Pelvic Exenteration

A. Total Pelvic Exenteration

Barbara A. Goff and Howard G. Muntz

PROCEDURE OVERVIEW

Total pelvic exenteration is a surgical procedure that involves the en bloc removal of female reproductive organs, rectosigmoid colon, and lower urinary tract. It may include a perineal phase to remove the urethra, vagina, and anus. Modifications can be made depending on tumor location and size.

The first series of pelvic exenterations was published in 1948 by Alexander Brunschwig for the palliative treatment of advanced pelvic malignancies.¹ Although the operative mortality in this group of 22 patients was 23%, there were also several long-term survivors, indicating potential benefit beyond palliation. The original operation included implanting both ureters into the colon to produce a wet colostomy; however, this resulted in significant problems with hyperchloremic acidosis, pyelonephritis, and renal failure. In 1956, Bricker² published a technique of using a closed loop of ileum as a bladder substitution. Over the past 50 years, there have been many advances in perioperative care such as blood products, antibiotics, intensive care support, and surgical techniques such as retractors, cautery, and staplers that now allow for a variety of vaginal reconstructions and urinary conduits that can reduce the impact this procedure has on quality of life.^3-10 As a result, pelvic exenteration is now considered a safe and feasible procedure that can cure selected patients for whom there are no other treatment options. In modern series, operative mortality ranges from 0% to 5%, and 5-year survival rates range from 39% to 53% depending on the specific indications for the exenteration.^3–7 Patient selection, patient preparation, surgical technique, and postoperative care can have a major impact on the outcome for patients undergoing this operation.

Indications

The main indication for pelvic exenteration is the central persistence or recurrence of cervical, vaginal, or vulvar cancer after primary radiation or chemoradiation. Central recurrence is defined as the absence of both pelvic sidewall involvement and distant disease. Some have advocated the use of exenteration for primary treatment of stage IVA cervical cancer; however, with modern chemoradiation, this has become uncommon. Long-term survival after exenterative surgery in women with pelvic failure after surgery and radiation for endometrial cancer or sarcomas has also been reported.^11,12 Extensive radiation injury to bladder, vagina, and/or rectum, especially if patients have evidence of significant necrosis with fistula formation, is another potential indication for exenteration.⁷

Exenterative surgery to resect centrally recurrent pelvic cancer is only rational in the absence of metastatic disease. Para-aortic nodal involvement is generally considered an absolute contraindication for exenteration. If pelvic lymph nodes are found to be the only site of metastatic disease, then patients can still be considered surgical candidates, although long-term cure rates will only be about 15%.¹³ Palliative exenteration (documented extrapelvic disease with no expectation for cure) should be performed only if there is a high likelihood for significant improvement in quality of life, because 70% of patients will experience major complications.^6,8 In general, pelvic side-wall involvement is a contraindication to performing an exenteration, but with laterally extended endopelvic resections¹⁴ or intraoperative radiation therapy,^15,16 selected patients can also be considered candidates for exenteration. Common selection criteria include the following: (1) a central pelvic malignancy potentially curable by exenteration; (2) absence of local or distant metastases; (3) medical and psychological fitness to withstand exenterative surgery; and (4) ability for postoperative self-care. The likelihood of discovering metastatic disease or an unresectable pelvic tumor at exploratory surgery and abandoning exenterative surgery is 30% to 50%, depending on preoperative selection criteria (eg, tumor size).

Classification of Exenteration

Pelvic exenteration includes 3 basic variations (Figure 32A-1). Total pelvic exenteration consists of en bloc removal of the gynecologic organs, bladder, and rectosigmoid colon. Anterior exenteration is a combination of radical hysterectomy-vaginectomy and cystectomy, and posterior exenteration is a combination of radical hysterectomy-vaginectomy and rectosigmoid colectomy. Pelvic exenteration can also be classified according to the extent of tissue resection and associated anatomical alteration (Figure 32A-2). A type I, or supralevator, exenteration is indicated for lesions confined to the upper pelvis without involvement of the lower one-half of the vagina. A type II, or infralevator, exenteration is the most commonly performed variation and includes visceral resection below the levator ani muscles with limited resection of the levator muscles and urogenital diaphragm. Rarely, a type III exenteration (infralevator with vulvectomy) is required for tumor extension to the vulva or perineum and includes resection of the urogenital diaphragm.

FIGURE 32A-1. Variations of exenteration: (A) total pelvic exenteration; (B) anterior pelvic exenteration; and (C) posterior pelvic exenteration.

FIGURE 32A-2. Classification of pelvic exenteration: (A) supralevator exenteration; (B) infralevator exenteration; and (C) infralevator exenteration with vulvectomy.

Expected Clinical Outcomes

Table 32A-1 shows clinical outcomes of the most contemporary series of pelvic exenterations.^3–7 Long-term disease-free survival ranges from 30% to 60% depending on nodal and margin status, time from initial radiation to recurrence, size of the lesion, and primary disease site.^3–10 Factors that have not been shown to impact survival are age and subsequent treatment following exenteration. Operative mortality is quite low (0%-5%) and is usually a result of sepsis with multiorgan failure, pulmonary embolism, or cardiac events.

