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Ileal orthotopic neobladder after pelvic exenteration for cervical cancer
Gynecologic Oncology 113 (2009) 47–51
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y g y n o
Ileal orthotopic neobladder after pelvic exenteration for cervical cancer Luis M. Chiva a,⁎, Fernando Lapuente a, Carlos Núñez b, Pedro T. Ramírez c a b c
Department of Gynecologic Oncology, M. D. Anderson International España, Madrid, Spain Department of Urology, M. D. Anderson International España, Madrid, Spain Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
a r t i c l e
i n f o
Article history: Received 19 October 2008 Available online 26 January 2009 Keywords: Exenteration Recurrence Cervical cancer Urinary diversion Neobladder
a b s t r a c t Objective. We aimed to describe our preliminary experience in creating an ileal orthotopic urinary conduit in patients with a history of pelvic irradiation undergoing pelvic exenteration for recurrent cervical cancer and to evaluate the feasibility, complication rates, and outcomes of this procedure. Methods. A retrospective chart review was performed in all 6 patients who underwent ileal orthotopic neobladder creation at our institution between January 2005 and March 2008. Main outcome measures were surgical complications, continence rate, neobladder function, and oncologic outcome. Results. The mean patient age was 46.6 years (range, 38–61). Four patients underwent anterior exenteration and 2 total pelvic exenterations. There were no intraoperative complications. The median operative time was 456 min (range, 372–600). The median time to create the orthotopic urinary conduit was 70 min (range, 55–90). Three patients had postoperative neobladder anastomotic leak. Two of them had this complication successfully managed conservatively and 1 surgically. Daytime urinary continence was good or satisfactory in 4 of 6 patients. Nighttime urinary continence was good or satisfactory in 3 of 6 patients. All patients reported being satisfied with their decision to undergo this procedure. Median follow-up time was 20.5 months (range, 6–34). At last visit, 3 patients were alive without evidence of disease, 1 was alive with stable retroperitoneal disease, and 2 had died of disease recurrence after exenteration. Conclusions. Ileal orthotopic neobladder creation in patients undergoing exenteration for recurrent cervical cancer is feasible after radiation. The rate of urinary continence is acceptable. © 2008 Elsevier Inc. All rights reserved.
Introduction Since Bricker first described his technique for creating an ileal conduit in 1950 [1], this procedure has been considered the gold standard for urinary diversions after cystectomy for bladder cancer or after pelvic exenteration for gynecologic malignancies. In fact, the Bricker conduit accounts for about half of all urinary diversions performed today [2]. Unfortunately, the ileal urinary conduit does not afford the patient a continent urinary mechanism. A number of reports in the literature have documented the safety and utility of a continent urinary diversion in patients with gynecologic malignancies [3,4]. However, compared to the ileal urinary conduit, the continent urinary diversion is associated with higher complication rates and decreased patient acceptance [5,6]. Orthotopic reconstruction of the lower urinary tract is currently considered a standard procedure for patients diagnosed with bladder cancer [2]. In this procedure, the segment of bowel used as the urinary reservoir is anastomosed to the urethra to avoid the need for a urostomy on the patient's anterior abdominal wall. This orthotopic bladder reconstruction is associated with an approximately 80% rate ⁎ Corresponding author. Division of Gynecologic Oncology M. D. Anderson International España Gómez Hemans No. 4, 28033 Madrid, Spain. Fax: +34 91 768 06 87. E-mail address: [email protected] (L.M. Chiva). 0090-8258/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2008.12.020
of urinary continence [7]. In gynecologic oncology, there is limited experience with orthotopic reconstruction of the bladder. In addition, most patients undergoing a pelvic exenteration for recurrent cervical cancer have previously been irradiated, which poses potential healing difficulties. Moreover, only a select group of patients with recurrent cervical cancer may be candidates for a urethra-sparing surgical approach. In carefully selected patients in whom the urethra can be spared, creating an orthotopic neobladder might enable the patient to maintain urethral continence while sparing her an external appliance for urinary drainage. This could have a positive impact on the patient's quality of life. The goal of this study was to describe our preliminary experience with creating ileal orthotopic urinary conduits in patients with a history of pelvic irradiation undergoing pelvic exenteration for recurrent cervical cancer. We report on surgical indications, intraoperative and postoperative complications, and ultimate outcome in patients who underwent this procedure. Methods Between January 2005 and March 2008, 6 patients with recurrent cervical cancer underwent cystectomy as part of an exenterative procedure for recurrent cervical cancer. Our selection criteria for
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L.M. Chiva et al. / Gynecologic Oncology 113 (2009) 47–51
pelvic exenteration takes into account three major factors. These include the absence of extra pelvic disease, adequate performance status, and patient's willingness to undergo this procedure. The urinary tract in these patients was reconstructed with a Yshaped ileal orthotopic neobladder. Before surgery, all patients were counseled regarding standard approaches, which were described as ileal conduit and continent urinary conduit. All patients consented to having their information evaluated for research purposes. Data collection and analysis All patient records were reviewed for patient's age, primary diagnosis, stage of disease at time of diagnosis, tumor histology, initial therapy, location of recurrence, and type of surgery at the time of recurrence. We also evaluated variables related to the neobladder, such as operative time, intraoperative complications, and early (b30 days after surgery) and late (≥30 days after surgery) surgical complications. The grade of continence after the urinary reconstruction and the neobladder capacity were also studied. The degree of continence was classified as good (completely dry), satisfactory (using no more than 1 pad per day or night), or poor (using more than 1 pad per day or night). The maximum bladder capacity was tested 6 months after surgery by cystography and was defined as the point at which the patient experienced discomfort or leakage with introduction of a 10% solution of nonionic contrast material. In addition, cystography provided information regarding the integrity of the pouch. Finally,
Fig. 2. (A) The ileum is detubularized through the antimesenteric edge with linear stapler device. (B) The neobladder is ready to perform the anastomosis.
we reviewed patient satisfaction with the orthotopic urinary conduit, rate of cervical cancer recurrence after exenteration, and overall survival. Surgical technique
Fig. 1. First steps for ileal neobladder's creation. (A) The urethra is exposed. (B) The loop of ileum that can be best approximated to the deep pelvis is chosen.
