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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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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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Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures. Int Urol Nephrol 2018; 50:1375-1380. [DOI: 10.1007/s11255-018-1904-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/30/2018] [Indexed: 10/28/2022]
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Degener S, Roth S, Mathers MJ, Ubrig B. [Follow-up care - consequences of urinary diversion after bladder cancer]. Urologe A 2014; 53:253-62; quiz 263-4. [PMID: 24477880 DOI: 10.1007/s00120-013-3376-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Radical cystectomy is the standard of care for muscle-invasive bladder cancer. Continent urinary diversions utilizing both small and large bowel are becoming more prominent: therefore, the postoperative follow-up has to focus on different aspects. In the first instance after radical cystectomy functional issues with respect to potential stenosis, post-void residual urine and micturition disorders are important. In the early phase the oncological follow-up aims to detect local, urethral and systemic recurrences and new data show the importance of the first 3 years after surgery. Long-term follow-up focuses on metabolic aspects, such as cobalamin or bile acid deficits, acidosis and disorders of calcium and bone metabolism. Follow-up care should consider specific complications of different types of urinary diversions; however to date standardized follow-up guidelines are lacking.
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Affiliation(s)
- S Degener
- Klinik für Urologie und Kinderurologie, Helios Klinikum Wuppertal, Zentrum für Forschung in der klinischen Medizin (ZFKM), Universität Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Deutschland,
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Mise au point du FRancilian Oncogeriatric Group (FROG) pour la prise en charge du cancer de vessie du sujet âgé. Bull Cancer 2014; 101:841-55. [DOI: 10.1684/bdc.2014.1939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Morbidity after pelvic exenteration for gynecological malignancies: a retrospective multicentric study of 230 patients. Int J Gynecol Cancer 2014; 24:156-64. [PMID: 24362721 DOI: 10.1097/igc.0000000000000011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Our study purpose was to evaluate morbidity and postoperative mortality in patients who underwent pelvic exenteration (PE) for primary or recurrent gynecological malignancies. METHODS We identified 230 patients who underwent PE, referred to the gynecological oncology units of 4 institutions: Charitè University in Berlin, Friedrich-Schiller University in Jena, S. Orsola-Malpighi University in Bologna, and Catholic University in Rome and in Campobasso. RESULTS The median age was 55 years. The tumor site was the cervix in 177 patients, the endometrium in 28 patients, the vulva in 16 patients, and the vagina in 9 patients. Sixty-eight anterior, 31 posterior, and 131 total PEs were performed in 116 women together with hysterectomy. A total of 82.6% of the patients required blood transfusion. The mean operative time was 446 (95-970) minutes, and the median hospitalization was 24 (7-210) days. We noted a major complication rate of 21.3% (n = 49). We registered 7 perioperative deaths (3%) calculated within 30 days. The operation was performed within clear margins in 166 patients (72.2%). The overall mortality rate depending on tumor site at the end of the study was 75% for vulvar cancer, 57.6% for cervical cancer, 55.6% for vaginal cancer, and 53.6% for endometrial cancer. CONCLUSIONS Although an important effort for surgeons and for patients, PE remains a therapeutic option with an acceptable complication rate and postoperative mortality. A strict selection of patients is mandatory to reach adequate surgical and oncologic outcomes.
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Hautmann RE, Abol-Enein H, Davidsson T, Gudjonsson S, Hautmann SH, Holm HV, Lee CT, Liedberg F, Madersbacher S, Manoharan M, Mansson W, Mills RD, Penson DF, Skinner EC, Stein R, Studer UE, Thueroff JW, Turner WH, Volkmer BG, Xu A. ICUD-EAU International Consultation on Bladder Cancer 2012: Urinary Diversion. Eur Urol 2013; 63:67-80. [DOI: 10.1016/j.eururo.2012.08.050] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 08/27/2012] [Indexed: 11/25/2022]
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Weingärtner K. [Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]. Urologe A 2012; 51:956-64. [PMID: 22772494 DOI: 10.1007/s00120-012-2909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.
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Affiliation(s)
- K Weingärtner
- Klinik für Urologie und Kinderurologie, Klinikum Bamberg, Buger Straße 80, 96049 Bamberg, Deutschland.
