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Tillu N, Zaytoun O, Kolanukuduru K, Venkatesh A, Dovey Z, Choudhary M, Petitti T, Autorino R, Buscarini M. Analysis of early perioperative outcomes of robot-assisted radical cystectomy and colonic diversion. J Robot Surg 2024; 18:286. [PMID: 39025997 DOI: 10.1007/s11701-024-02047-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/09/2024] [Indexed: 07/20/2024]
Abstract
Studies of right colon pouch urinary diversion have widely varying estimates of the risk of perioperative complications, reoperation, and readmission. We sought to describe the association between specific risk factors and complication, readmission, and reoperation rates following right colon pouch urinary diversion. Patients undergoing robot-assisted right colon pouch urinary diversion from July 2013 to December 2022 were analyzed. Outcome measures include high-grade (Clavien-Dindo grade ≥ 3) complications within 90 days, readmission within 90 days, and reoperation at any time during follow-up. Specific risk factors such as age, gender, body mass index (BMI), diabetes, Charlson comorbidity index (CCI), and prior radiation were analyzed to establish an association with these outcomes. During the study period, 77 patients underwent the procedure and were eligible to study. The average follow-up was 88.7 (SD 14) months. 90-day high-grade complications were 24.67%, and 90-day readmission was 33.76%. The cumulative rate of any reoperation was 40.2%, and major reoperation was 24.67%. Female gender (OR 3.3, p = 0.015), 1 kg/m2 increase in BMI (OR 3.77, p = 0.014), diabetes (OR 3.49, p = 0.021), higher CCI (OR 1.59, p = 0.034), prior radiation (OR 1.97, p = 0.026), lower eGFR (OR 0.99, p = 0.032) and BMI ≥ 25 kg/m2 (OR 3.9, p value 0.02) was associated with Clavien III-IV complications. Female gender (OR 3.3, p = 0.015), diabetes (OR 3.97, p = 0.029), higher Charlson Comorbidity Index (OR 1.73, p = 0.031), prior radiation (OR 1.45, p = 0.029), lower eGFR (OR 0.87, p = 0.037) and BMI ≥ 25 kg/m2 (OR 3.86, p = 0.031) were predictive of reoperation. Overall, the rate of postoperative complications, readmissions, and reoperation was high but consistent with other studies. This study helps further characterize surgical outcomes after right colon pouch urinary diversion and highlights patients who may benefit from enhanced preoperative management for minimising complications.
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Affiliation(s)
- Neeraja Tillu
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA.
| | - Osama Zaytoun
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA
| | - Kaushik Kolanukuduru
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | | | - Zachary Dovey
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA
| | - Manish Choudhary
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA
| | | | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Maurizio Buscarini
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 1427 Madison Ave, New York, NY, 10029, USA
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Kunkel G, Patel H, Kaldany A, Allu S, Elsamra S, Cancian M. Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease. World J Urol 2023; 41:1459-1468. [PMID: 37014391 DOI: 10.1007/s00345-023-04378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.
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Affiliation(s)
- Gregory Kunkel
- Department of Urology, UMass Chan: University of Massachusetts Medical School, Worcester, MA, USA.
| | - Hiren Patel
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alain Kaldany
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sai Allu
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sammy Elsamra
- Division of Urology, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Madeline Cancian
- Division of Urology, Brown University Warren Alpert Medical School, Providence, RI, USA
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Patient Selection and Outcomes of Urinary Diversion. Urol Clin North Am 2022; 49:533-551. [DOI: 10.1016/j.ucl.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mabuchi S, Waki K. The first case of recurrent small cell neuroendocrine carcinoma of the uterine cervix successfully treated with robotic-assisted super radical hysterectomy. Gynecol Oncol Rep 2021; 38:100882. [PMID: 34926763 PMCID: PMC8651782 DOI: 10.1016/j.gore.2021.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/07/2021] [Accepted: 10/10/2021] [Indexed: 12/02/2022] Open
Abstract
Recurrent cervical cancer occurring in a previously irradiated field is one of the most complicated challenges for gynecological oncologists. Super-radical hysterectomy is a standard procedure for laterally extended cervical tumors, particularly recurrent cervical cancer in a previously irradiated field. This potentially curative procedure is challenging to perform due to the technical complexities and lack of reproducibility. Thus, it is performed only by skilled surgeons, either via open or laparoscopic approaches wherein the entire paracervix at the pelvic wall and the hypogastric vessels are transected. In this report, we described the first case of recurrent small cell neuroendocrine carcinoma of the uterine cervix that was successfully treated with robot-assisted super-radical hysterectomy.
