Urinary complications of Miami pouch: trend of conservative management

Recommendations for the treatment of vulvar cancer in settings with limited resources: Report from the International Gynecological Cancer Society consensus meeting

Introduction

Due to scant literature and the absence of high-level evidence, the treatment of vulvar cancer is even more challenging in countries facing limited resources, where direct application of international guidelines is difficult. Recommendations from a panel of experts convened to address some of these challenges were developed.

Methods

The panel met in Rio de Janeiro in September 2019 during the International Gynecological Cancer Society congress and was composed of specialists from countries in Africa, Asia, Eastern Europe, Latin America, and the Middle East. The panel addressed 62 questions and provided recommendations for the management of early, locally advanced, recurrent, and/or metastatic vulvar cancer. Consensus was defined as at least 75% of the voting members selecting a particular recommendation, whereas a majority vote was considered when one option garnered between 50.0% and 74.9% of votes. Resource limitation was defined as any issues limiting access to qualified surgeons, contemporary imaging or radiation-oncology techniques, antineoplastic drugs, or funding for the provision of contemporary medical care.

Results

Consensus was reached for nine of 62 (14.5%) questions presented to the panel, whereas a majority vote was reached for 29 (46.7%) additional questions. For the remaining questions, there was considerable heterogeneity in the recommendations.

Conclusion

The development of guidelines focusing on areas of the world facing more severe resource limitations may improve medical practice and patient care.

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.

Urinary diversion after pelvic exenteration for gynecologic malignancies

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.

High-Dose Rate Salvage Interstitial Brachytherapy: A Case-Based Guide to the Treatment of Therapeutically Challenging Recurrent Vulvar Cancer

Vulvar cancer is a rare gynecological malignancy with incidence rates steadily increasing over the past 10 years. Despite aggressive treatment, recurrent disease is common. Vulvar cancer recurrence poses a significant therapeutic challenge as most patients have been previously treated with surgery and/or radiation limiting the options for additional treatment. There are no consensus guidelines for the treatment of recurrent disease. Current literature supports the use of salvage interstitial brachytherapy. However, the total sample size is small. The goal of this case report is to review the current literature and to provide a guide for the use of salvage interstitial brachytherapy for recurrent disease by describing, in detail, the techniques used to treat two patients with unique cases of vulvar cancer recurrences in women with advanced disease and multiple medical comorbidities.

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

CONTEXT

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

OBJECTIVE

To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.

EVIDENCE SYNTHESIS

Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.

CONCLUSIONS

Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

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.

Ileal Conduit and Continent Ileocecal Pouch for Patients Undergoing Pelvic Exenteration: Comparison of Complications and Quality of Life

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.

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.

Long-term follow-up of continent urinary diversion after pelvic exenteration for gynecologic malignancies

OBJECTIVE

The objective of this retrospective study was to analyze the long-term outcome of patients undergoing a continent urinary diversion (UD) at the time of pelvic exenteration (PE).

PATIENTS AND METHODS

Between February 1993 and January 2001, 60 PE for gynecologic malignancies and requiring a UD were performed. Patient's preference, type of UD planned, type of UD performed, and late urinary morbidity (after day 90) were analyzed.

RESULTS

Eighty-two percent of the entire group (49/60) matched preoperatively criteria to have a continent UD and 41 continent UD were eventually performed (87%). Postoperative mortality in patients with a continent UD was 4.9% (2/41) and wasn't related to urinary complications. After a 20-month median follow-up, 18 patients (46%) with a continent UD developed late complications directly UD-related. These complications were: (a) major in 28% (5/18) requiring re-operation in 3 cases or endoscopic treatment in 2 cases; (b) minor in 72% (13/18) constantly medically treated. Chronic diarrhea was more frequent in patient who had small bowel or left colon resection (P < 0.05) and urine leakage was more frequent in patient with higher BMI (P < 0.05). At last follow-up, no patient had stopped self-catheterizations or asked for undiversion.

CONCLUSIONS

In our experience, continent UD at the time of PE despite high acceptability and feasibility rate, appeared to be strongly related to specific late complications, uncommon with ileal conduit. However, these complications remained more frequently minor and could be treated safely and conservatively.

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.

