Urinary Diversion

Composite pelvic exenteration: is it worthwhile?

BACKGROUND

In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis.

METHODS

Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3.

RESULTS

Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively.

CONCLUSIONS

Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.

Urinary diversion after total pelvic exenteration for rectal cancer

BACKGROUND

Total cystectomy is indicated for the treatment of bulky primary rectal cancers as well as previously treated, locally recurrent tumors that invade the bladder, prostate, seminal vesicle, or urethra. We review a 10-year Memorial Sloan-Kettering Cancer Center experience with urinary diversion in this setting.

METHODS

Between April 1988 and June 1998, 47 patients underwent urinary diversion during a total pelvic exenteration for rectal cancer. Charts and operative records were reviewed to determine pathological findings, short-term and long-term urological complications, and survival.

RESULTS

Forty-seven patients (25 males and 22 females; median age, 62 years; age range, 27-79 years) were included. Sixteen (34%) patients underwent cystectomy for a primary rectal tumor (including 1 for rectal sarcoma and 1 for synchronous invasive bladder cancer), and 31 (66%) patients underwent surgery for a locally recurrent rectal cancer. Thirty (64%) patients underwent preoperative, 18 (38%) underwent intraoperative, and 11 (23%) underwent postoperative radiotherapy. Twenty-six (55%) patients received preoperative and 16 (34%) underwent postoperative chemotherapy. Two patients had continent ileal cecal reservoirs, 1 a colonic conduit, and the remaining 45 had ileal conduits. The tumor invaded the bladder in 24 (51%) patients, the prostate in 5 (11%) patients, and the seminal vesicle in 5 (11%) patients. Complete resection was achieved in 42 (89%) patients. There were a total of eight complications in eight (17%) patients. There were three early complications, two of which were ileoureteral anastomotic leaks, one managed by reoperation, the second by percutaneous drainage, and one moderate hydronephrosis managed expectantly. There were five late complications; three patients had ureteral stricture/stenosis, leading to nephrectomy in one patient and percutaneous stenting in two patients. Two patients developed late hydronephrosis, so far managed expectantly. There was one perioperative death. After a median follow-up of 16.83 months, 20 patients were dead of the disease, 6 were alive with disease recurrence, 2 were dead of other causes, and 19 had no evidence of disease. Three-year actuarial disease-specific survival was 34%.

CONCLUSIONS

Complete resection of bulky primary or locally recurrent rectal cancer can be performed with acceptable urological morbidity. Complete resection was obtained in 89% of patients, with 72% having urological organ invasion. Overall urological complications of 17% are acceptably low despite intensive perioperative radiation and chemotherapy. Disease-specific survival in these patients remains limited.

Exenterative pelvic surgery

A review of the history, indications, basic technique, end results, and complications of exenterative surgery for pelvic neoplasms is provided. The authors discuss their broad personal experience with the operation. Much of this experience evolved from work at Barnes Hospital and the Ellis Fischel State Cancer Hospital. The techniques are applicable to advanced neoplasms of the cervix uteri, scrotum, urinary bladder, and other, less frequent neoplasms still confined to the pelvis.