Urinary diversion after pelvic exenteration for gynecologic malignancies

Abstract

Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5–50%), ureteral stricture (3–27%), urolithiasis (5–25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.

Pelvic Exenteration for Cervical Cancer that is Persistent or Recurrent after Radiotherapy or Chemoradiation. Institutional Experience of 51 Years

“…The specimen was extracted in a block, with sufficient margin to the vagina and removal of the bladder and / or rectum being necessary in some patients with transopertive report of tumor in the vaginal margin, to widen the margin with or without perineal approach for complete extraction of the specimen. Reconstruction of the urinary tract was performed using a defunctionalized segment of the terminal ileum, Bricker's ileal conduit, [14,15] or through a difunctional segment of the sigmoid rectum (sigmoid conduit). A colostomy terminal was carried out in the case of TPE and PPE.…”

Indocyanine Green to Assess Vascularity of Ileal Conduit Anastomosis During Pelvic Exenteration for Recurrent/Persistent Gynecological Cancer: A Pilot Study

“…All patients underwent intravenous injection of 3–6 ml of ICG (1.25 mg/ml) once the UD was completed. All ileal conduits were performed by the same urologist (NF), and the decision to perform Bricker–Nelaton vs. Wallace type I (medial-posterior wall continuous suture) ( 8 ) uretero-enteric anastomosis technique was taken according to the appearance, availability, and mobility of the distal ureters after the oncological resection and previous radiotherapy. A near-infrared laparoscopic camera (Olympus, Tokyo, Japan) or the SPY Portable Handheld Imager (SPY-PHI) (Stryker, Kalamazoo, MI, USA) was used to evaluate ICG perfusion a few seconds after intravenous ICG injection ( Figure 1A ).…”

“…In particular, postoperative complications range from 51% to 82%, of which 22%–32% are major complications ( 1 , 7 ). The anterior part of pelvic exenteration contemplates the reconstruction by urinary diversion (UD) that can be performed with different techniques ( 8 ). UD options (orthotopic neobladder, continent and incontinent diversions) require anastomosis of the ureters with selected bowel segments; among UD, ileal conduit continues to be the most widely UD used after pelvic exenteration for gynecologic malignancies ( 8 – 10 ).…”

“…The anterior part of pelvic exenteration contemplates the reconstruction by urinary diversion (UD) that can be performed with different techniques ( 8 ). UD options (orthotopic neobladder, continent and incontinent diversions) require anastomosis of the ureters with selected bowel segments; among UD, ileal conduit continues to be the most widely UD used after pelvic exenteration for gynecologic malignancies ( 8 – 10 ). A wide range of complications are not only related to the pelvic exenteration but specifically to UD: 45% of patients experience functional complications after 5 years, 50% at 10 years, and 94% at 15 years ( 11 ).…”

“…A wide range of complications are not only related to the pelvic exenteration but specifically to UD: 45% of patients experience functional complications after 5 years, 50% at 10 years, and 94% at 15 years ( 11 ). Despite the multiple variations in uretero-enteric anastomosis, ureteric fistula and benign ureteric stricture represent short- and long-term complications associated with ileal conduit urinary diversion in 5%–22% and 3%–27% of cases, respectively ( 8 , 12 ).…”