Guidelines of how to manage vesicovaginal fistula

Vesicovaginal fistulas are among the most distressing complications of gynecologic and obstetric procedures. The risk of developing vesicovaginal fistula is more than 1% after radical surgery and radiotherapy for gynecologic malignancies. Management of these fistulas has been better defined and standardized over the last decade. We describe in this paper the success rate reported in the literature by treatment modality and the guidelines used at our teaching hospitals, University of Rome Campus Biomedico and University of Miami School of Medicine. In general, our preferred approach is a trans-vaginal repair. To the performance of the surgical treatment, we recommend a minimum of a 4-6 week's wait from the onset of the fistula. The vaginal repair techniques can be categorized as to those that are modifications of the Latzko procedure or a layered closure with or without a Martius flap. The most frequently used abdominal approaches are the bivalve technique or the fistula excision. Radiated fistulas usually require a more individualized management and complex surgical procedures. The rate of successful fistula repair reported in the literature varies between 70 and 100% in non-radiated patients, with similar results when a vaginal or abdominal approach is performed, the mean success rates being 91 and 97%, respectively. Fistulas in radiated patients are less frequently repaired and the success rate varies between 40 and 100%. In this setting many institutions prefer to perform a urinary diversion. In conclusion, the vaginal approach of vesicovaginal fistulas repair should be the preferred one. Transvaginal repairs achieve comparable success rates, while minimizing operative complications, hospital stay, blood loss, and post surgical pain. We recommend waiting at least 4-6 weeks prior to attempting repair of a vesicovaginal fistula. It is acceptable to repeat the repair through a vaginal approach even after a first vaginal approach failure. In the more individualized management of fistulas associated with radiation, the vaginal approach should still be considered.

Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years

OBJECTIVE

A patient with a recurrent central pelvic malignancy after radiation will require urinary diversion as part of the reconstructive phase of the pelvic exenteration. The aim of our study was to assess the result of our 15-year experience with a continent ileocolonic urinary reservoir, which is known as the Miami pouch.

STUDY DESIGN

Since 1988, all patients who received a continent ileocolonic urinary reservoir in the Division of Gynecologic Oncology, University of Miami School of Medicine, were included in the study. Parameters that were evaluated during the study period include functional outcomes, early and late perioperative complications, and their treatment.

RESULTS

A total of 90 patients were identified from February 1988 to December 2002. Seventy-eight patients (87%) had a recurrent central pelvic malignancy, and 82 patients (91%) received radiation before the Miami pouch procedure. The non-reservoir-related morbidities were fever (76%), wound complication (30%), pelvic collection (12%), ileus/small bowel obstruction (12%), and postoperative death (11%). The most common reservoir-related complications were urinary infection (40%), ureteral stricture (20%), and difficulty with self-catheterization (18%). In our study, the overall complication rate that was related directly to the Miami pouch was 53%. Conservative treatment resolved>80% of these cases. The rate of urinary continence that was achieved in our patients was 93% during our 15-year experience with the Miami pouch.

CONCLUSION

The Miami pouch is a good alternative for continent urinary diversion during exenteration or radiation-induced damage. The rate of major complications that require aggressive surgical intervention is acceptable. Most postoperative complications (80%) can be corrected with the use of conservative techniques that are associated with fewer deaths than reoperation and thus should be used first. The technique is simple and effective in women who are at high risk, who have undergone previous radiation therapy, and who have a high rate of functional success and is a profound advantage for a woman's psychosocial well-being.

Pelvic exenteration and reconstruction

For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.

Major complications of urinary diversion after pelvic exenteration for gynecologic malignancies: a 23-year mono-institutional experience in 124 patients

OBJECTIVE

The objective of this study was to analyze the postoperative outcome of patients undergoing urinary diversion at the time of pelvic exenteration.

METHODS

Between January 1980 and December 2002, 232 pelvic exenterations for gynecologic malignancies were performed in our hospital. One hundred and twenty-four included a urinary diversion. There were locally advanced or recurrent cancers including 101 cervical, 11 endometrial, 5 vagina, 2 ovarian malignancies and 5 pelvic sarcoma.

RESULTS

Ninety patients (72.5%) had a history of previous irradiation. Exenterations were 69 anterior and 55 total. Urinary diversion included 14 bilateral ureterostomies, 62 trans-intestinal diversion and 48 continent diversion using distal ileum and right colon. Pelvic filling was performed in 56 patients (45%). Low colorectal anastomosis was performed in 42 of 48 supralevator pelvic exenteration (87.5%). Postoperative mortality rate was 8% (10/124). Overall 12-week postoperative morbidity rate was 52% (65/124) and appears to be significantly higher in irradiated patients and after total exenteration. In trans-intestinal noncontinent group, eight patients were reoperated for a complication directly related to urinary diversion procedure. No reoperation for such a complication was performed in the continent urinary diversion group.

CONCLUSIONS

Ileocolic continent pouch seems to be the safer urinary diversion procedure after exenteration for gynecological malignancies especially in irradiated patients and after total exenteration.