Our technique is a variation of the technique described by Lilien and Camey [8] and later modified by Fontana et al. [9]. Briefly, the objective is to create a Y-shaped neobladder with detubularized ileum. Once the exenterative part of the surgical procedure is completed, the loop of ileum that most easily reaches the urethra is chosen to create the neobladder (Fig. 1). An approximately 50 cm segment of ileum, sparing the distal 20 cm of terminal ileum, is isolated with a linear stapler device (PROXIMATE Reload Linear Cutter, 75 mm, Ethicon). A small incision is made in the distal loop of the ileal segment on the antimesenteric part of the bowel. The same linear stapler device is inserted through this incision and used to detubularize the ileum and create the vertical arm of the neobladder that will be connected to the proximal urethra. In all these procedures, the entire urethra may be spared. Two passes of 7.5 cm each are needed to obtain a sufficiently long ileal neobladder (Fig. 2). Before the anastomosis is started, 3 stitches of 3-0 Vicryl are placed between the serosa of the ileal neobladder and the periurethral tissue to give stability to the junction. The ileal–urethral anastomosis is initiated on the posterior aspect of the anastomosis with a 3-0 reabsorbable monofilament running suture. After that, a Foley catheter is introduced into the neobladder, and the anterior aspect is completed with a new running suture of the same type. Once the
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continence, bleeding, infections, lumbar pain (related to episodes of renal colic), and episodes of overflow incontinence due to a mucus plug. BUN and creatinine levels are checked every 3 months to evaluate renal function. After the Foley catheter is removed, usually 4 to 6 weeks after surgery, the following voiding schedule is suggested to patients: week 1, void every 2 h during the day and every 3 h at night; week 2, void every 3 h during the day and every 4 h at night; week 3, void every 4 h during the day and every 5 h at night; week 4, void every 5 h during the day and every 6 h at night; week 5, void every 6 h day and night. Patients are trained to do self-catheterization of the neobladder, to measure the post-void residual urine volume, and to clean any mucus plug that forms in the neobladder. For patients who complain of mucous plug formation, we recommend oral N-acetyl-L-cysteine (200 mg every 8 h) to decrease the viscosity of ileal neobladder mucus. Renal sonography is performed 1 to 2 months after the pigtail catheters are removed to exclude hydronephrosis due to ureteral stricture, and excretory urography and cystography are performed at 6 and 12 months after surgery to test the ureteral patency and bladder capacity. Results The mean age of the 6 patients in our series was 47 years (range, 38 to 61). Three patients were diagnosed with squamous carcinoma and 3 with adenocarcinoma. After the initial diagnosis of cervical cancer, 3 patients were treated with a radical hysterectomy followed by adjuvant concomitant chemotherapy and radiation therapy, and the other 3 patients were treated with chemoradiation therapy without surgery. Three patients were diagnosed with recurrent cervical cancer within the first 6 months after completion of initial therapy. The other 3 patients were diagnosed with recurrent disease at 8, 12, and 72 months after completion of initial therapy. Patient characteristics are shown in Table 1. Prior to the exenterative procedure, all patients underwent an examination under anesthesia, colonoscopy, cystoscopy, positron emission tomography-computed tomography (PET-CT), and pelvic magnetic resonance imaging. This was done to determine the feasibility of surgical resection. In every case, the entire urethra and the vagina located underneath were visibly free of tumor. Five patients had diseases localized to the pelvis (uterine cervix, vaginal cuff, or proximal parametrium); 1 patient had a suspicious para-aortic lymph node on PET-CT. Before this patient's surgery, an extensive discussion was held with her regarding the indication for pelvic exenteration when a suspicious para-aortic node is encountered. Other therapeutic options, such as chemotherapy, were offered. A systematic para-aortic lymphadenectomy was performed in this patient. All enlarged nodes were sent for frozen section examination, and all were found to be negative for tumor. At the time of exenteration, all the other 5 patients underwent sampling of the para-aortic lymph nodes. Four patients underwent an anterior exenteration. Two patients underwent a total pelvic exenteration: a supralevator exenteration with end-to-end anastomosis of the distal sigmoid colon. This was done before the orthotopic urinary conduit was performed. In these
Fig. 3. “Y” shaped ileal neobladder once the urethral anastomosis is done. Note the omental wrap over this area (⁎).
anastomosis is completed, an omental J-flap is developed. The omental flap is then used to cover the anastomosis circumferentially. Subsequently, both ureters are prepared to be anastomosed directly to the ipsilateral arm of the Y-shaped neobladder. First, each ureter is spatulated with Potts scissors, and then is catheterized with a 30-cm, 5-French, double-pigtail catheter that is left in the neobladder for approximately 30 to 45 days after surgery. A 5-mm linear incision is made in the area of ileum closest to the ipsilateral ureter. Approximately 6 to 8 5-0 Vicryl interrupted sutures are used to perform the anastomosis. The integrity of the neobladder anastomoses is evaluated by injecting methylene blue through the Foley catheter in the neobladder (Fig. 3). The Foley catheter is removed 4 to 6 weeks after surgery, and at the same time, both ureteral catheters are removed through an ambulatory cystoscopy. Before this is performed, we routinely obtain a cystogram to confirm the absence of leaks. All patients are followed every month for the first 6 months, every 3 months for the remainder of the first year, every 4 months for the second year, and then every 6 months until 5 years. We ensure that all symptoms related to the neobladder are documented and addressed accordingly. These symptoms include but are not limited to urinary leakage, grade of Table 1 Patients' characteristics Patient #
Age, year
Histology
Disease stage
Prior therapy⁎
Time to recurrence
Location of tumor recurrence
1 2
61 50
Adenocarcinoma Squamous carcinoma
IB1 IIB
Surgery + chemoradiation Chemoradiation
3 months 12 months
Vaginal cuff Cervix and rectovaginal septum
3 4 5 6
38 39 54 38
Adenocarcinoma Adenocarcinoma Squamous carcinoma Squamous carcinoma
IB2 IB1, node-positive IB1, node-positive IB2
Chemoradiation Surgery + chemoradiation Surgery + chemoradiation Chemoradiation
4 months 5 months 72 months 8 months
Cervix Vaginal cuff Vaginal cuff Cervix
All the patients were treated with weekly cisplatin with doses between 40 and 50 mg/m2.
