Urinary diversion in gynecologic oncology

Primary retrograde urinary drainage using image and endoscopy guidance via urostomies

AIM

To report the technical success of image and endoscopy-guided retrograde trans-urostomy urinary drainage as a primary catheter placement method performed by interventional radiology (IR).

MATERIALS AND METHODS

Nine patients (15 attempted drain placements) with ureteric obstruction following radical cystectomy and urostomy creation were included. The patients were referred to IR for urinary drainage. All patients underwent primary image and endoscopy-guided retrograde trans-urostomy urinary drainage.

RESULTS

Primary image and endoscopy-guided retrograde trans-urostomy urinary drainage was successful in 13/15 (86.6%) attempts. The proposed technique had a limited complication rate omitting the percutaneous nephrostomy access step.

CONCLUSION

Primary image and endoscopy guided retrograde trans-urostomy urinary drainage should be considered before percutaneous nephrostomy in all patients with a urostomy.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion

OBJECTIVE

To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use.

PATIENTS AND METHODS

A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC.

RESULTS

Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed.

CONCLUSIONS

For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Antibiotic prophylaxis is not associated with reduced urinary tract infection-related complications after cystectomy and ileal conduit

OBJECTIVES

Majority of complications after ileal conduit urinary diversion with cystectomy are related to urinary tract infections (UTIs). Controversy exists regarding use of prophylactic antibiotics after surgery. We determined if prophylactic antibiotic use during ureteral stent placement after ileal conduit urinary diversion decreased incidence of UTI-related complications.

METHODS

We retrospectively identified 75 consecutive patients who underwent ileal conduit urinary diversion with cystectomy at our institution from 2010 to 2016. Patients were stratified based on presence or absence of a UTI-related complication in the 90-day postoperative period. Means were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of UTI-related complications.

RESULTS

Forty-five patients (60%) were prescribed prophylactic antibiotics after surgery. Mean duration of antibiotic use was 15 d, and mean duration of ureteral stenting was 25 d. Most common antibiotics used included fluoroquinolones (n = 23, 30.7%) followed by sulfamethoxazole-trimethoprim (n = 14, 18.7%). Rate of 90-day UTI-related complications was 36% (n = 27), and 90-day UTI-related readmission rate was 14.7% (n = 11). On bivariate and multivariate analysis, prophylactic antibiotic use was not associated with reduced 90-day UTI-related complications (P > 0.05). Patients prescribed prophylactic antibiotics had increased incidence of Clostridium difficile infections in the 90-day postoperative period compared to controls (20% vs. 3.3%; P = 0.038).

CONCLUSIONS

Prophylactic antibiotic use after ileal conduit urinary diversion with cystectomy was not associated with reduced UTI-related complications, and rate of Clostridium difficile infections was higher in this patient cohort. The effect of early removal of ureteral stents on UTI risk still has to be elucidated.

Comprehensive Imaging and Surgical Review of Urinary Diversions: What the Radiologist Needs to Know

Urinary diversions are surgical procedures that reconstruct the lower urinary tract following cystectomy. The 2 common surgical approaches are based on the continence status of the urinary tract. Incontinent diversions have continuous urine drainage through a cutaneous stoma, whereas continent diversions offer the patient the ability to self-void either via stoma catheterization or with the patient's own urethra. Given the large number of diversion procedures available, postsurgical anatomy may be complex. Multiple imaging modalities can be used to assess the postprocedural anatomy, potential complications, and for on-going oncologic monitoring. The purpose of this review is to describe the common surgical techniques and associated complications.

Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies

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.

Creation of the Miami Pouch During Laparoscopic-Assisted Pelvic Exenteration: The Initial Experience

Purpose:

To describe the initial experience of laparoscopic hand-assisted Miami pouch in a group of patients undergoing pelvic exenterations for pelvic malignancies.

Materials and Methods:

Thirteen female patients underwent laparoscopic-assisted pelvic exenteration in our center between September 2000 and November 2007. Six of them had the Miami pouch created for urinary diversion. The continent diversion was created extracorporeally through a right iliac fossa minilaparotomy.

Results:

The mean total operative time for the laparoscopic-assisted exenteration and reconstruction was 382 minutes (range, 270-480 minutes), but specifically for the Miami pouch, it took a mean time of 106 minutes (range, 90-130 minutes). Four patients (66.7%) had postoperative urinary tract infection that resolved with antibiotics. One patient had a ureteral stenosis requiring stenting and one had a Miami pouch cutaneous fistula that required a fistulectomy. The mean follow-up was 23 months (range, 9-48 months). All patients were continent and were able to self-catheterize approximately 3 to 6 times/d.

Conclusions:

It is technically feasible to incorporate the creation of the Miami continent urinary pouch through a minilaparotomy during laparoscopic pelvic exenteration without compromising the benefits of laparoscopic surgery.