Innovations in the treatment of invasive cervical cancer

Invasive cervical cancer is characterized by basement membrane-invading lesions capable of metastasizing through the lymphatic and vascular systems. Treatment methods were reviewed by panelists at the Second International Conference on Cervical Cancer (Houston, TX, April 11-14, 2002), and new opportunities for translational research were discussed. Reviews encompassed hysterectomy with or without lymph node dissection or cervical conization in cases with microinvasion and radical trachelectomy with or without lymph node dissection as fertility-sparing surgery. Chemoradiation is used to treat advanced cervical malignancies, and the risks and benefits of radiotherapy are significant. Pelvic exenteration is used to treat certain types of recurrences. Use of the Miami pouch for continent urinary diversion was highlighted. Gynecologic oncologists expect novel in vivo imaging techniques currently being developed to help guide therapy choices within the next decade. The most significant research priorities are large group-randomized trials involving fertility-sparing procedures and the management of microinvasive carcinoma (MICA); better identification of candidates for chemoradiation; and the development of innovative approaches to exenteration. Improving diagnostic technologies, refining the criteria by which therapies are chosen, and preserving fertility remain challenges in selecting the most appropriate treatment for invasive cervical cancer. Research advances in both diagnosis and treatment are expected to improve therapy and outcomes.

Continent urinary diversion and low colorectal anastomosis after pelvic exenteration. Quality of life and complication risk

INTRODUCTION

Pelvic exenteration is one of the most destructive gynecologic operations performed on an elective basis, with consequent detrimental effects on the quality of life. The use of reconstructive surgery has significantly improved the quality of life of women undergoing this type of procedure. In this paper we review our experience with continent urinary diversion (Miami Pouch) and low colorectal anastomosis at the Division of Gynecologic Oncology of the University of Miami.

METHODS

Patients who underwent creation of the continent urinary diversion Miami Pouch from 1988 to 1997 and supralevator pelvic exenteration with low colorectal resection and primary anastomosis from 1990 to 1997 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared. Analysis of complications in irradiated and nonirradiated patients was performed.

RESULTS

77 patients who underwent creation of the Miami Pouch entered this study. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. The most common urinary complications were ureteral stricture/obstruction (22.1%), difficult catheterisation (19.5%) and pyelonephritis (16.9%). Conservative management strategies were successfully used in 80% of the complications. Analysis of breakdown and fistula formation after low colorectal anastomosis was performed on 77 patients. Thirty-five percent of the irradiated patients developed anastomotic breakdown or fistulas, while the occurrence of this type of complications was only 7.5% in the nonirradiated group.

CONCLUSIONS

Reconstructive procedures after pelvic exenteration present a significant risk of complications, especially in irradiated patients. Most of the complications related to the creation of continent urinary diversion can safely be treated conservatively. Low colorectal anastomosis carries an acceptable risk of complications in nonirradiated patients, but the risk in irradiated patients is very high, therefore, detailed patient selection and extensive counselling in these groups of patients is mandatory.

Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies

OBJECTIVE

The purpose of this study was to review our experience with continent urinary diversions in patients with gynecologic malignancies and evaluate the presentation and management of early and late complications.

METHODS

A retrospective chart review was performed of all patients who underwent a continent urinary diversion on the Gynecologic Oncology Service at The University of Texas M. D. Anderson Cancer Center during the period January 1988 to March 2001. We analyzed our data to evaluate potential risk factors for complications. Renal status, conduit integrity, and overall patient outcomes were also studied.

RESULTS

We identified 40 patients who underwent a continent urinary diversion using an ileocolonic segment (Miami pouch technique). All patients had a history of gynecologic malignancies. The median age at the time of the procedure was 50 years (range 24 to 76 years), and the median weight was 69.6 kg (range 47 to 125 kg). A total of 39 patients (98%) had a history of radiotherapy. Continent urinary diversion was performed as part of an anterior pelvic exenteration in 12 patients (30%), in conjunction with a total pelvic exenteration in 18 patients (45%), and as the main procedure in 10 patients (25%). The median estimated blood loss was 2100 ml (range 200 to 8500 ml). The median length of hospitalization was 19.5 days (range 7 to 56 days). A total of 24 patients (60.0%) had a postoperative complications unrelated to the reservoir. Complications directly related to the continent urinary diversion were seen in 26 (65.0%) of 40 patients. None of the patients in this study group developed chronic renal failure, and there were no perioperative deaths. At last evaluation, 36 (90%) of 40 patients reported normal continent conduit function.