Surgical morbidity with pelvic exenteration can be substantial. The median estimated blood loss ranges from 1290 to 2500 mL, and 70% to 85% of patient will require blood transfusions. Median operative time is approximately 8 hours but varies widely depending on the reconstructive procedures that are done following the exenteration. The average length of stay following exenteration is 15 to 28 days. Major morbidity is seen in 30% to 50% of patients. The most common complications seen with exenterations include infection, abscess, anastomotic leaks, wound dehiscence, thromboembolic events, ileus, bowel obstruction, secondary bleeding, and cardiovascular events.^3–10

Table 32A-1 Clinical Outcomes of Pelvic Exenteration

PREOPERATIVE PREPARATION

Patient Evaluation and Work-up

A thorough preoperative assessment is mandatory. Assuming only physiologically fit and psychologically sound patients are being evaluated, the key factors for consideration include histologic confirmation of recurrent disease, resectability of the recurrent tumor, and absence of metastatic disease.

Because radiation necrosis can mimic the appearance of recurrent cancer (and vice versa), an examination under anesthesia should be performed with multiple biopsies, including deep Tru-cut biopsies. Directed biopsies obtained with interventional radiology guidance may be required.

Resectability of a centrally recurrent pelvic tumor is not always predictable. The triad of ipsilateral leg edema, sciatic pain, and ureteral obstruction is almost always associated with sidewall extension and unresectability. Evaluation of disease resectability can be aided by pelvic magnetic resonance imaging and positron emission tomography/computed tomography. However, in the setting of fibrosis, infection, and fistula formation, all of these modalities can have significant false-positive rates.^17–20 Examination under anesthesia is often the best way for a surgeon to determine sidewall involvement. If there is any question about resectability because of sidewall involvement, patients should be offered surgical exploration and possible exenteration.

Even after thorough preoperative assessment, there is still a 30% chance that at the time of exploration for exenteration, the procedure will be abandoned due to unresectable pelvic disease or small-volume peritoneal metastases.²⁰

Consent Considerations

Patients should understand there is a 30% chance that the operation will not be completed,²⁰ and even if completed, cure rates vary widely (30%-60%).^3–10 Patients need to be counseled about the loss or severe alteration of bladder, rectal, and sexual function, as well as potential emotional distress.^21,22

Patient Preparation

Nutritional status and pulmonary function should be optimized prior to exenteration. Medical comorbidi-ties, such as diabetes, hypertension, and heart disease, should be under good control. Consultation with a stoma therapist to mark location(s) and review function is recommended. Psychological evaluation and consultation with a surviving patient having previously undergone a similar exenterative procedure may be helpful in assessing the patient’s emotional readiness for surgery. Patients should undergo a mechanical bowel preparation the day before surgery and receive appropriate antibiotic and thromboembolic prophylaxis. Placement of a central line and having adequate blood product availability are also advised.

Required Instrumentation

Instrumentation for exenteration varies according to surgeon preference but should include a self-retaining retractor such as a Bookwalter, bowel staplers, ureteral stents, vaginal stents, and stoma appliances. Electrothermal bipolar coagulation instruments, such as the vessel-sealing and cutting device LigaSure, can decrease the need for suturing, decrease surgical time, and reduce intraoperative blood loss.⁷

OPERATIVE PROCEDURE

Anesthesia and Positioning

General anesthesia is mandatory; an epidural catheter can be placed for postoperative pain management. Patients are placed in a low dorsal lithotomy position in Allen or Yellow Fin stirrups, and the surgical preparation should extend from the nipple line to the knees to ensure adequate access for use of abdominal or lower extremity–based myocutaneous flaps for pelvic reconstruction.

Surgical Exploration and Evaluation of Para-aortic Lymph Nodes

A generous midline incision is made, taking into account the potential need for abdominal flap creation and stoma placement, and normal anatomy restored. A thorough exploration is performed to evaluate for intraperitoneal malignancy or other distant metastasis, and suspicious lesions are sent for frozen-section analysis. A self-retaining retractor is placed, para-aortic lymph node basins are explored (see Chapter 28) and dissected, and specimens are sent for frozen-section analysis while attention is directed toward developing the pelvic phase of the operation. Involvement of para-aortic lymph nodes would be a contraindication to proceeding.

Opening the Pelvic Sidewall and Evaluation of Pelvic Lymph Nodes

The pelvic sidewalls are opened by incising the round ligaments and mobilizing the broad ligament medially and developing the pararectal and paravesical spaces. The external iliac and obturator lymph nodes are dissected (see Chapter 28), and any suspicious nodes are sent for frozen-section analysis. With the lymph nodes removed and the paravesical and pararectal spaces developed, the pelvic sidewalls can now be directly assessed for involvement. To verify the absence of side-wall extension, a finger is inserted in the paravesical space, and a finger is inserted into the pararectal space, and the intervening tissue of the cardinal ligament is palpated down to the pelvic floor to evaluate the proximity of tumor to the pelvic wall.

