- Email: [email protected]
Urinary tract fistulas following ligation of the internal iliac artery during radical hysterectomy
GYNECOLOGIC
ONCOLOGY
21, 359-363 (1985)
Urinary Tract Fistulas following Ligation of the Internal Iliac Artery during Radical Hysterectomy WILLIAM S. ROBERTS, M.D. ,* DENIS CAVANAGH, M.D., DONALD E. MARSDEN, M.D., AND VIRGINIA C. ROBERTS, R.N. *University
of South Florida, Division of Gynecologic Oncology, Suite No. 611, Tampa, Florida 33606
1 Davis Boulevard,
Received May 31, 1984 One hundred patients underwent radical hysterectomy at the University of South Florida over a 4f-year period. In all patients the anterior division of the internal iliac artery was ligated on the left, and the uterine artery was ligated at its origin from the internal iliac artery on the right. One patient developed a left ureterovaginal fistula for a urinary tract fistula rate of 1%. Preservation of the distal branches of the anterior division of the internal iliac artery may help prevent urinary tract fistulas following radical hysterectomy. This study would suggest, however, that this is of minimal importance. D 1985 Academic press, IN.
Urinary tract complications following radical hysterectomy has been an area of great concern to pelvic surgeons since the days of Wertheim and Bonney. Ureterovaginal and vesicovaginal fistulas are the most troublesome of these complications. Both of these complications were fairly common in early series of radical hysterectomies. Brunschwig reported a 23% incidence and Friedell reported a 20% incidence [1,2]. Liu and Meigs reported a 9% incidence in 473 patients [3]. As a result of this early experience, several factors were identified which predisposed to ureteral and vesical fistula formation. These included devascularization, surgical injury, previous radiation therapy to the pelvis, entrapment of the distal ureter and bladder base in infected collections of tissue fluid, and excessive distention of the bladder and distal ureter in the early postoperative period. Several techniques were developed to eliminate or minimize these factors. These techniques include suction drainage of the retroperitoneal pelvic spaces, placement of the pelvic ureter in the peritoneal cavity, suspension of the distal ureter to the superior vesical artery, preservation of the superior vesical artery, prolonged catheter drainage of the bladder in a postoperative period, and less radical dissection of the ureter with preservation of lateral blood supply to the distal ureter [4-71. The relative importance of these techniques is controversial. Some surgeons use all of them and some only use one or two. As a result of these efforts to reduce urinary tract fistulas the acceptable fistula rate has been reduced to 2 to 3% or less [8]. 359 0090-8258185$1SO Copyright 8 1985 by Academic Press, Inc. All rights of reproduction in any form reserved.
360
ROBERTS
ET AL.
The importance of preservation of the superior vesical artery has been controversial for several years. Several surgeons advocate ligation of the uterine artery at its origin from the anterior division of the internal iliac artery [7,9]. Others feel that the anterior division of the internal iliac artery itself can be ligated without an increase in the fistula rate [8]. This study is an attempt to determine if ligation of the anterior division of the internal iliac artery increases the urinary tract fistula rate. METHOD