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Table 2 Bladder function parameters 6 months after surgery Patient # Continence Daytime 1 2 3 4 5 6
Bladder capacity (mL)⁎ Residual volume (mL) Nighttime
Satisfactory Poor Poor Poor Good Good Good Good Satisfactory Satisfactory Foley still placed after Martius flap
290 280 310 340 300 N/A
100 80 10 10 100 N/A
⁎ Normal bladder capacity is 400 to 600 mL. The urinary bladder can normally hold 250 to 350 mL of urine before a patient becomes conscious of the urge to void.
patients, a protective temporary ileostomy was placed to protect the colorectal anastomosis. Three patients received intraoperative highdose-rate intraoperative brachytherapy because of close margins on frozen section examination. A margin was considered close when the pathologist reported that the tumor-free margin measured less than 5 mm. In these 3 patients, the close margins were located in the parametria. Intraoperative high-dose-rate brachytherapy was administered by delivering a single dose of 12.5 to 15 Gy with an Iridium131-loaded blanket. There were no intraoperative complications. The median operative time was 456 min (range, 372 to 600). The median time to create the orthotopic urinary conduit was 70 min (range, 55 to 90). In each case, the final pathology report showed tumor-free margins. All the lymph nodes sent for examination were free of disease except for the single suspicious para-aortic lymph node identified on preoperative PET-CT. Although the findings on frozen section examination in this patient were negative for metastatic disease, the final pathology report confirmed disease spread. The median length of postoperative hospital stay was 17 days (range, 14 to 31). Three patients had early complications. Another patient suffered a neobladder anastomotic leak diagnosed on postoperative day 15. The patient reported loss of urine despite having a bladder catheter. A cystogram revealed leaking from the posterior aspect of the urethral anastomosis. This patient was treated conservatively with placement of a larger Foley catheter and healed without any adverse events. Two months later, a cystoscopy confirmed that the anastomotic leak had sealed, and the Foley catheter was removed. Both patients who had a protective temporary ileostomy placed suffered intermittent episodes of metabolic acidosis during the first month after surgery as a result of chronic loss of bicarbonate through the neobladder and the ileostomy. This was manifested as hyperkalemia, asthenia, anorexia, thirst, and altered mental status. Oral sodium bicarbonate (3–10 g/day) was prescribed and produced complete resolution of symptoms. Two patients suffered late complications. Both of these patients were diagnosed with an orthotopic neobladder leak located on the posterior aspect of the urethral anastomosis. The first patient complained of sudden-onset urinary loss 3 months after surgery. A cystogram was performed, and a leak from the anastomosis of the pouch to the vagina was documented. This complication was managed by placing a Foley catheter in the orthotopic urinary conduit, and the leak healed spontaneously 2 months after it was diagnosed. The second patient, who was a heavy smoker, experienced urinary loss from the vagina approximately 6 weeks after surgery. The patient reported that the urine loss appeared following an episode of high intravesical pressure due to a mucus plug. On vaginal exam, the Foley balloon was visible on the anterior low vaginal wall. The defect was noted on the posterior aspect of the anastomosis. Since the defect was judged to be too large to close spontaneously with conservative management, it was repaired with a Martius flap 4 months after the initial surgery. At last follow-up, 2 months after the flap repair, this
patient still had a Foley catheter and had no complaints of further urinary loss. For each patient, the grade of continence achieved, the bladder capacity, and the residual urine volume after voiding are shown in Table 2. Six months after the procedure, 4 out of 6 patients were continent wearing only a small pad. One patient wears a large pad that requires changing 3 times per day and the other patient still has a Foley catheter in place due to a bladder fistula. One year after the procedure, 3 out of 6 patients are continent. One has not completed the year of follow up. The median follow-up time for all patients was 20.5 months (6 to 34 months). At last visit, all patients, including those who suffered a neobladder leak, reported being satisfied with their decision to undergo the neobladder procedure. At last follow up, all patients who were alive stated that they preferred an orthotopic urinary conduit rather than the alternative urinary stoma. At last visit, 3 patients were alive without evidence of disease, 1 patient was alive with stable retroperitoneal disease, and 2 patients had died of disease recurrence after exenteration. One of the patients who had died was diagnosed with recurrent disease in the lungs 16 months after exenteration, and the other was diagnosed with recurrent pelvic peritoneal relapse 7 months after exenteration. Discussion A pelvic exenteration remains the only curative option for many patients with central pelvic recurrence of cervical cancer. Unfortunately, the majority of these patients must have the urethra removed as part of this procedure. The most common urinary diversions performed during a pelvic exenteration are incontinent diversion, which requires that the patient wear a urostomy appliance, and continent diversion, which requires that the patient have a urostomy site in the abdominal wall that is intermittently catheterized. A select number of patients undergoing pelvic exenteration do not have to have the urethra removed. These are typically patients who undergo a supralevator exenteration in whom the urethra is free of any tumor involvement. In these patients, one may consider the option of an orthotopic bladder reconstruction, which spares the patient the need for a urostomy or external appliance. The rationale for recommending orthotopic neobladder reconstruction includes the fact that sparing the urethra does not compromise the oncologic outcome as evidenced by the literature dealing with bladder cancer [10]. Diurnal and nocturnal continence rates are acceptable in irradiated patients, although they will be always worse than in those non irradiated [11]. Orthotopic reconstruction of the lower urinary tract has long been performed in patients with bladder cancer [2]. As a result, most publications on this subject are found in the urology literature. Recent evidence in the literature has shown that only 80% of the urethra is
Table 3 Criteria that make a patient an ideal candidate for creation of an orthotopic neobladder after pelvic exenteration Urethra and adjacent vagina macroscopically free of tumor. Good performance status. Serum creatinine level b 2.0 mg/dl preoperatively. Absence of compromised intestinal function (inflammatory bowel disease). Absence of stress incontinence due to sphincteric incompetence. Absence of marked urethral hypermobility. (Hypermobility during straining is described as linear dorsocaudal movement N 15 mm.) No history of full-dose irradiation of the urethra. No indications for pelvic postoperative radiation therapy. Motivation to undergo intensive continence training if necessary. Motivation to wear pads if necessary. Motivation and dexterity to perform clean intermittent catheterization if necessary. Urethral margin and vaginal margin clearly free of disease on frozen section examination of the exenteration specimen.
