1 months (range 2.6-90.1 months). Early DBUC-related complications occurred in four patients (20.0%): urinary tract infection (UTI)/urosepsis (n = 4) and early ureteric stenosis requiring intervention (n = 1). Late DBUC-related complications occurred in five patients (25.0%): recurrent UTI/urosepsis (n = 4), chronic kidney disease (n = 4), ureteric stenosis (n = 2) and parastomal hernia (n = 4). No mortality occurred secondary to a DBUC complication.

CONCLUSION

DBUC is a safe reconstructive option with acceptable morbidity profile in patients requiring simultaneous urinary and faecal diversion.

Trends and current aspects of reconstructive surgery for gynecological cancers

Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the surrounding bony pelvis and pelvic musculature. As opposed to advanced ovarian cancer, where cytoreduction is the goal, in these scenarios, an oncologic approach to achieve negative margins is critical for benefit. Surgeries aimed at achieving a R0 resection in gynecologic oncology can have a significant impact on pelvic anatomy, and require reconstruction. Overall, it appears that these types of radical surgery are less frequently performed; however, when required, multidisciplinary teams at high-volume centers can potentially improve short-term morbidity. There are few data to examine the long-term, quality-of-life outcomes after reconstruction following oncologic resection in advanced and recurrent gynecologic cancers. In this review we outline considerations and approaches for reconstruction after surgery for gynecologic cancers. We also discuss areas of innovation, including minimally invasive surgery and the use of 3D surgical anatomy models for improved surgical planning.In the era of 'less is more', pelvic exenteration in gynecologic oncology is still indicated when there are no other curative-intent alternatives in persistent or recurrent gynecological malignancies confined to the pelvis or with otherwise unmanageable symptoms from fistula or radiation necrosis. Pelvic exenteration is one of the most destructive procedures performed on an elective basis, which inevitably carries a significant psychologic, sexual, physical, and emotional burden for the patient and caregivers. Such complex ultraradical surgery, which requires removal of the vagina, vulva, urinary tract, and/or gastrointestinal tract, subsequently needs creative and complex reconstructive procedures. The additional removal of sidewall or perineal structures, like pelvic floor muscles/vulva, or portions of the musculoskeletal pelvis, and the inclusion of intra-operative radiation further complicates reconstruction. This review paper will focus on the reconstruction aspects following pelvic exenteration, including options for urinary tract restoration, reconstruction of the vulva and vagina, as well as how to fill large empty spaces in the pelvis. While the predominant gastrointestinal outcome after exenteration in gynecologic oncology is an end colostomy, we also present some novel new options for gastrointestinal tract reconstruction at the end.

The double-barrel wet colostomy: An alternative for urinary diversion after pelvic exenteration

AIM

Pelvic exenteration is a radical procedure used to treat locally advanced and/or recurrent pelvic malignancies. Different reconstruction options exist, the most popular being the end colostomy with ileal conduit. The double barrel wet colostomy (DBWC) offers concomitant fecal and urinary diversion through a single stoma, but is infrequently utilized. We aim to review the evidence base of the postoperative complications, long-term oncologic risks and quality of life following creation of a double barrel wet colostomy.

METHODS

A narrative review of the literature was performed evaluating the DBWC. Patient demographics, perioperative complications, operative variables, long terms oncologic outcomes and quality of life data were extracted. Descriptive statistics were used to define the data.

RESULTS

Fourteen articles with a total of 300 patients undergoing DBWC following pelvic exenteration were selected. 41% of malignancies were gastrointestinal in origin while 41.7% were gynecologic and 5.3% genitourinary. 42% of patients experienced at least one complication within in 40 days of surgery, the most common being wound infection (8.7%) and urinary leak (8.3%). There was no evidence of malignancy within the DBWC during long-term surveillance. Quality of life following DBWC is comparable to other reconstructive methods.