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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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Hampel C, Thomas C, Thüroff JW, Roos F. [Symptomatic reflux and stenosis of ureteroenteric anastomosis. Diagnostics and therapy]. Urologe A 2012; 51:477-84. [PMID: 22419010 DOI: 10.1007/s00120-012-2812-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Stenosis of the ureteroenterostomy and symptomatic reflux are among the most dangerous complications of all forms of urinary diversion. Variations in ureter implantation techniques and different surgical expertises are responsible for the heterogeneity of the available prevalence data. Antirefluxive implantation techniques seem to be more vulnerable to stenosis and obstruction than refluxive techniques, although no difference in kidney function deterioration over time was shown according to the presence or absence of reflux protection. Despite frequent controls, approximately one quarter of all obstructed renal units show a complete loss of function. The reimplantation rate of stenotic ureters exceeds 30%.The development of an implantation stenosis may be silent and subtle. The loss of renal function often remains unnoticed if sonography and creatinine measurements are the only follow-up tools employed. Neither of these tests is reliable in estimating kidney function and may mislead both doctor and patient. DMSA scintigraphy and retrograde contrast studies (conduitogram, pouchogram) are the most sensitive tools available to evaluate a symptomatic reflux, whereas MAG-3 renal scans and antegrade function tests (nephrostogram, renal pelvic pressure measurement) are recommended for investigating ureteric obstruction. Stenosis of the ureteroenterostomy usually occurs within 2 years after urinary diversion; delayed occurrence of ureteric obstruction is indicative of malignant local recurrence or compressive metastases.There are various minimally invasive treatment options such as balloon dilatation, internal ureterotomy, stenting and nephrostomy placement. However, the technical challenge of a ureteroenterostomy should not be a deterrent. In fact, if surgically possible, the patient should be offered open revision, since this is the only way to durably cure the underlying pathology and re-establish the already impaired quality of life of patients with urinary diversion as much as possible.
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Affiliation(s)
- C Hampel
- Urologische Klinik und Poliklinik, Johannes-Gutenberg-Universität, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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Eswara JR, Efstathiou JA, Heney NM, Paly J, Kaufman DS, McDougal WS, McGovern F, Shipley WU. Complications and Long-Term Results of Salvage Cystectomy After Failed Bladder Sparing Therapy for Muscle Invasive Bladder Cancer. J Urol 2012; 187:463-8. [DOI: 10.1016/j.juro.2011.09.159] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Jairam R. Eswara
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Niall M. Heney
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Paly
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald S. Kaufman
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - W. Scott McDougal
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis McGovern
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - William U. Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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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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Chimioradiothérapie concomitante des carcinomes de la vessie. Bull Cancer 2010; 97 Suppl Cancer de la vessie:19-25. [DOI: 10.1684/bdc.2010.1099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zafirakis H, De EJB, Pisters LL, Pettaway C, Westney OL. Long-term outcomes and patient satisfaction of continent catheterizable limb and augmentation cystoplasty simultaneous with salvage prostatectomy. Neurourol Urodyn 2010; 29 Suppl 1:S51-6. [PMID: 20419802 DOI: 10.1002/nau.20898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
AIMS We evaluated the long-term outcomes of augmentation cystoplasty and continent catheterizable limb formation in patients who underwent simultaneous salvage prostatectomy. METHODS Twelve men who underwent salvage prostatectomy with augmentation cystoplasty and either an appendicovesicostomy or Monti ileovesicostomy between October 2000 and February 2003 were assessed for long-term surgical complications, reoperations, continence rates, and patient satisfaction using the Incontinence Symptom Index (ISI) questionnaire and a self-designed catheterization questionnaire. RESULTS In addition to bladder augmentation, six patients underwent appendicovesicostomy, four had a Monti ileovesicostomy and two a spiral Monti ileovesicostomy. There were no intraoperative complications or surgical-related deaths. Four patients required revision surgery (33%) at a mean of 39 months. Minor revisions were performed for stomal stenosis in two patients with stomal relocation in two patients. Ten of 12 patients were dry (83.3%) with a catheterization frequency of between 3 and 8 hr. At a mean follow-up of 61 months (SD = 20.51), the mean ISI severity score was 1.86 (SD = 3.54) and the mean ISI bother score was 1 (SD 0.74). The majority (86%) would choose to undergo the surgery again. CONCLUSIONS Although surgically challenging and associated with significant morbidity, salvage prostatectomy with concomitant bladder augmentation and continent catheterizable reconstruction is a feasible and effective means of obtaining adequate long-term urinary continence, while preserving the native bladder. In comparison to similar historical patients with catheterizable limbs only, fewer of the augmented patients needed antimuscarinic medication and delayed augmentation was not necessary. Complications do not increase over time and the continence rates are stable.