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necessary to maintain urinary continence [12]. In addition, women who undergo a distal partial urethrectomy for the management of either urethral diverticula or malignancy remain continent unless a major portion of the middle third of the urethra has been removed [13,14]. It also has been previously suggested that to preserve continence at the time of a cystectomy, the vagina located underneath the remaining urethra must be spared along with the urethra [15]. According to Stenzl et al. [10], the rate of satisfactory daytime urinary continence among women after orthotopic neobladder creation for pelvic malignancies is higher than 80%, and the rate of satisfactory nighttime continence exceeds 75%. The authors reviewed combined data on 102 women aging 28 to 79 years (mean, 59 years) who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient). In all patients, the bladder neck and up to 1 cm of the adjacent urethra were removed with the bladder. Only 4 (4%) of the 102 patients had received preoperative radiation therapy. Fourteen pouchrelated late complications necessitated interventions in 12 patients The criteria that make a patient an ideal candidate for an orthotopic neobladder after pelvic exenteration are shown in Table 3 [16]. One should note that most of the reported patients who underwent orthotopic neobladder surgery were patients with no history of pelvic irradiation. However, a number of reports in men who have undergone this procedure have shown that the results are similar between irradiated and nonirradiated patients in terms of complications and continence [17,18]. Ali-el-Dein et al. [19] recently published their experience in 192 nonirradiated women who underwent orthotopic neobladder creation after radical cystectomy for bladder cancer. Their data showed that early and late diversion-related complications developed in a significant number of patients. Of the 177 patients eligible for urodynamic evaluation, 62 experienced a total of 75 late complications, and 10 of these patients developed different types of fistulas. Most early complications were treated conservatively, whereas most late complications were treated with endourological and/or open surgery. Ungar and Palfalvi [20] published their experience in 13 women who underwent an exenteration after irradiation for cervical cancer. They used a colonic orthotopic neobladder. In their procedure, a 10cm segment of the terminal ileum, the cecum, and a 20-cm segment of the ascending colon are separated from the fecal stream. A 15-cm segment of the ascending colon is opened longitudinally along the taenia, and the open colon is closed by a transverse suture line. The colonic pouch is anastomosed to the urethra, and both ureters are sutured to the terminal ileum. In that report, 30% of patients suffered a fistula formation, and 70% achieved adequate daytime continence. Orthotopic neobladder reconstruction is ideally performed after anterior exenteration; however, it may also be accomplished after a total pelvic exenteration. In the latter setting, it might increase the complication rates. In our series, both patients with total pelvic exenteration underwent a temporary loop ileostomy. This was done in order to prevent any colorectal leakage that might increase the risk of urethral anastomosis breakdown. We recommend that when performing a total pelvic exenteration, a colorectal anastomosis should be performed before the neobladder reconstruction and a temporary stoma should be considered. To our knowledge, this is the first report of ileal orthotopic neobladder in irradiated patients after pelvic exenteration for cervical cancer. We found that all patients in our series were satisfied with having elected to undergo the neobladder procedure despite the documented complications in the postoperative period. We found that daytime continence was satisfactory whereas nighttime continence was less optimal. We recognize that our study has limitations, including the small number of patients; the retrospective data collection; the lack of a
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formal quality-of-life assessment; and the lack of objective measures of urinary continence. We propose, on the basis of our results, that sparing the urethra in selected patients does not increase the risk of local recurrence and that the procedure is feasible in irradiated patients. Even though we believe this procedure can be performed safely with minimal intraoperative complications and without significantly extending the operative time, we still recognize that a prior history of radiation therapy remains a reason for the high postoperative complication rate. Therefore, this option may be offered as an alternative, but patients must be carefully counseled regarding both the benefits and the drawbacks. Conflict of interest statement The authors report no conflict of interest.
Acknowledgment The authors wish to thank Stephanie Deming for her editorial assistance. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ygyno.2008.12.020. References [1] Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30:1511–21. [2] World Health Organization (WHO) Consensus Conference on Bladder CancerHautmann RE, Abl-Enein H, Hafez K, et al. Urinary diversion. Urology 2007;69(1 Suppl):17–49 Review. [3] Penalver MA, Bejany DE, Averette HE, Donato DM, Sevin BU, Suarez G. Continent urinary diversion in gynecologic oncology. Gynecol Oncol 1989;34:274–88. [4] Estape R, Mendez LE, Angioli R, Penalver M. Urinary diversion in gynecologic oncology. Surg Clin North Am 2001;81(4):781–97 Review. [5] 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(2):261–8. [6] Okada Y, Oishi K, Shichiri Y, et al. Quality of life survey of urinary diversion patients: comparison of continent urinary diversion versus ileal conduit. Int J Urol 1997;4:26–31. [7] Hautmann RE, Volkmer BG, Schumacher MC, Gschwend JE, Studer UE. Long-term results of standard procedures in urology: the ileal neobladder. World J Urol 2006;24(3):305–14. [8] Lilien OM, Camey M. 25-Year experience with replacement of the human bladder (Camey procedure). J Urol 1984;132:886–91. [9] Fontana D, Bellina M, Fasolis G, et al. Y-neobladder: an easy, fast, and reliable procedure. Urology 2004;63(4):699–703. [10] Stenzl A, Bartsch G, Rogatsch H. The remnant urothelium after reconstructive bladder surgery. Eur Urol 2002;41(2):124–31 Review. [11] Hautmann RE. 15 years experience with the ileal neobladder: what have we learned? Urologe A 2001;40:360–7. [12] Stenzl A, Jarolim L, Coloby P, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer 2001;92 (7):1864–71. [13] Neuwirth H, Stenzl A, de Kernion J. Urethral cancer. In: Haskell C, editor. Cancer treatment. Philadelphia: Williams & Wilkins; 1990. p. 762–4. Spence H, Duckett J. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol 1990;104:432. [14] Colleselli K, Stenzl A, Eder R, Strasser H, Poisel S, Bartsch G. The female urethral sphincter: a morphological and topographical study. J Urol 1998;160:49–54. [15] Hautmann RE, Paiss T, de Petriconi R. The ileal neobladder in women: 9 years of experience with 18 patients. J Urol 1996;155(1):76–81. [16] Stenzl A, Höltl L. Orthotopic bladder reconstruction in women—what we have learned over the last decade. Crit Rev Oncol/Hematol 2003;47(2):147–54 Review. [17] Bochner BH, Figueroa AJ, Skinner EC, et al. Salvage radical cystoprostatectomy and orthotopic urinary diversion following radiation failure. J Urol 1998;160 (1):29–33. [18] Abbas F, Biyabani SR, Talati J. Orthotopic bladder replacement to the urethra following salvage radical cystoprostatectomy in men with failed radiation therapy. Tech Urol 2001;7(1):20–6. [19] Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-Azab M, Ashamallah A, Ghoneim MA. Surgical complications following radical cystectomy and orthotopic neobladders in women. J Urol 2008;180(1):206–10 discussion 210. [20] Ungar L, Palfalvi L. Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients. Int J Gynecol Cancer 2006;16(1):364–8.
