Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies.

BACKGROUND: There are few reports describing series of cases about development on laparoscopic urinary diversions no related to cystectomy. The aim of this paper is to show the experience of our reference institutions for treatment of pelvic malignancies when laparoscopic techniques were applied to perform only urinary diversion without cystectomy or pelvic exenteration.
MATERIALS AND METHODS: We included retrospectively 12 cases of cutaneous ureterostomy and 21 cases with a reservoir (16 ileal conduits, 2 colonic conduits and 3 wet colostomies) treated in our institute from 2004 to 2010. It was evaluated operative time, blood loss, intraoperative complications, conversion rate, length of large incision, post operative complications, analgesic consumption, time to food intake, hospital stay, time to recovery to normal activities. Mean time to follow-up was 3(2-7) years.
RESULTS: All procedures were completed without conversions. In the cutaneous ureterostomy group the mean surgical time.

INTRODUCTION

In oncologic surgical practice, urinary diversion is a commonly performed procedure after pelvic exenteration or as palliation for untreatable advanced pelvic neoplasm.[1-3] In some cases, urinary diversion is an option for extrinsic obstruction or fistulas, usually caused by external beam radiation therapy.[4]

It is important for those who perform urologic reconstructive surgeries, to have the knowledge of a wide variety of urinary diversions.[5]

Laparoscopic surgery in urology has progressed significantly during the last decade and increasingly complex reconstructive procedures are being performed laparoscopically.[16]

Choosing the type of laparoscopic urinary diversion best suited to each patient does not differ from their open surgical indications and depends on several factors: The chronology of disease, bilateral or unilateral obstruction, temporary or definitive diversion, patient's general health and prognosis.[7]

There are few papers describing series of cases or prospective studies about development on laparoscopic urinary diversions not related to cystectomy.

The aim of this study is to show the experience of our reference institutions for treatment of pelvic malignancies when laparoscopic techniques were applied to perform only urinary diversion without cystectomy or pelvic exenteration in a large series of patients.

MATERIALS AND METHODS

We included retrospectively a series of patients treated in our institute from 2004 to 2010 with indication of urinary diversion. Those includes advanced pelvic malignancy (gynaecologic disease, advanced prostate and bladder tumours), pelvic radiotherapy with actinic cystitis or ureteral stenosis and urinary fistulas. We excluded all patients who underwent laparoscopic radical cystectomy with continent or incontinent diversion.

Groups division

Group I

Patients with indications to cutaneous ureteroenterostomy: Bilateral obstruction of radiated ureters and renal failure (13 cases), actinic vesico-vaginal fistula with previous failed repair (2 cases)

Good nutritional and performance status.

Low risk for surgical complications (ASA I or II).

Group II

Patients with indication of cutaneous ureterostomy (7 cases).

Unilateral diversion with limited prognosis due to neoplasia.

Patients with poor performance status were excluded.

Group III

Candidates for urinary and faecal concomitant diversion (3 cases): actinic complex fistula including rectum, vagina and bladder that have failure after attempting to repair.

Summarised surgical steps

Laparoscopic-assisted cutaneous ureteroenterostomy.

Bricker surgery – patient positioned in lithotomy position, access with 4 infraumbilical transperitoneal trocars (one of this planned in the stoma place, complete laparoscopic dissection of ureters, selection of ileal loop and extracorporeal anastomosis through a 4-6 cm periumbilical incision.

Colonic conduit – described previously, with 4 trocars, transperitoneal access and extracorporeal anastomosis through a 4-6 cm infraxiphoid incision.[4]

Double-barrelled wet colostomy – previously described, retroperitoneal and minilaparotomy associated access with 3-4 trocars (one of this planned in the stoma site), laparoscopic dissection of ureter and colonic loop, exteriorisation of ureters and colon through a 4-6 cm incision, isolation of loop and extracorporeal intestinal and ureteral anastomosis.[5]

Retroperitoneoscopic cutaneous ureterostomy – Patient positioned in lateral decubitus, extraperitoneal space developed through digital and balloon dissection, access with 3 triangulated trocars (the anterior incision located medial to 11th costal rib, complete laparoscopic dissection and exteriorisation through the anterior incision). A double J stent is left completing the surgery.

Evaluation criteria

Operative time, blood loss, intra-operative complications, conversion rate, length of large incision, post-operative complications, analgesic consumption, time to food intake, hospital stay, time to recovery to normal activities.

Follow-up

Every 3 months: clinical and laboratory evaluation.

Every 6 months or if clinical suspecting: serial imaging studies, with ultrasound and contrasted radiography.

Mean time to follow-up was 3 (2-7) years.

RESULTS

We included 12 cases of cutaneous ureterostomy and 21 cases with a reservoir (16 ileal conduits, 2 colonic conduits and 3 wet colostomies). The results can be seen in Table 1 and complications according to Clavien classification can be seen in Table 2.

