Reconstruction of Urinary Tract Combined with Surgical Management of Locally Advanced Non-Urological Cancer Involving the Genitourinary Organs

Abstract

Introduction: The objective of this study was to review our experience with urinary reconstruction in patients undergoing surgical management for locally advanced pelvic cancer, and to evaluate the role of urologists in these procedures. Materials and Methods: This study included a total of 37 patients undergoing some type of urinary reconstruction due to invasion of the urological organs by locally advanced pelvic cancers, including 17 rectal cancers, 9 cervical cancers, 4 sigmoid cancers, 4 retroperitoneal sarcomas, 2 ovarian cancers and 1 appendiceal cancer. Among these 37, 18 were recurrent cancers following initial surgery for primary tumors. The clinical outcomes of these approaches were retrospectively analyzed. Results: Of the 37 patients, 9 underwent cystectomy (group A) with the following urinary diversions: ileal neobladder in 3, ileal conduit in 5 and colon conduit in 1, and 12 underwent partial cystectomy (group B), among whom 11 received additional urinary reconstruction as follows: bladder flap repair in 5, psoas hitch in 2, ileal ureter in 2, bladder augmentation in 1 and ureteroureterostomy in 1, while the remaining 16 (group C), in whom complete bladder preservation was possible, underwent the following types of urinary reconstruction: bladder flap repair in 6, psoas hitch in 3, en bloc removal of the rectum with prostate in 3, ileal ureter in 2, and ureteroureterostomy in 2. There were 10 early urological complications, including leakage of urine in 7 and acute pyelonephritis in 3. As a late urological complication, hydronephrosis was observed in 8 patients, but ureteral stent was not required in any of these 8. There were no significant differences in the incidence of postoperative complications, the status of surgical margin and the survival among groups A–C. Conclusion: Our experience with extended surgical management of non-urological pelvic cancer with reconstruction of the urinary tract suggests that the urological portion of this procedure can be performed with acceptable morbidity, and that the role of the urological surgeon during this procedure is potentially important.

Urological complications after cystectomy as part of pelvic exenteration are higher than that after cystectomy for primary bladder malignancy

“…Patients in the PE group had a higher rate of urine leaks and were also more likely to return to theatre either for a conduit related complication or during which the conduit is inadvertently injured, causing an intra-operative complication. High-urine leak rates after PE have been previously reported [4,[8][9][10][11] and results of this study confirm a true difference in complication rates between these two groups of patients.…”

“…Morbidity associated with cystectomy and its reconstruction can be considerable but in the setting of re-operative surgery where multi-visceral en bloc resection is required in an irradiated field, as is commonly the case in PE surgery for locally recurrent cancer, this morbidity is even more marked [7][8]. Several exenteration units have published urine leak rates in excess of 15% after conduit formation and this contrasts sharply against the urine leak rates in contemporary urological literature where a leak rate of <5% is generally reported following conduit formation for a primary urological malignancy [4,[8][9][10][11][12][13][14]. Whether this disparity reflects true differences in complication rates between a more radical versus a less radical operation, primary versus re-operative surgery or whether this difference reflects institutional differences in complication rates or selection bias is unclear.…”

Ureteral reconstruction for retroperitoneal tumors in children

“…Within the adult literature, the use of urinary reconstruction as a part of the treatment of locally advanced pelvic tumors has been reported with good success [4]. Many techniques and procedures have been developed to reconstruct the continuity of the urinary tract in the event of injury.…”

“…A combination of the Boari flap with the psoas hitch has been used to provide additional length for long defects [8][9][10]. This combined procedure does not affect the ipsilateral or contralateral kidneys and can be used safely in patients with diminished renal function [10] with only minor complications and good long-term patency rates [4,11]. Urinary reflux appears to occur only in a small percentage of patients, and urinary tract infections can be managed effectively with oral antibiotics [12].…”

“…Historically, a section of ileum has been used to replace segments of ureter. Studies, however, have shown complications resulting from excessive mucous production, stone formation, and electrolyte imbalances with lengthy graft segments [4,11,18]. The appendix can be used to repair the right or left ureter, can be used in multiple positions along the ureter, comes with its own blood supply, and has a similar caliber to the ureter and does not have to be tapered unlike ileal interpositions [16].…”