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y g y n o
Ileal orthotopic neobladder after pelvic exenteration for cervical cancer Luis M. Chiva a,⁎, Fernando Lapuente a, Carlos Núñez b, Pedro T. Ramírez c a b c
Department of Gynecologic Oncology, M. D. Anderson International España, Madrid, Spain Department of Urology, M. D. Anderson International España, Madrid, Spain Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
a r t i c l e
i n f o
Article history: Received 19 October 2008 Available online 26 January 2009 Keywords: Exenteration Recurrence Cervical cancer Urinary diversion Neobladder
a b s t r a c t Objective. We aimed to describe our preliminary experience in creating an ileal orthotopic urinary conduit in patients with a history of pelvic irradiation undergoing pelvic exenteration for recurrent cervical cancer and to evaluate the feasibility, complication rates, and outcomes of this procedure. Methods. A retrospective chart review was performed in all 6 patients who underwent ileal orthotopic neobladder creation at our institution between January 2005 and March 2008. Main outcome measures were surgical complications, continence rate, neobladder function, and oncologic outcome. Results. The mean patient age was 46.6 years (range, 38–61). Four patients underwent anterior exenteration and 2 total pelvic exenterations. There were no intraoperative complications. The median operative time was 456 min (range, 372–600). The median time to create the orthotopic urinary conduit was 70 min (range, 55–90). Three patients had postoperative neobladder anastomotic leak. Two of them had this complication successfully managed conservatively and 1 surgically. Daytime urinary continence was good or satisfactory in 4 of 6 patients. Nighttime urinary continence was good or satisfactory in 3 of 6 patients. All patients reported being satisfied with their decision to undergo this procedure. Median follow-up time was 20.5 months (range, 6–34). At last visit, 3 patients were alive without evidence of disease, 1 was alive with stable retroperitoneal disease, and 2 had died of disease recurrence after exenteration. Conclusions. Ileal orthotopic neobladder creation in patients undergoing exenteration for recurrent cervical cancer is feasible after radiation. The rate of urinary continence is acceptable. © 2008 Elsevier Inc. All rights reserved.
Introduction Since Bricker first described his technique for creating an ileal conduit in 1950 [1], this procedure has been considered the gold standard for urinary diversions after cystectomy for bladder cancer or after pelvic exenteration for gynecologic malignancies. In fact, the Bricker conduit accounts for about half of all urinary diversions performed today [2]. Unfortunately, the ileal urinary conduit does not afford the patient a continent urinary mechanism. A number of reports in the literature have documented the safety and utility of a continent urinary diversion in patients with gynecologic malignancies [3,4]. However, compared to the ileal urinary conduit, the continent urinary diversion is associated with higher complication rates and decreased patient acceptance [5,6]. Orthotopic reconstruction of the lower urinary tract is currently considered a standard procedure for patients diagnosed with bladder cancer [2]. In this procedure, the segment of bowel used as the urinary reservoir is anastomosed to the urethra to avoid the need for a urostomy on the patient's anterior abdominal wall. This orthotopic bladder reconstruction is associated with an approximately 80% rate ⁎ Corresponding author. Division of Gynecologic Oncology M. D. Anderson International España Gómez Hemans No. 4, 28033 Madrid, Spain. Fax: +34 91 768 06 87. E-mail address: [email protected] (L.M. Chiva). 0090-8258/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2008.12.020
of urinary continence [7]. In gynecologic oncology, there is limited experience with orthotopic reconstruction of the bladder. In addition, most patients undergoing a pelvic exenteration for recurrent cervical cancer have previously been irradiated, which poses potential healing difficulties. Moreover, only a select group of patients with recurrent cervical cancer may be candidates for a urethra-sparing surgical approach. In carefully selected patients in whom the urethra can be spared, creating an orthotopic neobladder might enable the patient to maintain urethral continence while sparing her an external appliance for urinary drainage. This could have a positive impact on the patient's quality of life. The goal of this study was to describe our preliminary experience with creating ileal orthotopic urinary conduits in patients with a history of pelvic irradiation undergoing pelvic exenteration for recurrent cervical cancer. We report on surgical indications, intraoperative and postoperative complications, and ultimate outcome in patients who underwent this procedure. Methods Between January 2005 and March 2008, 6 patients with recurrent cervical cancer underwent cystectomy as part of an exenterative procedure for recurrent cervical cancer. Our selection criteria for
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pelvic exenteration takes into account three major factors. These include the absence of extra pelvic disease, adequate performance status, and patient's willingness to undergo this procedure. The urinary tract in these patients was reconstructed with a Yshaped ileal orthotopic neobladder. Before surgery, all patients were counseled regarding standard approaches, which were described as ileal conduit and continent urinary conduit. All patients consented to having their information evaluated for research purposes. Data collection and analysis All patient records were reviewed for patient's age, primary diagnosis, stage of disease at time of diagnosis, tumor histology, initial therapy, location of recurrence, and type of surgery at the time of recurrence. We also evaluated variables related to the neobladder, such as operative time, intraoperative complications, and early (b30 days after surgery) and late (≥30 days after surgery) surgical complications. The grade of continence after the urinary reconstruction and the neobladder capacity were also studied. The degree of continence was classified as good (completely dry), satisfactory (using no more than 1 pad per day or night), or poor (using more than 1 pad per day or night). The maximum bladder capacity was tested 6 months after surgery by cystography and was defined as the point at which the patient experienced discomfort or leakage with introduction of a 10% solution of nonionic contrast material. In addition, cystography provided information regarding the integrity of the pouch. Finally,
Fig. 2. (A) The ileum is detubularized through the antimesenteric edge with linear stapler device. (B) The neobladder is ready to perform the anastomosis.
we reviewed patient satisfaction with the orthotopic urinary conduit, rate of cervical cancer recurrence after exenteration, and overall survival. Surgical technique
Fig. 1. First steps for ileal neobladder's creation. (A) The urethra is exposed. (B) The loop of ileum that can be best approximated to the deep pelvis is chosen.
