Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies

doi:10.1016/j.ygyno.2013.02.024

Gynecologic Oncology

Volume 129, Issue 3, June 2013, Pages 580-585

https://doi.org/10.1016/j.ygyno.2013.02.024 Get rights and content

Abstract

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.

Highlights

► Complications between continent and incontinent conduits are the same except for stone formation. ► The incidence of urinary incontinence in continent urinary diversion is 28.3%.

Introduction

In patients with gynecologic malignancies, pelvic exenteration is an option for treatment of recurrent localized pelvic disease [1]. During a total or anterior pelvic exenteration, urinary diversion is routinely performed [2]. Patients can choose either continent or incontinent urinary diversion, and there are advantages and disadvantages associated with both of these techniques [3], [4], [5], [6], [7], [8], [9], [10], [11].

Incontinent urinary diversion was first described by Bricker in 1950 [3]. Bricker used ileum to form the urinary diversion; later, techniques involving use of non-irradiated transverse colon were also described [4], [12]. Incontinent diversion is faster and less technically challenging than continent diversion; also, incontinent diversion may have the advantage of requiring less maintenance effort and self-care by the patient [9], [12]. The incidences of early and late complications of incontinent urinary diversion have been reported to be 33% and 28%, respectively [13]. The most commonly reported complications are anastomotic leakage (3%), fistula formation (3%–19%), need for reoperation (8%–19%), renal insufficiency (6%–17%), urostomy stricture (7%), and ureteral obstruction (7%) [4], [12], [13]. The search for better surgical options with fewer complications led to the development of techniques for continent urinary diversion.

Continent urinary diversion has undergone many technical modifications since first described in 1982 by Koch et al. [5], [6], [7], [8], [14]. The Miami pouch, first described in recurrent gynecologic malignancies in 1988 by Penalver et al. [8], is the most commonly performed continent urinary diversion at The University of Texas MD Anderson Cancer Center. Continent urinary diversion offers better cosmetic results than incontinent diversion; however, overall complication rates with continent diversion remain significant and range from 37% to 66% [15], [16]. The most common complications associated with continent urinary diversion are pyelonephritis (13%–42%), difficulty with catheterization (12%–54%), ureteral (anastomotic) stricture (2%–22%), urostomy stricture (4%–22%), incontinence (7%–13.3%), urinary stone formation (7%–18%), ureteral (anastomotic) leaks (2%–14%), fistula (2%–15%), and permanent renal failure (3%) [15], [16], [17], [18], [19], [20], [21], [22]. There is also the potential risk of development of hyperchloremic metabolic acidosis [23].

There are only 3 studies in the gynecologic oncology literature to date that compare complications between the continent and incontinent urinary diversion techniques [16], [19], [22]. Limitations of these studies include short follow-up time, limited comparison of demographic characteristics, small number of postoperative complications analyzed, and the fact that these studies were not specifically designed to examine postoperative complications. The goal of this study was to compare postoperative outcomes of patients undergoing continent and incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies. Our aim was to specifically evaluate complications related to the urinary diversion.

Section snippets

Materials and methods

Information about patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 was obtained from the institutional electronic database. The inclusion criteria included a diagnosis of gynecologic cancer, pelvic exenteration performed at MD Anderson Cancer Center, and urinary diversion performed at the time of pelvic exenteration. The exclusion criteria included posterior pelvic exenteration,

Results

A total of 161 patients with pelvic exenteration were identified in the selected time period. Of these, 17 patients were excluded because they had only a posterior exenteration (n = 16), or because the urinary conduit procedure was performed as a separate procedure before pelvic exenteration (n = 1). Therefore, 144 patients met inclusion criteria; however, 11 patients were excluded because follow-up was less than 30 days. The remaining 133 patients were included in the study.

Discussion

In our study, the only postoperative complication with an incidence that differed significantly between continent and incontinent urinary diversion was stone formation after postoperative day 60, which was more common among patients with continent urinary diversion (34.8% vs. 1.1%). In a previous study from our own institution, Ramirez et al. [17] reviewed postoperative complications in 40 patients with gynecologic malignancies and continent urinary diversion from 1988 to 2001 and reported that

Conflicts of interest

The authors declare that there are no conflicts of interest.

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This is reflected in our data with a median OS of 20.6 months and remarkable 2- and 3-year survival year of 46% and 35.2%, representing a real chance of long-term survival. Reported 5-year overall survival rates differ greatly within a range of 21% to 64% (Baiocchi et al., 2012; Benn et al., 2011; Berek et al., 2005; de Gregorio et al., 2019; Fleisch et al., 2007; Goldberg et al., 2006; Jäger et al., 2013; Kaur et al., 2012; Maggioni et al., 2009; McLean et al., 2011; Schmidt et al., 2012; Urh et al., 2013; Westin et al., 2014). Most likely, these differences occur due to very heterogenous study populations not only in terms of tumor entities but also in regard to patient selection.
Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis.
All women treated with anterior (APE) or total (TPE) pelvic exenteration at our University hospital within a five-year period were identified and their data retrospectively analysed. Parameters such as demographic information, tumor type and stage, previous therapy as well as complication rate and overall survival were evaluated.
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Evaluar las complicaciones, morbilidad y resultados oncológicos de la exenteración pelviana como tratamiento para los tumores ginecológicos.
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La edad media de las pacientes fue de 53,8 años. Se realizó exenteración anterior en 20 pacientes, mientras que en 15 se realizó exenteración total.
En 24 pacientes se realizó derivación urinaria de tipo Bricker, neovejiga ileal en 8 y ureterostomía cutánea en 3.
Las complicaciones postoperatorias se dividieron en 2 grupos: tempranas (<30 días) y tardías (>30 días).
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^☆: This research was supported in part by the National Institutes of Health through MD Anderson's Cancer Center Support Grant, CA016672.

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Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies☆

Abstract

Objective

Methods

Results

Conclusion

Highlights

Introduction

Section snippets

Materials and methods

Results

Discussion

Conflicts of interest

Surg Clin North Am

Surg Clin North Am

Gynecol Oncol

Surg Clin North Am

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Am J Obstet Gynecol

Gynecol Oncol

J Urol

J Urol

Kidney Int