EVALUATION AND MANAGEMENT OF MECHANICAL DYSFUNCTION IN CONTINENT COLONIC URINARY RESERVOIRS

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.

A multi-institutional study of orthotopic neobladders: functional results in men and women

OBJECTIVES

To analyse the incidence of diurnal incontinence (DI) and nocturnal incontinence (NI), the need for intermittent catheterization (IC),and the rate of ureteric obstruction (UO) among a group of men and women with ileal and colonic orthotopic neobladders in four countries.

PATIENTS AND METHODS

In all, 138 patients (113 men and 25 women) had an orthotopic neobladder constructed after radical cystectomy for carcinoma. The mean(range) age was 61.3 (28-76) years and the follow-up 41 (6-144) months. All patients underwent surgery by experienced surgeons associated with the Confederation of American Urology. A retrospective evaluation was designed to review the functional results and the incidence of UO. The technique of orthotopic neobladder construction was at each surgeon's discretion. Various detubularized bowel segments were used, including ileum, colon or sigmoid. Patients were followed by chart reviews and personal interviews at 1, 3 and 6 months after surgery and then every 6 months, and were evaluated by a physical examination, urine analysis, cytology and renal ultrasonography.

RESULTS

An ileal or colonic neobladder was constructed in 74 and 64 patients, respectively. Five (7%), 23 (31%), 10 (14%) and 14(9.6%) with an ileal neobladder developed DI, NI, IC and UO, respectively; the respective values for patients with a colonic neobladder were eight (12%), 19 (30%), seven (11%)and 15 (12%). Statistical analysis by Fisher's exact test showed no significant differences between the ileal and colonic neobladder groups or with gender.

CONCLUSIONS

Using this specific protocol for evaluating many men and women with ileal and colonic orthotopic neobladders showed no significant differences in the incidence of DI, NI, IC or UO. Neobladders constructed from detubularized bowel, irrespective of bowel segment(s) used, can provide satisfactory diurnal results. A moderate incidence of NI and UO continue to be a problem.

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.

Continent colonic urinary reservoir (Florida pouch): long-term surgical complications (greater than 11 years)

PURPOSE

We analyzed the long-term results (greater than 10 years) of a continent cutaneous colonic urinary reservoir (Florida pouch), focusing primarily on the incidence of significant complications.

MATERIALS AND METHODS

Between January 1986 and October 1991, 179 patients underwent continent cutaneous colonic urinary reservoir construction. Of these patients 105 died of primary disease or were lost to followup, leaving 38 males and 36 females with a mean followup of 133 months with adequate data for analysis who are the subject of this report. The surgical technique has been previously reported. Briefly, a detubularized right colonic segment forms the reservoir, a tapered external limb reinforced at the ileocecal valve level allows continent catheterization and the ureters are directly anastomosed to the pouch. The diseases that prompted urinary diversion included bladder cancer in 28 cases, conversion from another diversion in 12, neurogenic bladder in 11, interstitial cystitis in 10, crippling incontinence in 4, radiation cystitis in 6, hemorrhagic cystitis in 1, exstrophy in 1 and colon cancer in 1. A total of 146 direct ureterocolonic reimplantations were performed.

RESULTS

Complications were grouped by etiology and the number of patients, including abdominal wall (peristomal hernia in 3 patients or 4%), external limb (incontinence in 5 or 6.7%, stomal stenosis in 3 or 4% and difficult catheterization in 1 or 1.4%), reservoir stones (4 or 5.4%), ureteral obstruction (primary reimplantation in 7 of 108 or 6.3%, repeat reimplantation in 4 of 24 or 16.4% and radiated ureters in 4 of 14 or 28.4%) and metabolic (persistent diarrhea in 2 or 2.7%, renal failure in 2 or 2.7% and low vitamin B12 in 3 or 4%). Severe acidosis developed in 4 individuals (5.5%). Of the 12 patients who underwent conversion from another type of diversion 7 (58%) experienced metabolic alterations.

CONCLUSIONS

In the long term continent colonic reservoirs have an acceptable complication rate. The most common problem is ureteral obstruction, especially in patients who have previously undergone irradiation (28.4% versus 6.3%, Fisher's test p = 0.02). Patients in whom longer bowel segments were resected, such as those with conversion from another type of diversions, experienced a greater number of complications, especially ureteral obstruction associated with repeat reimplantation (16.4% versus 6.3%, Fisher's test p = 0.23) and metabolic derangements (58% versus 6.4%, Fisher's test p = 0.0001).

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.