Table 1

Video laparoscopic procedures performed to incontinent urinary diversion non-related to cystectomy from 2004 to 2010

Table 2

Surgical complications according to Clavien classification

All procedures were completed laparoscopically without conversions.

For cutaneous ureterostomy, mean surgical time was 45 (25-55) minutes; blood loss was 105 (25-250) ml, with no intra-operative complications. Mean hospital stay was 2 days. Fifty percent of these patients presented at least one urinary tract infection (UTI) treated in the follow-up period. As all patients performed stent change every 30 days, no stenosis occurred. Three patients lost the double J stent but none requested reoperation to relocation.

In cases with intestinal reservoir (36 ureters reimplantation in 21 patients), mean surgical time was 150 minutes (110-170 minutes), with a mean blood loss of 130 ml (85-158 ml), with no intra-operative complications. Blood transfusion was not necessary. One patient had postoperative pneumonia and 3 ureteral units (10%) presented urinary leak. In 2 patients, percutaneous nephrostomy was indicated with success and in one case, reoperation was necessary in the fifth postoperative day to perform a new ureteral implantation. Mean hospital stay was 7 days (5-15 days). After 3 years of follow-up, two patients developed ureteral stenosis (6%). In one case, it was necessary to have an open repair with intestinal interposition and the other lost renal function and was treated conservatively. Seven patients submitted to intestinal diversion (33%) presented at least one episode of UTI reported.

For all series, the mean time to oral intake was 2 days (1-5 days) and time to normal activities was about 25 (20-30) days. There was no peri-operative mortality.

Overall survival rate after 3 years was 50 and 65%, for patients treated by cutaneous ureterostomy and intestinal urinary diversion, respectively.

DISCUSSION

Patients with locally advanced pelvic malignancies frequently underwent radiation therapy at some point in their treatment. Urinary tract involvement is generally observed and in some cases with immediate indication of urinary diversion. Recurrent disease after local treatment can occur and hydronephrosis with acute uraemia can emerge as life-threatening condition.

Diversion without exenteration may be offered if the surgery is feasible and when worthwhile benefit can be anticipated.[3]

In addition, patients with multiple medical co-morbidities are often recommended for a conduit diversion only if the procedure is performed with short operative time. This makes unbiased comparisons between these reconstructions difficult and should be considered whenever comparing complications of different reconstructive options.[8]

Urinary diversions are usually performed with laparotomy access. The first laparoscopic-assisted ileal conduit was reported by Kozminski and Partamian, where a cystectomy was not performed. Operative time was 6 hours and 20 minutes.[9] Potter et al. performed a laparoscopic ileal conduit without cystectomy as a treatment for neurogenic bladder in a 28-year-old man. Five port sites were used, and total operative time was 4.5 hours.[10]

Since Sanchez de Badajos et al.[11] have described an experimental model for performing endoscopic ureteroileostomy with extracorporeal urinary diversion, many researchers have performed laparoscopic and robotic-assisted urinary diversion, whether with intra- or extracorporeal anastomosis.[1512]

Potential benefits of laparoscopic and robotic approaches that have been described include lower blood loss, early return of bowel function and more rapid post-operative convalescence.[13-15]

About the various approaches on urinary diversions, we must analyse each one within its particularities.

Percutaneous nephrostomy is the most common indication for palliative urinary tract drainage in patients with unilateral or bilateral ureteral obstruction. Although it is a procedure with low morbidity, rates may be poorly tolerated. Loss of nephrostomy catheter is the most frequent complication, observed in 37.5% patients, requiring new intervention in almost all of them.[16]

Laparoscopic cutaneous ureterostomy or ileal conduits may be an option as a more permanent urinary diversion with the advantage of not using external catheters.[17] Cutaneous ureterostomy was chosen in 12 patients with a mean operative time of 45 minutes with no complications or conversions, and ileal conduits were chosen in 16 patients with a great successful rate.

In rare cases, there is a need for urinary and faecal diversion or the need for a colonic diversion.[45] Advantages by maintaining an intermittent faecal and continuous urine flow, less stoma stenosis, use of non-irradiated loops, cosmetic appearance and quality of life seems to encourage more attention to those options.[45]

Although not a comparative study and no definitive conclusions can be done, we believe that in experienced hands the laparoscopic urinary diversion not related to cystectomy in patients with radiated or recurrent pelvic malignancies can be a good and safe alternative when properly indicated.

CONCLUSION

Laparoscopic urinary diversion is technically feasible and seems to be a reasonable alternative to percutaneous nephrostomy in selected cases of ureteral obstruction due to advanced pelvic disease when patient clinical conditions are acceptable.

Prospective randomised trials comparing open, laparoscopic and robotic approaches[18] are awaited to define advantages and to analyse long-term results of each alternative.