Our technique is a variation of the technique described by Lilien and Camey [8] and later modified by Fontana et al. [9]. Briefly, the objective is to create a Y-shaped neobladder with detubularized ileum. Once the exenterative part of the surgical procedure is completed, the loop of ileum that most easily reaches the urethra is chosen to create the neobladder (Fig. 1). An approximately 50 cm segment of ileum, sparing the distal 20 cm of terminal ileum, is isolated with a linear stapler device (PROXIMATE Reload Linear Cutter, 75 mm, Ethicon). A small incision is made in the distal loop of the ileal segment on the antimesenteric part of the bowel. The same linear stapler device is inserted through this incision and used to detubularize the ileum and create the vertical arm of the neobladder that will be connected to the proximal urethra. In all these procedures, the entire urethra may be spared. Two passes of 7.5 cm each are needed to obtain a sufficiently long ileal neobladder (Fig. 2). Before the anastomosis is started, 3 stitches of 3-0 Vicryl are placed between the serosa of the ileal neobladder and the periurethral tissue to give stability to the junction. The ileal–urethral anastomosis is initiated on the posterior aspect of the anastomosis with a 3-0 reabsorbable monofilament running suture. After that, a Foley catheter is introduced into the neobladder, and the anterior aspect is completed with a new running suture of the same type. Once the
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continence, bleeding, infections, lumbar pain (related to episodes of renal colic), and episodes of overflow incontinence due to a mucus plug. BUN and creatinine levels are checked every 3 months to evaluate renal function. After the Foley catheter is removed, usually 4 to 6 weeks after surgery, the following voiding schedule is suggested to patients: week 1, void every 2 h during the day and every 3 h at night; week 2, void every 3 h during the day and every 4 h at night; week 3, void every 4 h during the day and every 5 h at night; week 4, void every 5 h during the day and every 6 h at night; week 5, void every 6 h day and night. Patients are trained to do self-catheterization of the neobladder, to measure the post-void residual urine volume, and to clean any mucus plug that forms in the neobladder. For patients who complain of mucous plug formation, we recommend oral N-acetyl-L-cysteine (200 mg every 8 h) to decrease the viscosity of ileal neobladder mucus. Renal sonography is performed 1 to 2 months after the pigtail catheters are removed to exclude hydronephrosis due to ureteral stricture, and excretory urography and cystography are performed at 6 and 12 months after surgery to test the ureteral patency and bladder capacity. Results The mean age of the 6 patients in our series was 47 years (range, 38 to 61). Three patients were diagnosed with squamous carcinoma and 3 with adenocarcinoma. After the initial diagnosis of cervical cancer, 3 patients were treated with a radical hysterectomy followed by adjuvant concomitant chemotherapy and radiation therapy, and the other 3 patients were treated with chemoradiation therapy without surgery. Three patients were diagnosed with recurrent cervical cancer within the first 6 months after completion of initial therapy. The other 3 patients were diagnosed with recurrent disease at 8, 12, and 72 months after completion of initial therapy. Patient characteristics are shown in Table 1. Prior to the exenterative procedure, all patients underwent an examination under anesthesia, colonoscopy, cystoscopy, positron emission tomography-computed tomography (PET-CT), and pelvic magnetic resonance imaging. This was done to determine the feasibility of surgical resection. In every case, the entire urethra and the vagina located underneath were visibly free of tumor. Five patients had diseases localized to the pelvis (uterine cervix, vaginal cuff, or proximal parametrium); 1 patient had a suspicious para-aortic lymph node on PET-CT. Before this patient's surgery, an extensive discussion was held with her regarding the indication for pelvic exenteration when a suspicious para-aortic node is encountered. Other therapeutic options, such as chemotherapy, were offered. A systematic para-aortic lymphadenectomy was performed in this patient. All enlarged nodes were sent for frozen section examination, and all were found to be negative for tumor. At the time of exenteration, all the other 5 patients underwent sampling of the para-aortic lymph nodes. Four patients underwent an anterior exenteration. Two patients underwent a total pelvic exenteration: a supralevator exenteration with end-to-end anastomosis of the distal sigmoid colon. This was done before the orthotopic urinary conduit was performed. In these
Fig. 3. “Y” shaped ileal neobladder once the urethral anastomosis is done. Note the omental wrap over this area (⁎).
anastomosis is completed, an omental J-flap is developed. The omental flap is then used to cover the anastomosis circumferentially. Subsequently, both ureters are prepared to be anastomosed directly to the ipsilateral arm of the Y-shaped neobladder. First, each ureter is spatulated with Potts scissors, and then is catheterized with a 30-cm, 5-French, double-pigtail catheter that is left in the neobladder for approximately 30 to 45 days after surgery. A 5-mm linear incision is made in the area of ileum closest to the ipsilateral ureter. Approximately 6 to 8 5-0 Vicryl interrupted sutures are used to perform the anastomosis. The integrity of the neobladder anastomoses is evaluated by injecting methylene blue through the Foley catheter in the neobladder (Fig. 3). The Foley catheter is removed 4 to 6 weeks after surgery, and at the same time, both ureteral catheters are removed through an ambulatory cystoscopy. Before this is performed, we routinely obtain a cystogram to confirm the absence of leaks. All patients are followed every month for the first 6 months, every 3 months for the remainder of the first year, every 4 months for the second year, and then every 6 months until 5 years. We ensure that all symptoms related to the neobladder are documented and addressed accordingly. These symptoms include but are not limited to urinary leakage, grade of Table 1 Patients' characteristics Patient #
Age, year
Histology
Disease stage
Prior therapy⁎
Time to recurrence
Location of tumor recurrence
1 2
61 50
Adenocarcinoma Squamous carcinoma
IB1 IIB
Surgery + chemoradiation Chemoradiation
3 months 12 months
Vaginal cuff Cervix and rectovaginal septum
3 4 5 6
38 39 54 38
Adenocarcinoma Adenocarcinoma Squamous carcinoma Squamous carcinoma
IB2 IB1, node-positive IB1, node-positive IB2
Chemoradiation Surgery + chemoradiation Surgery + chemoradiation Chemoradiation
4 months 5 months 72 months 8 months
Cervix Vaginal cuff Vaginal cuff Cervix
All the patients were treated with weekly cisplatin with doses between 40 and 50 mg/m2.