Bladder Mobilization and Development of Retropubic Space

The peritoneal incision is extended along the posterior border of the symphysis pubis, and the retropubic space of Retzius is developed using a combination of blunt and sharp dissection down to the pelvic floor. The anterior pelvic dissection proceeds laterally, resulting in unification of the retropubic space and the bilateral paravesical spaces.

Rectum Mobilization and Development of Presacral Space

Following the anterior pelvic dissection, the ureters are fully mobilized down the cardinal ligament and held with Vessi-loops for traction. The peritoneal incision is extended medially into the posterior pelvis toward the sigmoid mesentery. The pararectal spaces are extended posteriorly and medially underneath the sigmoid mesentery to develop the presacral (retrorectal) space, working in the avascular plane anterior to the sacrum. The absence of sacral involvement should be verified by confirming the ability to lift the rectosigmoid colon out of the sacral hollow. This is the last decision point to abandon the exenteration before dividing the bowel and ureters.

Division of Rectosigmoid Colon and Ureters; Unification of Pelvic Spaces

The rectosigmoid colon is divided using a linear stapling device (eg, gastrointestinal anastomotic), and the sigmoid mesentery is taken down between clamps or using a vessel-sealing and cutting device (eg, LigaSure); the inferior mesenteric vascular pedicle is clamped, divided, and secured with suture ligatures (see Chapter 30). The presacral space is then developed down to the pelvic floor. The ureters are ligated and divided at least 2 cm from the central pelvic tumor mass. The proximal ureters and sigmoid colon can be packed out of the operative field until the reconstructive phase. At this point, the pelvic spaces are unified with the exception of the cardinal ligaments and anterior division of the internal iliac vessels (Figure 32A-3).

FIGURE 32A-3. Initial phase of total pelvic exenteration. The retropubic space is extended laterally to reach continuity with the paravesical spaces, and the presacral space is extended laterally to reach continuity with the pararectal spaces.

Division of Cardinal Ligaments

The central pelvic tumor specimen is placed on contralateral traction with the surgeon’s fingers or straightened Heaney retractors used to expose the pelvic sidewall. The internal iliac vessels are often indistinguishable as separate structures in a previously radiated field but lie within the tissue of the cardinal ligament. Working from the pelvic brim toward the pelvic floor, the cardinal ligament tissue is serially clamped at the pelvic sidewall, divided, and secured with suture ligatures (Figure 32A-4). If the internal iliac artery and vein are identifiable, they can either be preserved and the uterine vascular pedicle divided at its origin, or resected en bloc. If sacrificed, the internal iliac vessels should be individually secured with vascular clamps and divided a short distance from the pelvic wall to allow for an adequate pedicle in the event of unexpected hemorrhage. Division of the internal iliac arteries may limit neovagina reconstructive options (see Chapter 32C). Posteriorly, the mesorectum and rectal pillars are divided between clamps or taken down to the pelvic floor using a vessel-sealing and cutting device (eg, LigaSure). The exposure and dissection are duplicated on the contralateral side.

FIGURE 32A-4. Total pelvic exenteration. The cardinal ligaments (with or without the internal iliac vessels) are resected at the level of the pelvic wall down to the levator muscles of the pelvic floor for a supralevator exenteration; the levator muscles are included in the resection for infralevator exenteration.

Supralevator Exenteration: Final Extirpative Steps

The final extirpative phase of a supralevator exenteration begins by placing posterior traction on the central specimen exposing the anterior pelvis. The Foley catheter can be palpable within the urethra. The surrounding paravesical tissue is taken down to the pelvic floor, and the urethra is divided using the electrosurgical blade. The vagina can be cross-clamped and divided or circumscribed using the electrosurgical blade at the level of the pelvic floor. The distal rectum is divided using a linear stapling (eg, transverse anastomosis) device (see Chapter 30), and the specimen is removed (Figure 32A-5). A laparotomy pack is placed in the pelvis to tamponade any small bleeding sites while the specimen is inspected to ensure grossly negative resection margins.

FIGURE 32A-5. Total supralevator pelvic exenteration: extirpation of the specimen with resulting pelvic defect.

Infralevator Exenteration: Resection of Levator Muscles

For an infralevator exenteration, a second surgical team begins the perineal phase when the abdominal dissection reaches the level of the levator muscles. The central pelvic tumor specimen is placed on counter-traction, and the electrosurgical blade is used to incise the levator muscle plate circumferentially at least 2 cm lateral to the area of tumor extension (Figure 32A-6).

FIGURE 32A-6. Total infralevator pelvic exenteration: resection of levator muscle plate.

Infralevator Exenteration: Perineal Phase and Specimen Removal

The second surgical team outlines the planned peri-neal resection to encompass a variable extent of vulvectomy tailored to the extent of tumor involvement (Figure 32A-7). The subcutaneous dissection is developed in the paravesical and pararectal spaces cephalad, using a combination of clamps with suture ligatures and the electrosurgical blade. The abdominal surgeon can place a hand in the pelvis to help guide the peri-neal dissection. After the perineal phase has reached the fascial plane of the pelvic floor, 4 potential spaces are developed: the suprapubic and presacral spaces and the right and left paravaginal spaces (Figure 32A-8). These potential spaces are separated by 5 pedicles: 2 pubourethral, 2 rectal pillar, and the posterior anococcygeal. These pedicles are clamped, divided, and secured with suture ligatures. Circumferential dissection results in complete detachment of the specimen, which can be removed abdominally or vaginally (Figure 32A-9).