Rectus abdominis myocutaneous flap in radical oncopelvic surgery: a safe and useful procedure

AIMS

The aim of this retrospective study was to evaluate the usefulness of rectus abdominis myocutaneous (RAM) flaps to treat locally advanced pelvic gynaecological or digestive tumours.

METHODS

We reviewed 46 patients, who received RAM flaps after radical oncopelvic surgery, including: (a) total vaginal reconstruction (TVR); (b) partial vaginal reconstruction (PVR); (c) perineal reconstruction (PR).

RESULTS

Between 1989 and 1998, 46 patients underwent pelvi-perineal reconstruction with RAM flaps after radical pelvic surgery for carcinoma of the cervix (n=22), anal carcinoma (n=11), rectal carcinoma (n=7), or other pelvic tumours types (n=6). There were two post-operative deaths. Overall surgical morbidity was 45, 6% (n=21). Specific morbidity of the RAM flap was 21, 7% (n=10). Global re-intervention rate was 13% (n=6).

CONCLUSION

Rectus abdominis myocutaneous flap in radical oncopelvic surgery is useful for vaginal or perineal reconstruction and prevention of pelvic collections after extended resections with a low rate of associated morbidity.

Sigmoid impaction secondary to urinary stones: case report and review of literature

BACKGROUND

This is the first case report of a Miami pouch sigmoid fistula developing passage of urinary stones resulting in the presentation of constipation secondary to impaction.

CASE REPORT

A 49-year-old woman who developed a recurrence of invasive squamous cell cervical carcinoma 1 year after pelvis radiation. She then underwent anterior pelvic exenteration and creation of a Miami pouch. Approximately 14 years after the primary radiation therapy and 13 years after the creation of the exenterative procedure, the patient developed a Miami pouch sigmoid fistula. The decision was made at this time to repair the fistula and remove the urinary stones from the sigmoid colon. Postoperatively, the patient remained continent using intermittent catheterization of the pouch and there was no evidence of recurrence of the cancer.

CONCLUSION

Conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. When indicated, surgical management should not be delayed.

Long-term complications associated with the Indiana pouch urinary diversion in patients with recurrent gynecologic cancers after high-dose radiation

Few studies have assessed the long-term risks associated with the Indiana pouch continent urinary diversion after high-dose radiation therapy. A retrospective review of consecutive female patients who underwent cystectomy and Indiana pouch urinary diversion identified 12 with a history of high-dose pelvic irradiation (mean total 78.1 Gy). Long-term complications and outcomes in this group were compared to a synchronous group of patients (n = 14) with no history of radiation. Mean follow-up in the radiation therapy (RT) and nonirradiated comparison group (CG) were 48.5 and 40.8 months, respectively, with all patients having over 12 months of outcomes assessed. In the RT group, 83% of patients experienced a one or more complications (n = 29) while 57% of the CG did (n = 15; P = 0.2). Complications seen more commonly in the RT group included ureteral stricture/obstruction (5 vs. 2), renal insufficiency (3 vs. 1) and severe incontinence (3 vs. 0). Notably, 23 secondary operative procedures were required in the RT group versus CG (n = 11, P = 0.2). Percutaneous nephrostomy (6 vs. 1; P = 0.03) and ureteral reimplantation (4 vs. 0; P = 0.03) were seen significantly more commonly in the RT group than the CG. Long-term follow-up is critical to assess the complications associated with urinary diversions. We conclude that frequent complications and a significant increase in specific operative procedures are observed in heavily irradiated patients with recurrent gynecologic cancers receiving an Indiana Pouch urinary diversion. Given the risk of renal insufficiency, close monitoring of renal drainage and function is recommended. These considerable long-term complications should be considered when counseling patients contemplating Indiana Pouch urinary diversion after radiation therapy.

Conversion of an incontinent urinary conduit to a continent urinary reservoir (Miami Pouch)

OBJECTIVE

External urinary or gastrointestinal appliances can impair a patient's quality of life. We report on the feasibility of converting an incontinent colonic urinary diversion to a continent urinary reservoir (Miami Pouch).

CASE

We describe the case of a 66-year-old white female with a history of stage Ib(2) cervical cancer treated by radical abdominal hysterectomy and adjuvant radiation therapy. The patient developed severe radiation cystitis with a neurogenic bladder and bilateral ureteral obstruction. After failing conservative management, a urinary diversion with a transverse colon conduit was performed. The patient remained without evidence of disease for 2 years and led an active lifestyle with regular tennis games. After 7 months of an external appliance for the urinary conduit, the patient presented to the University of Miami for conversion to a continent urinary mechanism which would not require an appliance. We performed an exploratory laparotomy, conversion of a transverse colon conduit to a continent ileo-colonic urinary reservoir (Miami Pouch). There were no postoperative complications. The patient remains disease-free and performs self-catheterization with no need for an external appliance. The patient has been able to resume an active life including sports.

CONCLUSIONS

Successful conversion of an incontinent urinary conduit to a continent urinary reservoir is possible in a select case resulting in a perceived improvement of quality of life.