One hundred patients underwent radical hysterectomy at the University of South Florida between June 6, 1979 and March 6, 1984. All modified radical hysterectomies were excluded. The mean age was 42.2 years with a range of 23 to 79, and the mean parity was 3.2. The indications for surgery are listed in Table 1. Each patient was treated with a uniform operative technic. The abdomen was entered through a midline vertical incision extending from the pubic symphysis to above the umbilicus. The upper abdomen was explored followed by sampling of the periaortic lymph nodes. The pelvic lymph nodes were then removed followed by double ligation of the anterior division of the internal iliac artery on the left, and ligation of the uterine artery at its origin from the internal iliac artery on the right. The ureters were then dissected from their uterovesical tunnels after appropriate dissection of the bladder. Lateral dissection of the distal ureter was kept to a minimum. The uterosacral ligaments were then removed at the sacrum and the cardinal ligaments removed at the lateral pelvic sidewalls. The specimen was then removed including the upper one-third of the vagina. The vaginal cuff was drained with a “t” tube and the retroperitoneal pelvic spaces were drained with medium Hemovac suction drains brought out through stab wounds in the lower quadrants of the abdomen. The distal portions of both ureters were suspended to the superior vesicle arteries. The pelvic peritoneum
TABLE OPERATIVE
1
INDICATIONS
Squamous carcinoma of cervix Stage IS Stage 2B Adenocarcinoma of cervix Stage 1B Stage 2A Adenosquamous carcinoma of cervix Stage 1B Adenocarcinoma of endometrium Stage 2 Adenosquamous carcinoma of endometrium Stage 2 Carcinosarcoma of cervix Total
77 6 7 1 4 3 1 1 100
FISTULAS
FOLLOWING
RADICAL
361
HYSTERECTOMY
was closed leaving the ureters in a retroperitoneal position. The vaginal “t” tube was removed on the third postoperative day. The pelvic Hemovacs were usually removed on the fourth or fifth postoperative day depending on the amount of drainage. The Foley catheter draining the bladder was removed 6 weeks after surgery. Forty-four patients received.postoperative whole pelvis radiation to a maximum of 5000 rad for various reasons. Presence of metastatic disease in pelvic lymph nodes and deep cervical stromal invasion were the two most common reasons. None of these patients received radiotherapy until at least 6 weeks after surgery. One patient received an unknown dosage of pelvic radiation 20 years prior to her surgery. Two patients received both external pelvic radiation and intracavitary radiation prior to surgery for Stage II-B squamous cancers with bulky central tumors. RESULTS
One patient died in the postoperative period of a massive pulmonary embolus for an operative mortality of 1%. The mean estimated blood loss was 924 ml with a range of 300-2500 ml. The mean transfusion requirement was 1.61 units of blood with a range of O-5 units. The mean hospital stay was 12.25 days with a range of 9-27 days. Intraoperative complications were fairly rare and are listed in Table 2. None of these complications resulted in permanent sequelae. Postoperative complications are listed in Table 3. One patient developed a urinary tract fistula for a rate of 1%. This was a left ureterovaginal fistula with no unusual predisposing circumstances that could be identified. This fistula was corrected with a left ureteroneocystostomy 3 months after her original surgery. The patient has had no recurrence of her fistula and is doing well. There were no right ureterovaginal fistulas or vesicovaginal fistulas. One patient developed bilateral distal ureteral stenosis requiring bilateral ureteroneocystostomy. No patient who received postoperative external pelvic radiation developed a fistula. The present status of the patients in this study are listed in Table 4. The mean duration of follow-up is 13 months with a range of 2-43 months. DISCUSSION
The incidence of urinary tract fistulas in this series of radical hysterectomies was very low. One ureterovaginal fistula occurred on the left where the anterior TABLE 2 INTRAOPERATIVE COMPLICATIONS
1 2 3 4 5 6 7
.
Injury to right external iliac artery Injury of right internal iliac vein Injury to bladder Injury to rectum Failed radical vaginal hysterectomy completed abdominally Tumor spillage after rupture of lower uterine segment Transection of left ureter
362
ROBERTS
ET
TABLE POSTOPERATIVE
AL.
