Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies.

Urinary fistulae and obstruction following pelvic exenteration are frequent and life-threatening complications. They increase the mortality and morbidity rates of large exereses performed during pelvic exenteration for gynecological cancers. From a series of 97 patients who underwent pelvic exenteration for gynecological cancers we report the incidence, risk factors, and management of major urinary complications. Eighty patients had had previous surgery and/or pelvic radiation therapy at the time of pelvic exenteration. A urinary diversion was performed in 63 patients. Major early urinary complications were: urinary fistula in seven patients and ureteral obstruction in four patients (11.3% of the patients). Ten patients had a late urinary complication: stenosis of the cutaneous ureteral meatus (five), stenosis of the ureteroileal anastomosis following ileal loop (two), and urinary fistulae (three). Cancer recurrence was found in 4 of these 10 cases. Major early urinary complications were significantly increased in patients who had received previous pelvic radiation therapy (P < 0.05) and in patients who had had an intestinal conduit for urinary diversion (P < 0.05). Reoperation was done in six of seven cases of early urinary fistula (urinary undiversion four, nephrectomy one, ureteral reimplantation one). Three of four ureteral obstructions were managed with percutaneous nephrostomy and ureteral stent. We recommend the use of nonirradiated bowel segment for urinary diversion as transverse colon or jejunal conduit in patients who have received previous high doses of pelvic radiotherapy. For the management of urinary complications post pelvic exenteration, reoperation is required for most urinary fistula but ureteral obstructions can be managed with percutaneous nephrostomy and ureteral stent.