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Table 2 Bladder function parameters 6 months after surgery Patient # Continence Daytime 1 2 3 4 5 6
Bladder capacity (mL)⁎ Residual volume (mL) Nighttime
Satisfactory Poor Poor Poor Good Good Good Good Satisfactory Satisfactory Foley still placed after Martius flap
290 280 310 340 300 N/A
100 80 10 10 100 N/A
⁎ Normal bladder capacity is 400 to 600 mL. The urinary bladder can normally hold 250 to 350 mL of urine before a patient becomes conscious of the urge to void.
patients, a protective temporary ileostomy was placed to protect the colorectal anastomosis. Three patients received intraoperative highdose-rate intraoperative brachytherapy because of close margins on frozen section examination. A margin was considered close when the pathologist reported that the tumor-free margin measured less than 5 mm. In these 3 patients, the close margins were located in the parametria. Intraoperative high-dose-rate brachytherapy was administered by delivering a single dose of 12.5 to 15 Gy with an Iridium131-loaded blanket. There were no intraoperative complications. The median operative time was 456 min (range, 372 to 600). The median time to create the orthotopic urinary conduit was 70 min (range, 55 to 90). In each case, the final pathology report showed tumor-free margins. All the lymph nodes sent for examination were free of disease except for the single suspicious para-aortic lymph node identified on preoperative PET-CT. Although the findings on frozen section examination in this patient were negative for metastatic disease, the final pathology report confirmed disease spread. The median length of postoperative hospital stay was 17 days (range, 14 to 31). Three patients had early complications. Another patient suffered a neobladder anastomotic leak diagnosed on postoperative day 15. The patient reported loss of urine despite having a bladder catheter. A cystogram revealed leaking from the posterior aspect of the urethral anastomosis. This patient was treated conservatively with placement of a larger Foley catheter and healed without any adverse events. Two months later, a cystoscopy confirmed that the anastomotic leak had sealed, and the Foley catheter was removed. Both patients who had a protective temporary ileostomy placed suffered intermittent episodes of metabolic acidosis during the first month after surgery as a result of chronic loss of bicarbonate through the neobladder and the ileostomy. This was manifested as hyperkalemia, asthenia, anorexia, thirst, and altered mental status. Oral sodium bicarbonate (3–10 g/day) was prescribed and produced complete resolution of symptoms. Two patients suffered late complications. Both of these patients were diagnosed with an orthotopic neobladder leak located on the posterior aspect of the urethral anastomosis. The first patient complained of sudden-onset urinary loss 3 months after surgery. A cystogram was performed, and a leak from the anastomosis of the pouch to the vagina was documented. This complication was managed by placing a Foley catheter in the orthotopic urinary conduit, and the leak healed spontaneously 2 months after it was diagnosed. The second patient, who was a heavy smoker, experienced urinary loss from the vagina approximately 6 weeks after surgery. The patient reported that the urine loss appeared following an episode of high intravesical pressure due to a mucus plug. On vaginal exam, the Foley balloon was visible on the anterior low vaginal wall. The defect was noted on the posterior aspect of the anastomosis. Since the defect was judged to be too large to close spontaneously with conservative management, it was repaired with a Martius flap 4 months after the initial surgery. At last follow-up, 2 months after the flap repair, this
patient still had a Foley catheter and had no complaints of further urinary loss. For each patient, the grade of continence achieved, the bladder capacity, and the residual urine volume after voiding are shown in Table 2. Six months after the procedure, 4 out of 6 patients were continent wearing only a small pad. One patient wears a large pad that requires changing 3 times per day and the other patient still has a Foley catheter in place due to a bladder fistula. One year after the procedure, 3 out of 6 patients are continent. One has not completed the year of follow up. The median follow-up time for all patients was 20.5 months (6 to 34 months). At last visit, all patients, including those who suffered a neobladder leak, reported being satisfied with their decision to undergo the neobladder procedure. At last follow up, all patients who were alive stated that they preferred an orthotopic urinary conduit rather than the alternative urinary stoma. At last visit, 3 patients were alive without evidence of disease, 1 patient was alive with stable retroperitoneal disease, and 2 patients had died of disease recurrence after exenteration. One of the patients who had died was diagnosed with recurrent disease in the lungs 16 months after exenteration, and the other was diagnosed with recurrent pelvic peritoneal relapse 7 months after exenteration. Discussion A pelvic exenteration remains the only curative option for many patients with central pelvic recurrence of cervical cancer. Unfortunately, the majority of these patients must have the urethra removed as part of this procedure. The most common urinary diversions performed during a pelvic exenteration are incontinent diversion, which requires that the patient wear a urostomy appliance, and continent diversion, which requires that the patient have a urostomy site in the abdominal wall that is intermittently catheterized. A select number of patients undergoing pelvic exenteration do not have to have the urethra removed. These are typically patients who undergo a supralevator exenteration in whom the urethra is free of any tumor involvement. In these patients, one may consider the option of an orthotopic bladder reconstruction, which spares the patient the need for a urostomy or external appliance. The rationale for recommending orthotopic neobladder reconstruction includes the fact that sparing the urethra does not compromise the oncologic outcome as evidenced by the literature dealing with bladder cancer [10]. Diurnal and nocturnal continence rates are acceptable in irradiated patients, although they will be always worse than in those non irradiated [11]. Orthotopic reconstruction of the lower urinary tract has long been performed in patients with bladder cancer [2]. As a result, most publications on this subject are found in the urology literature. Recent evidence in the literature has shown that only 80% of the urethra is
Table 3 Criteria that make a patient an ideal candidate for creation of an orthotopic neobladder after pelvic exenteration Urethra and adjacent vagina macroscopically free of tumor. Good performance status. Serum creatinine level b 2.0 mg/dl preoperatively. Absence of compromised intestinal function (inflammatory bowel disease). Absence of stress incontinence due to sphincteric incompetence. Absence of marked urethral hypermobility. (Hypermobility during straining is described as linear dorsocaudal movement N 15 mm.) No history of full-dose irradiation of the urethra. No indications for pelvic postoperative radiation therapy. Motivation to undergo intensive continence training if necessary. Motivation to wear pads if necessary. Motivation and dexterity to perform clean intermittent catheterization if necessary. Urethral margin and vaginal margin clearly free of disease on frozen section examination of the exenteration specimen.