FIGURE 32A-7. Total infralevator exenteration. The extent of the perineal resection is tailored to the degree of lower vaginal or vulvar involvement with tumor.

FIGURE 32A-8. Total infralevator exenteration. The suprapubic, paravaginal, and presacral spaces are developed to define the pubourethral, rectal pillar, and anococcygeal pedicles.

FIGURE 32A-9. Total infralevator exenteration: pelvic defect.

Prior to closing the abdomen, the operative site should be copiously irrigated and hemostasis confirmed. The abdomen and pelvis should be adequately drained to promote wound healing. There will be extensive third spacing and small urinary leaks from the conduit, so adequate drainage is essential. The wound should be closed in a mass closure with delayed absorbable or permanent suture.

Closure and Final Steps

The simplest and most expedient way to close the perineum is for the second surgical team to perform a layered closure of the deep pelvic and perineal tissues (Figure 32A-10). Reconstruction of the urinary tract should be performed next according to the patient’s desires and available surgical options (see Chapter 32B). Due to the large amount of dead space left after an exenteration, a neovagina, a rectus flap, or an omental flap is needed to fill the pelvis and bring in tissue with a good blood supply. Our recommendation, even in women who do not want a neovagina, is that a rectus flap be placed into the pelvis and an omental J-flap placed on top of it (see Chapter 32C).

FIGURE 32A-10. Total infralevator exenteration: simple closure of the pelvic floor.

Once the vaginal, pelvic, and urinary reconstructions are performed, attention is directed to the intestinal tract. Re-establishing intestinal continuity should be undertaken with caution, because the risk of anastomotic dehiscence or leak is as high as 50% after radiation. After tolerance-dose pelvic radiation, our preference is to perform end colostomy at the time of total or posterior pelvic exenteration. The colostomy is usually the final procedure prior to closing. A 2- to 3-cm circular piece of skin is removed from the site of the stoma (see Chapter 30). The subcutaneous tissue is dissected to the fascia, and a cruciate incision is made in the anterior abdominal wall fascia so that the rectosigmoid can easily be brought through the anterior abdominal wall. Retraction of the colon back into the abdomen is prevented by carefully placing sutures between the fascia and proximal bowel. Additional sutures can also be placed on the peritoneal side. The stoma should be matured to the skin in a rosebud fashion (skin to proximal bowel to distal bowel edge) once the abdomen is closed to prevent any fecal contamination.

Anterior Exenteration

If only the bladder, urethra, uterus, cervix, and vagina need to be removed and the rectum can be spared, then the posterior part of the dissection is modified. For an anterior exenteration, the peritoneum between the rectum and vagina is incised and the rectovaginal septum developed. The entire vaginal tube can be mobilized in a combined abdominal and perineal approach if the entire vagina needs to be taken, or a portion of the posterior vagina can be left in place if margins are adequate.

Posterior Exenteration

With a posterior exenteration, the anterior part of the exenteration is modified. The ureters are dissected to their entry into the bladder, similar to a radical hysterectomy. The dissection between the vagina and bladder is taken down to the perineal dissection or until there are adequate margins around the cancer. The entire vaginal tube can be taken if needed, or a portion of the anterior vagina can be left if the margins are adequate. Posterior exenterations for central recurrence following radiation are not often performed because of the high likelihood of bladder dysfunction and urinary fistulization when the rectum, vagina, and cervix are removed. In addition, because of the damage to the hypogastric plexus that enervates the bladder, many patients will require some type of catheter drainage to facilitate bladder emptying.

POSTOPERATIVE CARE

It is common for many patients to require an intensive care unit stay for 24 to 48 hours after surgery to manage large blood loss, transfusion, and fluid shifts. Postoperative pain is best managed with patient-controlled epidural analgesia. Total parenteral nutrition can be started to help facilitate adequate nutrition and wound healing. Early feeding can be initiated, although prolonged ileus may prevent this. Venous thromboembolism prophylaxis should be continued during the entire hospitalization; some authors recommend a total of 4 weeks of medical prophylaxis. Ambulation is usually begun by day 2 to 3.

Drains should remain in place for approximately 7 to 10 days and may be discontinued when the output is less than 100 mL in a 24-hour period. If there is concern about ureteral leakage, the fluid in the drain can be sent for creatinine. A creatinine from drain fluid that is significantly higher than the serum value is indicative of a leak. If there is a leak, with adequate drainage and ureteral stenting, the leak will usually heal.

Complications following an exenteration will occur in approximately 50% of patients. Wound infections, pelvic abscess requiring drainage, anastomotic leaks, bowel obstruction, fistula, venous thrombosis, and other medical complications are the most common.

REFERENCES

1. Brunschwig A. A complete excision of pelvic viscera for advanced carcinoma: a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer. 1948;1:177-183.

2. Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950;30:1511-1512.

3. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA. Gynecol Oncol. 2005;99:153-159.

4. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: The Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003). Gynecol Oncol. 2006;101:261-268.

5. Maggioni A, Roviglione G, Landoni F, et al. Pelvic exenteration: ten-year experience at the European Institute of Oncology in Milan. Gynecol Oncol. 2009;114:64-68.

6. Fotopoulou C, Neumann U, Kraetschell R, et al. Long-term clinical outcome of pelvic exenteration in patients with advanced gynecologic malignancies. J Surg Oncol. 2010;101:507-512.

7. McLean K, Zhang W, Dunsmoor-Su RF, et al. Pelvic exenteration in the age of modern chemoradiation. Gynecol Oncol. 2011;121:131-134.

8. Spahn M, Weiss C, Bader P, et al. The role of exenterative surgery and urinary diversion in persistent or locally recurrent gynecologic malignancy: complications and survival. Urol Int. 2010;85:16-22.

9. Guimarães GC, Baiocchi G, Ferreira AC, et al. Palliative pelvic exenteration for patients with gynecological malignancies. Arch Gynecol Obstet. 2011;283:1107-1112.

10. Marnitz S, Dowdy S, Lanowska M, et al. Exenterations 60 years after first description: results of a survey among US and German gynecologic oncology centers. Int J Gynecol Cancer. 2009;19:974-977.

11. Barakat RR, Goldman NA, Patel DA, et al. Pelvic exenteration for recurrent endometrial cancer. Gynecol Oncol. 1999;75:99-102.

12. Morris M, Alvarez RD, Kinney WK, Wilson TO. Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecol Oncol. 1996;60:288-291.

13. Fleisch MC, Panthe P, Beckman MW, et al. Predictors of long-term survival after interdisciplinary salvage surgery for advanced or recurrent gynecologic cancers. J Surg Oncol. 2007;95:476-484.

14. Höckel M. Laterally extended endopelvic resection (LEER)—Principles and practice. Gynecol Oncol. 2008;111:S13-S17.

15. Stelzer KH, Koh WJ, Greer BE, et al. The use of intraoperative radiation therapy in radical salvage for recurrent cervical cancer: outcome and toxicity. Am J Obstet Gynecol. 1995;172(6):1881-1886.

16. Martinez-Monge R, Jurado M, Aristu JJ, et al. Intraoperative electron beam radiotherapy during radical surgery for locally advanced and recurrent cervical cancer. Gynecol Oncol. 2001;82(3):538-543.

17. Popovich MJ, Hricak H, Sugimura K, Stern JL. The role of MR imaging in determining surgical eligibility for pelvic exenteration. Am J Roentgenol. 1993;160:525-531.

18. Husain A, Akhurst T, Larson S, et al. A prospective study of the accuracy of 18-fluorodeoxyglucose positron emission tomography (18FDG PET) in identifying sites of metastasis prior to pelvic exenteration. Gynecol Oncol. 2007;106:177-180.

19. Lai CH, Huang KG, See LC, et al. Restaging of recurrent cervical carcinoma with dual-phase [18F]fluoro-2-deoxy-D-glucose positron emission tomography. Cancer. 2004;100:544-552.

20. Miller B, Morris M, Rutledge F, et al. Aborted exenterative procedures in recurrent cervical cancer. Gynecol Oncol. 1993;50: 94-99.

21. Hawighorst-Knapstein S, Schonefussrs G, Hoffmann SO, Knapsteinn PG. Pelvic exenteration: effects of surgery on quality of life and body image. A prospective longitudinal study. Gynecol Oncol. 1997;66:495-500.

22. Ratliff CR, Gershenson DM, Morris M, et al. Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration. Cancer. 1996;78:2229-2235.

B. Urinary Diversions

Thomas C. Krivak and Paniti Sukumvanich

PROCEDURE OVERVIEW

The utilization of urinary diversion and creation of urinary conduits have been developed and modified with the principal of maintaining a quality of life in the patients undergoing radical surgery for treatment of recurrent gynecologic cancer or complications from previous therapy.^1–5 Initially, Brunschwig used a “wet colostomy” (ie, an ureterosigmoidostomy) as a means to provide urinary diversion. This procedure unfortunately led to high rates of pyelonephritis and renal failure, which limited the utility of such a procedure. In subsequent years, Bricker described using the terminal ileum for diverting the urinary stream, whereas Rowland described using the large bowel as the reservoir for the urinary diversion. These 2 later techniques decreased the complication rate and had acceptable postoperative complications, thus making such procedures more widely used in patients undergoing pelvic exenteration.

Urinary diversions may be necessary in cases where there is obstruction of the ureters due to pelvic tumor growth or complications of radiation therapy (eg, radiation fibrosis or genitourinary fistula), or as part of a curative exenterative procedure. Depending on the clinical situation, the methods for urinary diversion may range from incontinent diversions, such as percutaneous nephrostomy tubes or ileal conduit, to continent urinary diversion, such as a large bowel continent urinary diversion.