3
COMPLICATIONS
Lung Severe atelectasis Embolus Pneumonia Wound Infection Hernia Dehisence Hematoma Pelvis Cellulitis Septic thrombophlebitis Lymphocyst (two required operative drainage) Iliofemoral thrombosis Bowel Prolonged ileus Small bowl obstruction (two required operative correction) Pseudomembranous colitis Urinary tract UT1 Pyelonephritis Ureterovaginal fistula Ureteral stenosis Stress incontinence
4
2 1 10 1 1 1 6 1 3 2 2 3 1 5 3 1 2 1
division of the internal iliac artery was ligated. Whether the loss of the distal branches of the internal iliac artery contributed to this fistula can not be determined. It is obvious that the distal branches of the internal iliac artery can be sacrificed on one side with a very low fistula rate. Webb and Symmonds reported a ureteral and vesical fistula rate of 2.5% in a large series of radical hysterectomies in which the anterior division of the internal iliac artery was ligated on both sides [8]. In addition, many of the patients in that series received maximum pelvic radiotherapy prior to their surgery. TABLE PRESENT
STATUS
4
OF PATIENT
Alive No evidence of disease Recurrent disease NED after secondary treatment Alive with disease present Dead Died with disease present Died without disease present Total
POPULATION
88 2 2 6 2 100
FISTULAS
FOLLOWING
RADICAL
HYSTERECTOMY
363
Preservation of the distal branches of the internal iliac artery may slightly decrease the incidence of urinary tract fistulas after radical hysterectomy. However, it appears to have been of minimal importance in this study. REFERENCES 1. Brunschwig, A., and Frick, H. Urinary tract fistulas following radical surgical treatment of carcinoma of the cervix (exclusive of exenterations), Amer. J. Obstef. Gynecol. 72, 479 (1956). 2. Friedell, G. H., and Graham, J. B. Regional lymph node involvement in small carcinoma of the cervix, Surg. Gynecol. Obstet. 108, 513 (1959). 3. Liu W., and Meigs, J. V. Radical hysterectomy and pelvic lymphadenectomy: A review of 473 cases including 244 for primary invasive carcinoma of the cervix, Amer. J. Obster. Gynecol. 69, 1 (1955). 4. Symmonds, R. E., and Pratt, J. H. Prevention of fistulas and lymphocysts in radical hysterectomy. Preliminary report of a new technic, Obstet. Gynecol. 17, 57 (1961). 5. Novak, F. The prevention of ureterovaginal fistulas, Inc. J. Gynecol. Obster. 7, 301 (1969). 6. Green, T. H., Meigs, J. V., er al. Urologic complications of radical Wertheim hysterectomy: Incidence, etiology, management and prevention, Obstet. Gynecol. 20, 293 (1962). 7. Piver, M. S., Rutledge, F., and Smith, J. P. Five classes of extended hysterectomy for women with cervical cancer, Obstet. Gynecol. 44, 265 (1974). 8. Webb, M. J., and Symmonds, R. E. Wertheim hysterectomy: A reappraisal, Obsret. Gynecol. 54, 140 (1979). 9. Meigs, J. V. Radical hysterectomy with bilateral pelvic lymph node dissections. A report of 100 patients operated on five or more years ago, Amer. J. Obstet. Gynecol. 62, 854 (1951).
ONCOLOGY
21, 359-363 (1985)
Urinary Tract Fistulas following Ligation of the Internal Iliac Artery during Radical Hysterectomy WILLIAM S. ROBERTS, M.D. ,* DENIS CAVANAGH, M.D., DONALD E. MARSDEN, M.D., AND VIRGINIA C. ROBERTS, R.N. *University
of South Florida, Division of Gynecologic Oncology, Suite No. 611, Tampa, Florida 33606
1 Davis Boulevard,
Received May 31, 1984 One hundred patients underwent radical hysterectomy at the University of South Florida over a 4f-year period. In all patients the anterior division of the internal iliac artery was ligated on the left, and the uterine artery was ligated at its origin from the internal iliac artery on the right. One patient developed a left ureterovaginal fistula for a urinary tract fistula rate of 1%. Preservation of the distal branches of the anterior division of the internal iliac artery may help prevent urinary tract fistulas following radical hysterectomy. This study would suggest, however, that this is of minimal importance. D 1985 Academic press, IN.
Urinary tract complications following radical hysterectomy has been an area of great concern to pelvic surgeons since the days of Wertheim and Bonney. Ureterovaginal and vesicovaginal fistulas are the most troublesome of these complications. Both of these complications were fairly common in early series of radical hysterectomies. Brunschwig reported a 23% incidence and Friedell reported a 20% incidence [1,2]. Liu and Meigs reported a 9% incidence in 473 patients [3]. As a result of this early experience, several factors were identified which predisposed to ureteral and vesical fistula formation. These included devascularization, surgical injury, previous radiation therapy to the pelvis, entrapment of the distal ureter and bladder base in infected collections of tissue fluid, and excessive distention of the bladder and distal ureter in the early postoperative period. Several techniques were developed to eliminate or minimize these factors. These techniques include suction drainage of the retroperitoneal pelvic spaces, placement of the pelvic ureter in the peritoneal cavity, suspension of the distal ureter to the superior vesical artery, preservation of the superior vesical artery, prolonged catheter drainage of the bladder in a postoperative period, and less radical dissection of the ureter with preservation of lateral blood supply to the distal ureter [4-71. The relative importance of these techniques is controversial. Some surgeons use all of them and some only use one or two. As a result of these efforts to reduce urinary tract fistulas the acceptable fistula rate has been reduced to 2 to 3% or less [8]. 359 0090-8258185$1SO Copyright 8 1985 by Academic Press, Inc. All rights of reproduction in any form reserved.