CONCLUSIONS

Continent urinary diversion using an ileocolonic segment is a reasonable alternative to the ileal and transverse colon conduit in bladder reconstruction in patients undergoing radical pelvic surgery. The routine use of postoperative total parenteral nutrition, the chronic use of antibiotics after discharge from the hospital, and the routine use of imaging studies remain controversial. In this group of patients, the majority of complications may be successfully managed conservatively.

Recurrent vulvar cancer

Recurrent vulvar cancer occurs in an average of 24% of cases after primary treatment after surgery with or without radiation. The relatively few primary vulvar cancers, combined with the low proportion of recurrences, has made it difficult to perform randomized studies to document the most appropriate therapeutic modalities. Most reports are small retrospective studies and anecdotal reviews that have emphasized the importance of surgery and have led to new approaches with respect to chemoradiation. Traditionally, the most accepted treatment of vulvar cancer has been and continues to be surgery. Recently, radiation and chemotherapy have been combined with very encouraging results. The therapeutic modality used depends on the location and extent of the recurrence. Most recurrences occur locally near the original resection margins or at the ipsilateral inguinal or pelvic lymph nodes. Lateralized local vulvar recurrences treated with a wide radical local excision with inguinal lymphadectomy results in an excellent cure rate of 70%. With a central pelvic recurrence with antecedent radiotherapy involving the urethra, upper vagina, and rectum, total pelvic exenteration is indicated in a select group of patients with curative intent. Radiotherapy or chemoradiation concomitantly with wide radical local excision of an advanced vulvar has proven successful in avoiding an exenteration, with improved survival and less morbidity. Prospective and retrospective studies have shown excellent results using radiation or chemoradiation with wide radical local excision in patients with locally advanced disease in whom adequate resection margins are difficult to achieve (with a central lesion requiring exenteration) or with debilitating medical conditions that preclude surgery. In these patients, chemoradiation has shown favorable results when used before a wide local resection. In patients with advanced local disease, external beam and interstitial radiation has been used for palliative and curative intent with encouraging results. Regional recurrences to the inguinal and pelvic lymph nodes have been shown to have a poor prognosis with a high mortality rate. We recommend that inguinal recurrences without prior radiation therapy undergo excision followed by radiotherapy with chemosensitization. In patients with previous radiation to the inguinal lymph nodes, we try to avoid any excisional procedures because of the high rate of complications. We offer these patients brachytherapy for palliation. With pelvic recurrences, we recommended chemoradiation as the treatment modality. In the subset of patients with distant metastasis, chemotherapy may be offered; however, few studies have been performed to advocate any single combination. The literature supports the use of 5-fluorouracil or cisplatin as single agents or in combination to have sensitivity against squamous cells. There are few studies revealing improvement in 5-year survival, thus these patients may benefit from recruitment into research protocols.

Urinary diversion in gynecologic oncology

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Pelvic exenteration

Pelvic exenterations are the most extensive surgeries performed for patients with gynecologic cancer, and the surgical team and patients have to be fully aware of the many issues that come into the discussion. This article discusses the history, indications, surgical techniques, and complications of pelvic exenteration.

Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery

OBJECTIVE

The primary aim of this study was to report on the prevalence of perioperative complications associated with reconstructive pelvic surgery. A secondary aim was to identify risk factors predictive of perioperative complications in this population.

STUDY DESIGN

A retrospective chart review was performed of 100 consecutive cases of reconstructive pelvic surgery. Statistical analysis included descriptive statistics and logistic regression.

RESULTS

The prevalence of perioperative complications was 46%, including 13 intraoperative complications and 33 postoperative complications. The readmission rate for complications was 15%. The number of procedures per patient was an independent risk factor for intraoperative blood loss (P <.0038). Intraoperative estimated blood loss in turn was an independent risk factor for perioperative complications (P <.0001).

CONCLUSIONS

Perioperative complications associated with reconstructive pelvic surgery were increased relative to those associated with general gynecologic surgery. The number of procedures per patient and associated blood loss appeared to contribute to the increase in perioperative complications.

Surgical management of advanced and recurrent cervical cancer

Since the early 1940s, the incidence of cervical cancer has dramatically decreased due in large part to the work of Papanicolaou and Traut. Successful treatment can now be done using simple or radical surgical intervention for early invasive lesions and radiation therapy for more advanced lesions. However, despite current advances in screening and early treatment, local recurrences still happen and are difficult to treat. The natural history of cervical cancers is that of a slowly growing, locally invasive tumor. As such, it lends itself to radical surgical resection in selected patients prior to distant metastasis. Current advances in intraoperative and postoperative monitoring, as well as improved surgical techniques and devices, have decreased the morbidity and mortality of radical surgical procedures to acceptable levels. Current data associated with these procedures for advanced or recurrent cervical cancer are described.