CONCLUSION

The DBWC is a well described reconstructive method for urinary and fecal diversion utilizing a single stoma following pelvic exenteration. The short- and long-term outcomes following DBWC are comparable to other reconstructive methods and the quality of life with a DBWC is acceptable. DBWC should remain a readily available option for reconstruction following pelvic exenteration.

Survival After Pelvic Exenteration for Cervical Cancer

BACKGROUND

The purpose of this work was to identify the results of pelvic exenteration for recurrent, persistent or locally advanced cervical cancer in terms of survival performed for 41 patients in Salah Azaiez Institute.

PATIENTS AND METHODS

We conducted a retrospective unicentric study. The association between PE and OS was estimated using the method of Kaplan-Meier using SPSS ver 24.

RESULTS

Median age at the time of intervention was 53.9 years old. FIGO stage IIB was the most frequent (46.3%). Eighteen patients had pelvic exenteration after neoadjuvant treatment. Resection margins were free of tumor in 83.3% of cases. Twenty-three patients underwent pelvic exenteration for recurrence of cervical cancer treated. The median time of recurrence was 23.4 months. Free resection margins were obtained in 69.5% of cases. Postoperative complications were noted in 61% of patients. Two deaths were seen in the early postoperative period. After a median follow-up of 40.5 months, 24.4% of recurrences were noted. Overall survival at 5 years was 51% and recurrence-free survival at one year was 39%. Prognostic factors which impact overall and recurrence-free survival were the size of recurrence and resection margins after exenteration. The time between the end of initial treatment and recurrence was the only predictive factor of recurrence after pelvic exenteration.

CONCLUSION

Pelvic exenteration remains a curative treatment of cervical cancer in certain indications despite high morbidity. A rigorous preoperative selection of candidate may reduce the morbidity and improve the survival of patients.

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer

BACKGROUND AND OBJECTIVES

The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE.

METHODS

A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used.

RESULTS

Most conducts and management strategies reviewed were strongly recommended by the participants.

CONCLUSIONS

Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

Pelvic exenteration with rectal resection for different types of malignancies at two tertiary referral centres

INTRODUCTION

Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction.

METHOD

From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers.

RESULTS

Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence.

CONCLUSION

Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.

Laparoscopic total pelvic exenteration for pelvic malignancies: the technique and short-time outcome of 11 cases

BACKGROUND

Previous reports about laparoscopic total pelvic exenteration (LTPE) are still limited. In the present study, we described our single-center experience of the initial 11 cases.

METHODS

Between April 2011 and September 2015, eight males and three females diagnosed as pelvic malignancies underwent LTPE by the same operation team. We retrospectively collected all cases' parameters about surgical technique. Thirty-seven patients who received open surgery were also retrospectively collected. A comparison between LTPE and open surgery was performed to evaluate the feasibility and safety of LTPE.

RESULTS

Eleven cases successfully underwent the LTPE without any intraoperative complication. No open conversion was required. Eight patients underwent Bricker's procedure. Three patients were performed with the cutaneous ureterostomy. Anus preservation operation was performed in three patients. Compared with open surgery, LTPE had longer mean operative time (565.2 vs 468.2 min, p = 0.004) but less mean blood loss (547.3 vs 1033.0 ml, p < 0.001) and shorter postoperative hospitalization time (15.3 vs 22.4 days, p = 0.004). One patient died of pulmonary embolism in the 7th month of follow-up time. One patient died of recurrence in the 12th month of follow-up time. Nine patients are still alive without recurrence and metastasis. The mean follow-up time was 11.1 months.

CONCLUSIONS

The technique of LTPE seems to be feasible and safe in the treatment of carefully selected patients of pelvic malignancies. LTPE can also decrease the blood loss, the recovery time, and the hospital stay. But the oncological safety and long-term outcome of LTPE still need to be explored.

Double barreled wet colostomy: initial experience and literature review

Background. Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. Methods. A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. Results. Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. Conclusion. In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.

Surgical results of pelvic exenteration in the treatment of gynecologic cancer

Background

Our aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration.

Methods

We performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications.

Results

Twenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367 minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3 days and total hospital stay of 9.4 days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage.