360
ROBERTS
ET AL.
The importance of preservation of the superior vesical artery has been controversial for several years. Several surgeons advocate ligation of the uterine artery at its origin from the anterior division of the internal iliac artery [7,9]. Others feel that the anterior division of the internal iliac artery itself can be ligated without an increase in the fistula rate [8]. This study is an attempt to determine if ligation of the anterior division of the internal iliac artery increases the urinary tract fistula rate. METHOD
One hundred patients underwent radical hysterectomy at the University of South Florida between June 6, 1979 and March 6, 1984. All modified radical hysterectomies were excluded. The mean age was 42.2 years with a range of 23 to 79, and the mean parity was 3.2. The indications for surgery are listed in Table 1. Each patient was treated with a uniform operative technic. The abdomen was entered through a midline vertical incision extending from the pubic symphysis to above the umbilicus. The upper abdomen was explored followed by sampling of the periaortic lymph nodes. The pelvic lymph nodes were then removed followed by double ligation of the anterior division of the internal iliac artery on the left, and ligation of the uterine artery at its origin from the internal iliac artery on the right. The ureters were then dissected from their uterovesical tunnels after appropriate dissection of the bladder. Lateral dissection of the distal ureter was kept to a minimum. The uterosacral ligaments were then removed at the sacrum and the cardinal ligaments removed at the lateral pelvic sidewalls. The specimen was then removed including the upper one-third of the vagina. The vaginal cuff was drained with a “t” tube and the retroperitoneal pelvic spaces were drained with medium Hemovac suction drains brought out through stab wounds in the lower quadrants of the abdomen. The distal portions of both ureters were suspended to the superior vesicle arteries. The pelvic peritoneum
TABLE OPERATIVE
1
INDICATIONS
Squamous carcinoma of cervix Stage IS Stage 2B Adenocarcinoma of cervix Stage 1B Stage 2A Adenosquamous carcinoma of cervix Stage 1B Adenocarcinoma of endometrium Stage 2 Adenosquamous carcinoma of endometrium Stage 2 Carcinosarcoma of cervix Total
77 6 7 1 4 3 1 1 100
FISTULAS
FOLLOWING
RADICAL
361
HYSTERECTOMY
was closed leaving the ureters in a retroperitoneal position. The vaginal “t” tube was removed on the third postoperative day. The pelvic Hemovacs were usually removed on the fourth or fifth postoperative day depending on the amount of drainage. The Foley catheter draining the bladder was removed 6 weeks after surgery. Forty-four patients received.postoperative whole pelvis radiation to a maximum of 5000 rad for various reasons. Presence of metastatic disease in pelvic lymph nodes and deep cervical stromal invasion were the two most common reasons. None of these patients received radiotherapy until at least 6 weeks after surgery. One patient received an unknown dosage of pelvic radiation 20 years prior to her surgery. Two patients received both external pelvic radiation and intracavitary radiation prior to surgery for Stage II-B squamous cancers with bulky central tumors. RESULTS
One patient died in the postoperative period of a massive pulmonary embolus for an operative mortality of 1%. The mean estimated blood loss was 924 ml with a range of 300-2500 ml. The mean transfusion requirement was 1.61 units of blood with a range of O-5 units. The mean hospital stay was 12.25 days with a range of 9-27 days. Intraoperative complications were fairly rare and are listed in Table 2. None of these complications resulted in permanent sequelae. Postoperative complications are listed in Table 3. One patient developed a urinary tract fistula for a rate of 1%. This was a left ureterovaginal fistula with no unusual predisposing circumstances that could be identified. This fistula was corrected with a left ureteroneocystostomy 3 months after her original surgery. The patient has had no recurrence of her fistula and is doing well. There were no right ureterovaginal fistulas or vesicovaginal fistulas. One patient developed bilateral distal ureteral stenosis requiring bilateral ureteroneocystostomy. No patient who received postoperative external pelvic radiation developed a fistula. The present status of the patients in this study are listed in Table 4. The mean duration of follow-up is 13 months with a range of 2-43 months. DISCUSSION
The incidence of urinary tract fistulas in this series of radical hysterectomies was very low. One ureterovaginal fistula occurred on the left where the anterior TABLE 2 INTRAOPERATIVE COMPLICATIONS
1 2 3 4 5 6 7
.