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Key Words
- CCRT, concurrent chemoradiotherapy
- CT, computed tomography
- Complete resection
- FDG, fluorodeoxyglucose
- H&E, hematoxylin and eosin
- LACC, laparoscopic approach to cervical cancer
- LEER, laterally extended endopelvic resection
- MIS, minimally invasive surgery
- MRI, magnetic resonance imaging
- PE, pelvic exenteration
- Persistent cervical cancer
- RH, radical hysterectomy
- Recurrent cervical cancer
- Robotic surgery
- SCNEC, small cell neuroendocrine carcinoma
- SRH, super-radical hysterectomy
- Super radical hysterectomy
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Affiliation(s)
- Seiji Mabuchi
- Department of Gynecology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka-shi, Osaka 541-8567, Japan
| | - Keita Waki
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Nara, Japan
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Hoeh B, Müller SC, Kluth LA, Wenzel M. Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review. Front Surg 2021; 8:688394. [PMID: 34434956 PMCID: PMC8381645 DOI: 10.3389/fsurg.2021.688394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Stefan C Müller
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
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Abstract
As useful and necessary as radiotherapy may be, it is associated with irreversible long-term adverse effects including loss of bladder function. In the majority of cases the small bowel, sigmoid rectum and ureter are also affected. The extent of injury depends on the irradiated area, the applied dose and the quality of application. Three factors are essential when choosing a urinary diversion: the length of functional ureter, the position of the bowel outside of the irradiated area and the type of diversion. A continent diversion is best performed through a ascending-transverse or transverse-descending colon pouch. The efferent segment is diverted through the umbilicus. The simplest technique for an incontinent diversion is a conduit using the ascending colon or the right colon flexure. If the length of the ureter does not suffice for such a conduit, the ideal solution is a transverse conduit, as this conduit can be attached to both renal pelves, while simultaneously allowing free choice of the lateral location of the stoma. In case of an exenteration, a double stoma on one side of the body should be avoided in order to prevent maintenance issues.
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Affiliation(s)
- A Pycha
- Urologische Abteilung, Landeskrankenhaus Bozen, Lorenz Böhler Straße 5, 39100, Bolzen, Italien. .,Medizinische Fakultät, Sigmund Freud Privat Universität, Wien, Österreich.
| | - E Trenti
- Urologische Abteilung, Landeskrankenhaus Bozen, Lorenz Böhler Straße 5, 39100, Bolzen, Italien
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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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Myers JB, Martin C, Cheng PJ, Zhang C, Presson AP. Outcomes of right colon continent urinary pouch using standardized reporting methods. Neurourol Urodyn 2019; 38:1290-1297. [PMID: 30901104 DOI: 10.1002/nau.23951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/21/2018] [Accepted: 12/10/2018] [Indexed: 01/06/2023]
Abstract
AIMS Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion. METHODS Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes. RESULTS During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission. CONCLUSIONS Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.
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Affiliation(s)
- Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Christopher Martin
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Philip J Cheng
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Chong Zhang
- Division of Epidemiology and Biostatistics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology and Biostatistics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Dobberfuhl AD. Evaluation and treatment of female stress urinary incontinence after pelvic radiotherapy. Neurourol Urodyn 2018; 38 Suppl 4:S59-S69. [DOI: 10.1002/nau.23839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Amy D. Dobberfuhl
- Department of UrologyStanford University School of MedicineStanfordCalifornia
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11
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Urinary Diversion for Severe Urinary Adverse Events of Prostate Radiation: Results from a Multi-Institutional Study. J Urol 2017; 197:744-750. [DOI: 10.1016/j.juro.2016.10.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2016] [Indexed: 11/19/2022]
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Perioperative and long-term surgical complications for the Indiana pouch and similar continent catheterizable urinary diversions. Curr Opin Urol 2016; 26:376-82. [DOI: 10.1097/mou.0000000000000300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Greear G, Lefkowits C, Parrillo LM, Flynn BJ. Incontinence, Voiding Dysfunction, and Other Urologic Complications After Radiotherapy for Gynecologic Malignancies. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0354-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Patient Selection, Operative Technique, and Contemporary Outcomes of Continent Catheterizable Diversion: the Indiana Pouch. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Affiliation(s)
- S A Ahyai
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Deutschland.