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necessary to maintain urinary continence [12]. In addition, women who undergo a distal partial urethrectomy for the management of either urethral diverticula or malignancy remain continent unless a major portion of the middle third of the urethra has been removed [13,14]. It also has been previously suggested that to preserve continence at the time of a cystectomy, the vagina located underneath the remaining urethra must be spared along with the urethra [15]. According to Stenzl et al. [10], the rate of satisfactory daytime urinary continence among women after orthotopic neobladder creation for pelvic malignancies is higher than 80%, and the rate of satisfactory nighttime continence exceeds 75%. The authors reviewed combined data on 102 women aging 28 to 79 years (mean, 59 years) who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient). In all patients, the bladder neck and up to 1 cm of the adjacent urethra were removed with the bladder. Only 4 (4%) of the 102 patients had received preoperative radiation therapy. Fourteen pouchrelated late complications necessitated interventions in 12 patients The criteria that make a patient an ideal candidate for an orthotopic neobladder after pelvic exenteration are shown in Table 3 [16]. One should note that most of the reported patients who underwent orthotopic neobladder surgery were patients with no history of pelvic irradiation. However, a number of reports in men who have undergone this procedure have shown that the results are similar between irradiated and nonirradiated patients in terms of complications and continence [17,18]. Ali-el-Dein et al. [19] recently published their experience in 192 nonirradiated women who underwent orthotopic neobladder creation after radical cystectomy for bladder cancer. Their data showed that early and late diversion-related complications developed in a significant number of patients. Of the 177 patients eligible for urodynamic evaluation, 62 experienced a total of 75 late complications, and 10 of these patients developed different types of fistulas. Most early complications were treated conservatively, whereas most late complications were treated with endourological and/or open surgery. Ungar and Palfalvi [20] published their experience in 13 women who underwent an exenteration after irradiation for cervical cancer. They used a colonic orthotopic neobladder. In their procedure, a 10cm segment of the terminal ileum, the cecum, and a 20-cm segment of the ascending colon are separated from the fecal stream. A 15-cm segment of the ascending colon is opened longitudinally along the taenia, and the open colon is closed by a transverse suture line. The colonic pouch is anastomosed to the urethra, and both ureters are sutured to the terminal ileum. In that report, 30% of patients suffered a fistula formation, and 70% achieved adequate daytime continence. Orthotopic neobladder reconstruction is ideally performed after anterior exenteration; however, it may also be accomplished after a total pelvic exenteration. In the latter setting, it might increase the complication rates. In our series, both patients with total pelvic exenteration underwent a temporary loop ileostomy. This was done in order to prevent any colorectal leakage that might increase the risk of urethral anastomosis breakdown. We recommend that when performing a total pelvic exenteration, a colorectal anastomosis should be performed before the neobladder reconstruction and a temporary stoma should be considered. To our knowledge, this is the first report of ileal orthotopic neobladder in irradiated patients after pelvic exenteration for cervical cancer. We found that all patients in our series were satisfied with having elected to undergo the neobladder procedure despite the documented complications in the postoperative period. We found that daytime continence was satisfactory whereas nighttime continence was less optimal. We recognize that our study has limitations, including the small number of patients; the retrospective data collection; the lack of a
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formal quality-of-life assessment; and the lack of objective measures of urinary continence. We propose, on the basis of our results, that sparing the urethra in selected patients does not increase the risk of local recurrence and that the procedure is feasible in irradiated patients. Even though we believe this procedure can be performed safely with minimal intraoperative complications and without significantly extending the operative time, we still recognize that a prior history of radiation therapy remains a reason for the high postoperative complication rate. Therefore, this option may be offered as an alternative, but patients must be carefully counseled regarding both the benefits and the drawbacks. Conflict of interest statement The authors report no conflict of interest.
Acknowledgment The authors wish to thank Stephanie Deming for her editorial assistance. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ygyno.2008.12.020. References [1] Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30:1511–21. [2] World Health Organization (WHO) Consensus Conference on Bladder CancerHautmann RE, Abl-Enein H, Hafez K, et al. Urinary diversion. Urology 2007;69(1 Suppl):17–49 Review. [3] Penalver MA, Bejany DE, Averette HE, Donato DM, Sevin BU, Suarez G. Continent urinary diversion in gynecologic oncology. Gynecol Oncol 1989;34:274–88. [4] Estape R, Mendez LE, Angioli R, Penalver M. Urinary diversion in gynecologic oncology. Surg Clin North Am 2001;81(4):781–97 Review. [5] 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(2):261–8. [6] Okada Y, Oishi K, Shichiri Y, et al. Quality of life survey of urinary diversion patients: comparison of continent urinary diversion versus ileal conduit. Int J Urol 1997;4:26–31. [7] Hautmann RE, Volkmer BG, Schumacher MC, Gschwend JE, Studer UE. Long-term results of standard procedures in urology: the ileal neobladder. World J Urol 2006;24(3):305–14. [8] Lilien OM, Camey M. 25-Year experience with replacement of the human bladder (Camey procedure). J Urol 1984;132:886–91. [9] Fontana D, Bellina M, Fasolis G, et al. Y-neobladder: an easy, fast, and reliable procedure. Urology 2004;63(4):699–703. [10] Stenzl A, Bartsch G, Rogatsch H. The remnant urothelium after reconstructive bladder surgery. Eur Urol 2002;41(2):124–31 Review. [11] Hautmann RE. 15 years experience with the ileal neobladder: what have we learned? Urologe A 2001;40:360–7. [12] Stenzl A, Jarolim L, Coloby P, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer 2001;92 (7):1864–71. [13] Neuwirth H, Stenzl A, de Kernion J. Urethral cancer. In: Haskell C, editor. Cancer treatment. Philadelphia: Williams & Wilkins; 1990. p. 762–4. Spence H, Duckett J. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol 1990;104:432. [14] Colleselli K, Stenzl A, Eder R, Strasser H, Poisel S, Bartsch G. The female urethral sphincter: a morphological and topographical study. J Urol 1998;160:49–54. [15] Hautmann RE, Paiss T, de Petriconi R. The ileal neobladder in women: 9 years of experience with 18 patients. J Urol 1996;155(1):76–81. [16] Stenzl A, Höltl L. Orthotopic bladder reconstruction in women—what we have learned over the last decade. Crit Rev Oncol/Hematol 2003;47(2):147–54 Review. [17] Bochner BH, Figueroa AJ, Skinner EC, et al. Salvage radical cystoprostatectomy and orthotopic urinary diversion following radiation failure. J Urol 1998;160 (1):29–33. [18] Abbas F, Biyabani SR, Talati J. Orthotopic bladder replacement to the urethra following salvage radical cystoprostatectomy in men with failed radiation therapy. Tech Urol 2001;7(1):20–6. [19] Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-Azab M, Ashamallah A, Ghoneim MA. Surgical complications following radical cystectomy and orthotopic neobladders in women. J Urol 2008;180(1):206–10 discussion 210. [20] Ungar L, Palfalvi L. Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients. Int J Gynecol Cancer 2006;16(1):364–8.