Conclusions

Postoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.

Double-Barreled Wet Colostomy versus Ileal Conduit and Terminal Colostomy for Urinary and Fecal Diversion: A Single Institution Experience

Background and Aims:

The aim of this study was to compare the feasibility and early postoperative outcomes between patients undergoing double-barreled wet colostomy and patients undergoing terminal colostomy and ileal conduit for simultaneous urinary and fecal diversion.

Material and Methods:

Between 1995 and 2012, we had 181 patients in whom it was necessary to make simultaneous urinary and fecal diversion. This is a retrospective study and patients were divided into two groups, depending on the technique applied for the fecal and urinary diversion. The first group consisted of patients undergoing ileal conduit and terminal colostomy and the second group consisted of patients undergoing  double-barreled wet colostomy.

Results:

Ileal conduit and terminal colostomy was performed in 77 (43%) cases, while wet colostomy was performed in 104 (57%) cases. Median length of stay was shorter for double-barreled wet colostomy (13.1 vs 18.1, p < 0.0001). Median operating times for urinary and fecal diversion were shorter for double-barreled wet colostomy (32 vs 64 min, p < 0.0001). The morbidity was lower for double-barreled wet colostomy (11.5% vs 23.4%, p = 0.0432), retrospectively. The mortality was 3.8% for double-barreled wet colostomy and 10.3% for ileal conduit and terminal colostomy group (p = 0.1282).

Conclusions:

Double-barreled wet colostomy is a safe, fast, and simple alternative to traditional ileal conduit and terminal colostomy diversion. The technique is relatively easy to learn, and it reduces the time for urinary and fecal diversion, length of stay, and morbidity rate.

A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database

AIM

The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome.

METHOD

There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database.

RESULTS

The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P=0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P=0.16).

CONCLUSION

Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.

Single institution experience comparing double-barreled wet colostomy to ileal conduit for urinary and fecal diversion

OBJECTIVE

To compare outcomes and feasibility of double-barreled wet colostomy and ileal conduit (IC) in patients undergoing total pelvic exenteration (TPE).

METHODS

Between 2004 and 2010, 54 patients underwent TPE for pelvic malignancies. Of those patients, 53 had complete records available for analysis. Two groups were identified based on the technique used for urinary diversion, either by way of an IC or a double-barreled wet colostomy (DBWC). Demographics, comorbidities, complications, length of stay, operative times, morbidity, and mortality were compared between the 2 groups.

RESULTS

Forty-three patients (81%) underwent a DBWC and ten patients (19%) underwent an IC. The 2 groups were similar in terms of age, gender, and comorbidities. Eighteen patients underwent an R0 resection (39%) and twenty-eight (61%) patients had a non-R0 resection. Seven patients (13%) had a complete response to therapy with no evidence of malignancy. A majority of the patients (68%) undergoing TPE had colorectal histology. Thirty-day morbidity directly related to complications of urinary or fecal diversion was 78% in the DBWC group and 58% in the IC group. There was no perioperative mortality in either group.

CONCLUSION

DBWC is a safe and feasible alternative to the traditional IC for urinary diversion. This technique is easy to learn and is associated with similar operative times, length of stay, morbidity, and mortality compared with IC.

[Surgical approach to the locoregional recurrence of cancer of the rectum]

A literature review has been made on the pelvic recurrence of rectal cancer using the MedLine, Ovid, EMBASE, Cochrane and Cinahl data bases. Assessment of the locoregional recurrence must be made using imaging tests in order to rule out the presence of metastasis, as well as for locating its exact location within the pelvis. As the only curative treatment should be complete resection of the recurrence with negative margins, a pre-operative CT, NMR, endorectal ultrasound and PET-CT must be performed to determine its resectability. For a potential cure, radical resections must be made, with the technique varying according to whether the location is central (axial), posterior (presacral) or lateral, as well as treatment directed at the primary tumour. Neoadjuvant treatments, brachiterapy and intra-operative radiotherapy improve the local control results and survival in these patients.