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Ileal Conduit and Continent Ileocecal Pouch for Patients Undergoing Pelvic Exenteration: Comparison of Complications and Quality of Life. Int J Gynecol Cancer 2011; 21:403-8. [DOI: 10.1097/igc.0b013e31820aab17] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives:Creating a continent urinary pouch has become an alternative to the ileal conduit for patients undergoing exenteration for advanced gynecologic malignancies. The objective of this study was to compare clinical outcomes for the 2 methods.Methods:In this retrospective study, we compared intraoperative and postoperative complications and quality-of-life scores for the modified ileocecal pouch and the ileal conduit in anterior or total pelvic exenteration.Results:In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes compared to an IC (IC, 453 minutes vs IP, 550 minutes;P= 0.009). Overall complication rates were similar, but patients with an IP had significantly more complications of urinary diversion (48%) than patients with an IC (31%;P= 0.03). Follow-up showed urinary loss and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal complications (n = 2) and treatment of bladderstones were necessary more frequently (n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire was similar in both groups.Conclusion:A continent IP is an alternative to the IC in cases of pelvic exenteration. Early complications are more frequent with an IP than with an IC. The mode of urinary diversion has little influence on the quality of life in patients with advanced genital cancer.
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Rink M, Kluth L, Eichelberg E, Fisch M, Dahlem R. Continent Catheterizable Pouches for Urinary Diversion. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.eursup.2010.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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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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Stolzenburg JU, Schwalenberg T, Liatsikos EN, Sakelaropoulos G, Rödder K, Hohenfellner R, Fisch M. Colon pouch (Mainz III) for continent urinary diversion. BJU Int 2007; 99:1473-7. [PMID: 17346278 DOI: 10.1111/j.1464-410x.2007.06767.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended. PATIENTS AND METHODS The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion. RESULTS The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea. CONCLUSIONS The Mainz pouch III is an alternative to other types of continent urinary diversion.
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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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Basavaraj DR, Harrison SCW. The Mitrofanoff procedure in the management of intractable incontinence: a critical appraisal. Curr Opin Urol 2006; 16:244-7. [PMID: 16770122 DOI: 10.1097/01.mou.0000232044.03051.aa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The term intractable urinary incontinence can be applied to urinary incontinence that cannot be managed using conventional treatments like drug therapy for detrusor overactivity or sling procedures for female stress incontinence. This review considers the role of the Mitrofanoff procedure in extending the range of options for the patient who might otherwise consider using an indwelling catheter or an ileal conduit diversion to overcome incontinence. Clinicians use the label 'Mitrofanoff procedure' quite loosely to describe any continent catheterizable abdominal stoma. For the purposes of this review, we will use the term in this generic sense while acknowledging our imprecision. RECENT FINDINGS Reviews confirm that the Mitrofanoff procedure has stood the test of time. Quality-of-life benefits, however, need a conclusive demonstration in scientific terms. Enthusiasts of laparoscopic surgery show that this type of lower urinary tract reconstruction can be carried out using minimally invasive methods. SUMMARY Reconstructive options using a catheterizable abdominal stoma should be discussed with patients with intractable urinary incontinence. Reliable surgical techniques are established; though complications are frequent, most can be dealt without recourse to major surgical intervention. Unfortunately, authoritative data on the impact of the Mitrofanoff procedure on patients' qualities of life are still lacking.
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Current World Literature. Curr Opin Urol 2005. [DOI: 10.1097/01.mou.0000188972.91538.be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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