The gynecologic oncology surgeon should carefully evaluate the clinical scenario in order to choose the most appropriate treatment, given the variety of methods available for urinary diversion. In cases where an exenteration is not being performed, one should also consider whether a nonpermanent diversion such as a percutaneous nephrostomy would suffice in place of permanent diversion. Another clinical scenario issue to consider is whether or not the procedure is for curative intent or palliation of symptoms. In cases where the procedure is needed as part of a pelvic exenteration procedure, the main point to consider is whether it should be a continent or incontinent urinary diversion. An example of a patient who would be an ideal candidate for continent colon urinary diversion would be a patient with an anterior cancer recurrence undergoing an anterior exenteration.^6–12 A continent diversion in this case would provide the patient with a better cosmetic result because only a small ostomy for catheterization of the continent reservoir will be present on her abdomen. Conversely, in a patient with a central recurrence and distant disease who has a large vesicovaginal fistula requiring urinary diversion, one should consider a percutaneous nephrostomy placement or noncontinent small bowel conduit, because this may have a better impact on her quality of life. This chapter will focus on the various methods for urinary diversion and the management of complications that can ensue from such procedures.

PREOPERATIVE PREPARATION AND INDICATIONS

The 4 main issues to consider in the preoperative planning phase of the procedure are as follows:

1. Determining the degree of renal function

2. Determining the type of urinary diversion

3. Obtaining informed consent

4. Determining the location of the stoma

Determining the Degree of Renal Function

Prior to performing a procedure that can have significant long-term consequences, it is important to determine that the patient’s kidneys are indeed functional. Laboratory tests such as serum electrolytes, blood urea nitrogen (BUN), and creatinine levels should be obtained to assess baseline renal function. If there has been any evidence of long-term obstruction, then one should consider a renal ultrasound and nuclear renal scan. Radiographic studies, such as a radionucleotide or renal Lasix scan, are important to obtain because a normal BUN or creatinine level does not always imply that both kidneys are functional. This should be done to ensure that a urinary diversion is not performed on a nonfunctioning kidney. Generally, a nonfunctioning kidney is confirmed by a less than 5% total glomerular filtration rate of one kidney. When a nonfunctioning kidney is encountered, a nephrectomy should be taken considered as part of the surgical procedure to avoid chronic pyelonephritis.

Determining the Type of Urinary Diversion

Urinary diversions can be divided into 2 types: permanent and temporary (ie, percutaneous nephrostomy). In a patient who is a poor surgical candidate and in whom the goal of any surgical intervention is palliation, one should consider the placement of percutaneous nephrostomy tubes. Such a procedure can provide relief of symptoms due to obstruction and fistulas with a minimum of morbidity. This technique may also allow the patient to regain her renal function as well as undergo antegrade passage of stents at a later time. This may be a temporary or permanent type of diversion based on patient prognosis. Another indication for percutaneous nephrostomy tube placement is a patient with ureteral strictures, because such treatment may allow for passage of a ureteral stent as well as balloon catheters for dilatation. In a patient undergoing definitive treatment with a pelvic exenteration, a permanent urinary diversion such as an incontinent ileal conduit or continent conduit would be indicated. In general, a patient who is undergoing a total exenteration is a good candidate for an ileal conduit.^12–14 Continent conduits can be considered for patients undergoing an anterior exenteration because the cosmetic result with a small stoma may be more appealing to the patient.

Obtaining Informed Consent

It is important to thoroughly explain the risks and benefits of any permanent urinary diversion procedure. Such counseling is often done in conjunction with the discussion on the expected outcomes, utility, and risks of the pelvic exenteration procedure. Patients have to be aware of the lifestyle changes that will be required, such as long-term care of the colostomy and urostomy or the care required for continent large bowel urinary diversion (self-catheterization). Complication rates reported in the literature for ileal conduits include a ureteral-ileal anastomosis postoperative leak rate of 5% to 10%, postoperative pyelonephritis risk of 5% to 20%, chronic pyelonephritis risk of 5% to 10%, parastomal hernia risk of less than 5%, stomal stenosis in continent conduits risk of 5% to 15%, nephrolithiasis risk of 5% to 10%, and a risk of chronic renal sufficiency.^5,7,8,11,15

Determination of the Location of the Stoma

Determining the placement of the stoma will often depend on what other procedures are being done at the same time. It is recommended that the patient should have a preoperative consultation with an enterostomal therapist to help with markings for the stoma. It should be kept in mind that locations that are at the level of the umbilicus are not ideal, as the waistbands of women’s pants are often placed at that level. Any stoma should be placed at a least 8 to 10 cm away from the mid-line incision, either above or below the umbilicus, not in a skin crease and clear of any bony prominences. Patients should be evaluated while standing and supine to ensure the location is ideal in both positions.