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Affiliation(s)
- Helen Zafirakis
- MD Anderson Cancer Center, University of Texas, Houston, Texas 77030, USA
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Biewenga P, Mutsaerts MA, Stalpers LJ, Buist MR, Schilthuis MS, van der Velden J. Can We Predict Vesicovaginal or Rectovaginal Fistula Formation in Patients With Stage IVA Cervical Cancer? Int J Gynecol Cancer 2010; 20:471-5. [DOI: 10.1111/igc.0b013e3181d224c8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Incorporating pelvic/vaginal reconstruction into radical pelvic surgery. Gynecol Oncol 2009; 115:154-163. [DOI: 10.1016/j.ygyno.2009.05.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 05/26/2009] [Accepted: 05/28/2009] [Indexed: 11/20/2022]
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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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Stotland PK, Moozar K, Cardella JA, Fleshner NE, Sharir S, Smith AJ, Swallow CJ. Urologic Complications of Composite Resection Following Combined Modality Treatment of Colorectal Cancer. Ann Surg Oncol 2009; 16:2759-64. [DOI: 10.1245/s10434-009-0663-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 06/05/2009] [Accepted: 06/05/2009] [Indexed: 01/17/2023]
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Hautmann RE, de Petriconi R, Volkmer BG. Neobladder formation after pelvic irradiation. World J Urol 2008; 27:57-62. [DOI: 10.1007/s00345-008-0346-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 10/18/2008] [Indexed: 11/30/2022] Open
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Bakke A, Jensen KM, Jonsson O, Jónsson E, Månsson W, Paananen I, Schultz A, Thind P, Tuhkanen K. The rationale behind recommendations for follow-up after urinary diversion: an evidence-based approach. ACTA ACUST UNITED AC 2008; 41:261-9. [PMID: 17763215 DOI: 10.1080/00365590600991284] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- August Bakke
- Department of Urology, Surgical Clinic, Haukeland University Hospital, Bergen, Norway.
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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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Khafagy M, Shaheed FA, Moneim TA. Ileocaecal vs ileal neobladder after radical cystectomy in patients with bladder cancer: a comparative study. BJU Int 2006; 97:799-804. [PMID: 16536777 DOI: 10.1111/j.1464-410x.2006.05996.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare an ileocaecal orthotopic bladder, (which has been the standard procedure in Egypt for >30 years) with the ileal neobladder, as there is no ideal continent orthotopic bladder replacement for patients after cystectomy for bladder cancer. PATIENTS AND METHODS Between June 1999 and December 2001, 60 patients with invasive bladder cancer were randomized into two groups. Group A comprised 29 patients who had radical cystectomy and reconstruction with an ileal neobladder (median age 50 years, 27 men and two women) and group B included 31 who had an ileocaecal bladder substitution after radical cystectomy (median age 51 years, 28 men and three women). RESULTS The complication rate after surgery in group A was 17%, with two deaths, one from acute myocardial infarction and the other from haematemesis. In group B, the complication rate was 13%, with two deaths, one from a massive pulmonary embolism and the other from liver cell failure. Daytime continence was achieved in 93% of patients in group A and 90% in group B. The mean (sd) postvoid residual urine volume was larger in group A than group B, at 90 (72) vs 12 (20) mL. Acidosis and hyponatraemia were evident in the patients in group A but in none in group B (P < 0.05). The pelvicalyceal systems were preserved in 85% of patients in group A and 93% in group B during the 2-year follow-up. The mean (sd) renal cortical thickness was less in group A than in group B, at 1.8 (0.5) and 1.9 (0.2) cm, respectively. Although the cystometric capacity was greater and the basal pressure less in group A than B, these were not reflected in the degree of diurnal and nocturnal continence or back pressure on the renal units. CONCLUSION Continence in both pouches was similar but the renal units were preserved better in the ileocaecal than in the ileal neobladder. Residual urine volume was greater in the ileal neobladder, with its potential complications of infection and stone formation, and acidosis was more evident.
