Presentation Authors: Brian M. Blair*, Jim Shen, Nora Ruel, Jonathan Yamzon, Ali Zhumkhawala, Clayton Lau, Bertram Yuh, Kevin Chan, Duarte, CA
Introduction: Radical cystectomy during multi-visceral resection for locally advanced pelvic malignancy requires urinary diversion. Outcomes with incontinent and continent urinary diversions performed during pelvic exenteration for non-urologic malignancy are not well documented in urologic literature. The aim of the study is to report our experience with urinary reconstruction in this complex operation.
Methods: A single tertiary-care institution, multi-surgeon, retrospective chart review was performed for patients undergoing urinary diversion as part of pelvic exenteration for non-urologic malignancy between February 1999 and April 2017. Patient demographics, surgical parameters, and complication rates were analyzed and then compared by diversion type. Statistical significance was set at p < 0.05.
Results: 57 patients were included with a median age of 56.0 years (IQR 47.0 - 67.0) and BMI 27.1 kg/m2 (IQR 21.8 - 31.5). 70.2% (n=40) were female and 29.8% male (n=17), with 68.4% having an ASA classification â‰¥ III. Patient's primary malignancy was categorized as colorectal for 49.1%, gynecologic for 43.9%, and other for 7.0% (sarcoma, adenocarcinoma). Prior chemotherapy (77.2%), pelvic radiation (71.9%), or chemoradiation (63.2%) was common. Indiana pouch (IP) continent diversion was used in 19.3% (n=11), and incontinent diversions included ileal conduit (IC) in 77.2% (n=44) and colon conduit in 3.5% (n=2). Comparing IP to IC diversions, there was no difference in age, gender, BMI, or tumor type. Those undergoing IP were less likely to have prior chemotherapy (36.4 vs 88.6%, p=0.0007) or radiation (63.6 vs 72.7%, p=0.007), and less likely to require intraoperative (36.4 vs 75.7%, p=0.02) or postoperative transfusion (18.2 vs 27.3%, p=0.02). Clinically, operative time was longer in patients who underwent IP compared to IC (650.5 vs 480 minutes, p=0.2), with comparable 30-day (63.6 vs 72.7%, p=0.4) and 31-90-day (36.4 vs 29.5%, p=0.3) complications. Fewer IP patients underwent adjuvant chemotherapy (9.1 vs 34.1%, p=0.05), and follow-up was longer for the IP group (34.1 vs 10.0 months, p=0.03), perhaps owing to better disease prognosis in those receiving a continent diversion.
Conclusions: This data provides insight into a scarcely reported topic in urologic literature. Diversion type should be individualized, with continent diversions in patients undergoing pelvic exenteration for non-urologic malignancy remaining a feasible option with comparable outcomes to incontinent diversions in appropriately selected patients.