OPERATIVE PROCEDURE

Noncontinent Urinary Diversion: Ileal Conduit

Ureteral Mobilization

Care should be taken with dissection of the ureters from the retroperitoneal space. Often, this dissection can be quite difficult due to radiation fibrosis. One should gently handle the ureters because they can easily be devascularized. In general, it is recommended to excise any portion of the ureter that shows signs of extensive radiation fibrosis and to use a portion of the ureter that is out of the radiated field. One should also try to conserve as much of the periureteral tissue as possible without completely stripping the ureter because this will also help to prevent devascularization of the ureter. Isolation of the ureters may begin with a pericolic gutter peritoneal incision in order to dissect from lateral to medial. This will allow for identification of the important vascular structures that are close to the ureter such as the infundibulopelvic ligament. The cecum and the ascending colon will also need to be mobilized as part of the right ureteral dissection. The left ureteral dissection can be done along with the rectosigmoid colon mobilization. The ileal conduit stoma is typically placed in the right lower quadrant. As such, the left ureter will need to be mobilized for a distance of approximately 15 cm to allow it to be brought underneath the inferior mesenteric artery and sigmoid colon mesentery to reach the conduit. Because the right ureter has a shorter path to travel to the conduit, it usually must be mobilized for a distance of 10 cm or so to ensure a tension-free anastomosis. One might need more or less dissection; the amount dissected should allow for a tension-free anastomosis to the conduit. Once the dissection has been performed, the ureters should be ligated with 2-0 silk ties. This will lead to dilatation of the ureters and will allow for easier placement of the ureteral stents, facilitating the ureteroileal anastomosis. The amount of time the ureters are ligated should be monitored, because the ureters cannot be ligated for longer than 3 to 4 hours due to the development of electrolyte abnormalities. The anesthesiologist should be notified of the ureteral ligation in order to allow for fluid optimization during this portion of the procedure.

Isolation of Small Bowel Segment

Once the ureters have been dissected and ligated, the next step is selecting the ileal segment to be used for the conduit. The ileal segment for the conduit should be at least 15 cm away from the ileocecal valve and should be a nonmottled, well-vascularized, healthy-appearing segment of bowel. Approximately 12 to 18 cm of bowel is typically required for an ileal conduit. The actual length required may depend on numerous factors such as whether a Turnbull loop will be needed or the segment is long enough to allow for a tension-free anastomosis with the ureters. The segment of ileum should not be too long, because redundancy can lead to postoperative electrolyte abnormalities from absorption of electrolytes from a long segment of ileum. Once the segment of ileum has been identified, one should ensure that there is adequate blood supply by elevating the distal ileum and transilluminating the mesentery. If good blood supply is identified, then a segment of ileum 15 cm away from the ileocecal valve is marked and tagged with a Penrose drain, and a proximal segment is measured between 12 and 20 cm in length for the proximal and distal ends of the ileal conduit. In an obese patient, an additional 5- to 10-cm segment should be considered to allow for the Turnbull loop. The Turnbull loop stoma allows for a longer segment of small bowel to traverse the abdominal wall without compromising vascular supply. Once the bowel has been marked and tagged with a Penrose drain, the proximal and distal portions may be isolated and divided using a GIA-60 stapler. A series of 3-0 silk horizontal mattress sutures are used to oversew the staple line at the proximal end of the conduit, where the ureters will be connected, in order to decrease contact of the staple line with urine and reduce the risk of nephrolithiasis.

Stoma Creation

Once the ileal loop has been isolated, the skin aperture is created, and the stoma is formed (Figure 32B-1). The layers that will need to be excised are the skin, the subcutaneous tissue, the anterior rectus sheath, the rectus muscle, the posterior rectus sheath, and the peritoneum. Ideally, the skin site will have been marked preoperatively to avoid any bony prominences, prior abdominal scars, and abdominal creases. Pulling up a piece of skin with a Kocher clamp and cutting across should result in a 2- to 2.5-cm small circumferential incision. Remove all the fatty tissue down to the anterior rectus sheath. Be sure to place tension on the anterior and posterior rectus sheath by pulling medially on the fascia through the midline incision, and then make a cruciate incision through the rectus sheath, rectus muscle, and underlying peritoneum using an electrosurgical unit (Bovie) device. The skin incision may need to be larger if a loop stoma (Turnbull loop) is going to be created. Care should be taken not to damage any of the surrounding structures, such as the inferior epigastric vessels, during this process. The aperture should accommodate 2 fingers to pass through easily. The distal end of the ileal conduit is then grasped by a Babcock clamp that has been passed through the aperture, and the conduit is then brought up to the skin. At this point, the surgeon must ensure that the bowel mesentery is not strangulated or twisted and that the direction of intestinal peristalsis is pointed toward the efferent limb of the conduit. Once the conduit has been safely pulled through the skin, Allis clamps are placed on the corners below the prior staple line. The staple line is excised, and copious irrigation should be performed to ensure that small bowel contents are removed completely. The ileal segment should be re-evaluated to ensure that there is adequate length for the ureteral-ileal anastomosis.

FIGURE 32B-1. Creation of the urinary conduit stoma. (A) Creation of the stoma aperature. (B), (C), (D) ‘Rosebud’ stoma creation.