Injury to right external iliac artery Injury of right internal iliac vein Injury to bladder Injury to rectum Failed radical vaginal hysterectomy completed abdominally Tumor spillage after rupture of lower uterine segment Transection of left ureter
362
ROBERTS
ET
TABLE POSTOPERATIVE
AL.
3
COMPLICATIONS
Lung Severe atelectasis Embolus Pneumonia Wound Infection Hernia Dehisence Hematoma Pelvis Cellulitis Septic thrombophlebitis Lymphocyst (two required operative drainage) Iliofemoral thrombosis Bowel Prolonged ileus Small bowl obstruction (two required operative correction) Pseudomembranous colitis Urinary tract UT1 Pyelonephritis Ureterovaginal fistula Ureteral stenosis Stress incontinence
4
2 1 10 1 1 1 6 1 3 2 2 3 1 5 3 1 2 1
division of the internal iliac artery was ligated. Whether the loss of the distal branches of the internal iliac artery contributed to this fistula can not be determined. It is obvious that the distal branches of the internal iliac artery can be sacrificed on one side with a very low fistula rate. Webb and Symmonds reported a ureteral and vesical fistula rate of 2.5% in a large series of radical hysterectomies in which the anterior division of the internal iliac artery was ligated on both sides [8]. In addition, many of the patients in that series received maximum pelvic radiotherapy prior to their surgery. TABLE PRESENT
STATUS
4
OF PATIENT
Alive No evidence of disease Recurrent disease NED after secondary treatment Alive with disease present Dead Died with disease present Died without disease present Total
POPULATION
88 2 2 6 2 100
FISTULAS
FOLLOWING
RADICAL
HYSTERECTOMY
363
Preservation of the distal branches of the internal iliac artery may slightly decrease the incidence of urinary tract fistulas after radical hysterectomy. However, it appears to have been of minimal importance in this study. REFERENCES 1. Brunschwig, A., and Frick, H. Urinary tract fistulas following radical surgical treatment of carcinoma of the cervix (exclusive of exenterations), Amer. J. Obstef. Gynecol. 72, 479 (1956). 2. Friedell, G. H., and Graham, J. B. Regional lymph node involvement in small carcinoma of the cervix, Surg. Gynecol. Obstet. 108, 513 (1959). 3. Liu W., and Meigs, J. V. Radical hysterectomy and pelvic lymphadenectomy: A review of 473 cases including 244 for primary invasive carcinoma of the cervix, Amer. J. Obster. Gynecol. 69, 1 (1955). 4. Symmonds, R. E., and Pratt, J. H. Prevention of fistulas and lymphocysts in radical hysterectomy. Preliminary report of a new technic, Obstet. Gynecol. 17, 57 (1961). 5. Novak, F. The prevention of ureterovaginal fistulas, Inc. J. Gynecol. Obster. 7, 301 (1969). 6. Green, T. H., Meigs, J. V., er al. Urologic complications of radical Wertheim hysterectomy: Incidence, etiology, management and prevention, Obstet. Gynecol. 20, 293 (1962). 7. Piver, M. S., Rutledge, F., and Smith, J. P. Five classes of extended hysterectomy for women with cervical cancer, Obstet. Gynecol. 44, 265 (1974). 8. Webb, M. J., and Symmonds, R. E. Wertheim hysterectomy: A reappraisal, Obsret. Gynecol. 54, 140 (1979). 9. Meigs, J. V. Radical hysterectomy with bilateral pelvic lymph node dissections. A report of 100 patients operated on five or more years ago, Amer. J. Obstet. Gynecol. 62, 854 (1951).