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Affiliation(s)
- Medhat Khafagy
- Department of Surgery, National Cancer Institute, Cairo University, Egypt
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Höckel M, Dornhöfer N. How to manage locally advanced primary and recurrent cancer of the uterine cervix: The surgeon's view. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.rigp.2005.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wilkin M, Horwitz G, Seetharam A, Hartenbach E, Schink JC, Bruskewitz R, Jarrard DF. Long-term complications associated with the Indiana pouch urinary diversion in patients with recurrent gynecologic cancers after high-dose radiation. Urol Oncol 2005; 23:12-5. [PMID: 15885577 DOI: 10.1016/j.urolonc.2004.07.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2004] [Revised: 07/26/2004] [Accepted: 07/31/2004] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Michael Wilkin
- Department of Surgery, Division of Urology, University of Wisconsin, Madison, 53792, USA
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Bochner BH, McCreath WA, Aubey JJ, Levine DA, Barakat RR, Abu-Rustum N, Poynor E, Wong D, Chi DS. Use of an ureteroileocecal appendicostomy urinary reservoir in patients with recurrent pelvic malignancies treated with radiation. Gynecol Oncol 2004; 94:140-6. [PMID: 15262132 DOI: 10.1016/j.ygyno.2004.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Evaluation of a modified right colon urinary reservoir in a heavily radiated patient population undergoing pelvic exenteration. METHODS A retrospective chart review was performed on all patients with recurrent gynecologic, colorectal, and urological tumors who underwent total pelvic or anterior exenteration and urinary diversion from 3/01 to 7/03 using an ureteroileocecal appendicostomy urinary reservoir. RESULTS Fourteen patients were identified over the study interval. The mean age of the patients was 53 years (range, 22-78 years). All patients received external beam, intracavitary, or a combination of both radiation treatment modalities to the pelvis preoperatively. Eight patients received intraoperative radiation therapy (IORT) at a mean dose of 16.25 Gy (range, 12.5-17.5 Gy). The primary sites of disease were as follows: cervix, five; prostate, three; uterus, two; colon/rectum two; and one each for vulva and bladder. Complete stomal continence was achieved in all patients after a median follow-up of 10 months (range, 2-31 months). Two patients experienced a traumatic disruption of the stomal-skin anastomosis in the early postoperative period (postoperative days 7 and 14). One late complication related to the ureterointestinal anastomosis was observed and consisted of an anastomotic stricture managed conservatively. One patient experienced an entero-pouch fistula following re-exploration for an acute postoperative hemorrhage. CONCLUSION The early outcomes using the ureteroileocecal appendicostomy urinary reservoir in heavily radiated patients demonstrate the technical feasibility of this design as both minimal early stoma and ureterointestinal complications may occur. Longer postoperative follow-up will be required to address the late outcomes of this procedure and its ultimate use in this population.
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Affiliation(s)
- Bernard H Bochner
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Salom EM, Mendez LE, Schey D, Lambrou N, Kassira N, Gómez-Marn O, Averette H, Peñalver M. Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years. Am J Obstet Gynecol 2004; 190:994-1003. [PMID: 15118628 DOI: 10.1016/j.ajog.2004.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Colon/surgery
- Female
- Florida/epidemiology
- Genital Neoplasms, Female/epidemiology
- Genital Neoplasms, Female/etiology
- Genital Neoplasms, Female/mortality
- Genital Neoplasms, Female/pathology
- Genital Neoplasms, Female/radiotherapy
- Genital Neoplasms, Female/surgery
- Humans
- Ileum/surgery
- Medical Records
- Middle Aged
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Outcome Assessment, Health Care
- Postoperative Complications
- Retrospective Studies
- Urinary Incontinence
- Urinary Reservoirs, Continent/statistics & numerical data
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Affiliation(s)
- Emery M Salom
- University of Miami, School of Medicine, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, Division of Gynecologic Oncology, 33136, USA.
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Hohenfellner R. RE: COMBINED URINARY AND FECAL DIVERSION USING A NO BOWEL ANASTOMOSIS TECHNIQUE. J Urol 2003. [DOI: 10.1016/s0022-5347(05)63972-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rudolf Hohenfellner
- Department of Urology, University of Mainz, Langenbeckstrabe 1, 55131, Mainz, Germany
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