Creation of the stoma is done by placing 4 equally spaced 3-0 Vicryl sutures first 1 cm from the skin edge, then approximately 4 cm from the stoma opening, and finally through the opening of the stoma to facilitate eversion (“rosebud”) of the stoma. It is extremely important to ensure that there is adequate eversion of the stoma, because low-profile stomas can make it very difficult for appliances to be placed around the stoma, thus allowing for caustic urinary leak on the skin. Care should also be taken not to ligate critical vascular supply within the mesentery so as not to devascularize the distal end of the conduit. The stoma should be pink and healthy and not blue with compromised blood supply. The ileal conduit is then fixed to the posterior rectus sheath using several 3-0 Vicryl sutures to decrease the risk of parastomal hernia.

Ureteroileal Anastomoses

The distal ureters should be incised and spatulated to allow for placement of the ureteral stent. Care should be taken not to make the opening too large because this can lead to reflux (the opening should be no larger than 1 cm). Once this has been completed, the screw-on tip of a metal Yankauer suction is removed, and it is then placed down through the stoma into the conduit to the location where the left ureter will be anastomosed to the conduit (Figure 32B-2). It is usually easiest to perform the left ureteral anastomosis first. A 1-cm incision is created with a #15 blade on ileum over the tip of the Yankauer to allow the suction tip to protrude. A guide wire is placed through the Yankauer and fed through the ureter. A single-J, 6- or 7-French ureteral stent is passed over the guide wire through the ureter into the kidney. Palpation of the ureter should be done while the stent is being passed to make sure the stent is placed up into the kidney. The ureter is then sutured into the conduit using a series of 5 to 8 interrupted 4-0 polydioxanone sutures on a vascular needle placed circumferentially. Care should be taken to go from the mucosa of the ureter to the mucosa of the ileum to achieve a mucosa-to-mucosa anastomosis. The ureter should be sutured in such a way that the knot is on the outside of anastomosis. The surgeon should be careful not to place too many sutures with this anastomosis, as this can compromise the blood flow and prevent adequate healing of the anastomotic site. The left ureter should not be kinked, and the anastomosis should be tension-free (Figure 32B-3). Once the left ureteral-ileal anastomosis is complete, a 1-0 chromic suture should be placed through-and-through the ileal conduit, piercing through the stent to prevent any stent migration during the immediate postoperative period. The procedure is repeated for the right ureter. Both anastomoses should be water-tight and tension-free without ureteral angulation, strictures, or twisting. A water-tight seal of the ureteral-ileal anastomosis can be confirmed by insufflating the conduit with a diluted indigo carmine blue solution. The stents should be flushed, and urine production from the stents should be confirmed. The distal ends of the ureteral stents emerging from the efferent end of the conduit should be trimmed to an appropriate length to fit within the urinary appliance and may be sutured to the peristomal skin as an additional measure to prevent migration during the postoperative period.

FIGURE 32B-2. Yankauer suction tip used to facilitate placing ureteral stent guide wire.

FIGURE 32B-3. Tension-free ureteroileal anastomosis.

Re-establish Intestinal Continuity

After completion of the conduit, intestinal continuity is re-established via a side-to-side functional end-to-end enteroenterostomy using the divided ends of ileum. The anastomosis is performed anterior to the ileal conduit. The anastomosis is done in the usual manner using GIA-60 and TA-60 stapling devices. The mesenteric defect is closed with a series of interrupted 3-0 Vicryl sutures to prevent an internal bowel hernia. When closing the mesenteric defect, avoid constricting the mesenteric blood supply to the ileal conduit. Finally, the proximal end of the conduit should be secured to the sacral promontory with several 2-0 or 3-0 delayed-absorbable sutures to prevent migration and creation of tension on the ureteral anastomoses (Figure 32B-4). A closed-suction drain (eg, Jackson-Pratt) is placed in the dependent pelvis. Postoperatively, an abdominal film should be obtained to confirm proper ureteral stent location.

FIGURE 32B-4. Completed ileal conduit.

Noncontinent Ileal Conduit: Alternatives and Modifications

Alternatives to the ileal conduit include a transverse colon conduit and a double-barrel wet stoma.^16–21 An advantage of the transverse colon noncontinent conduit is that it provides a large-caliber segment of bowel that has not been irradiated and may be used when the small bowel has been heavily irradiated. The double-barrel wet colostomy (ureters implanted directly into an end colostomy segment) has the advantage of a single stoma but is less than ideal due to the risk of ascending kidney infections. This procedure may be a viable option for patients who may have difficulty with care of 2 stomal sites.

There are several modifications of the previously described ileal conduit construction. In the technique of Leadbetter, the proximal end of the conduit is sutured to the sacral promontory, and both ureters are brought to the midline for the anastomosis of the intestinal segment. This allows for a more vertically oriented ileal conduit than the transverse oriented conduit of the Bricker method.^5,17 The Turnbull loop stoma can provide adequate blood supply and less compromise of the mesentery for patients who are obese or have had prior complications of ileal conduits such as stomal strictures.^18–20

A modification of the ileal conduit to help reduce ureteral-ileal anastomotic complications has been described by Barbieri et al²¹ in which a small linear incision is made in the ileal segment and the ureteroileal anastomoses created under direct visualization. The reported stricture rate was less than 2%, and the complications from making a linear incision along the small bowel conduit were minimal.

POSTOPERATIVE CARE

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