|Year : 2013 | Volume
| Issue : 1 | Page : 3-6
Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies
Marcos Tobias-Machado, Leonardo S Lopes, Felipe Brandao Correa de Araujo, Eduardo S Starling, Antonio Carlos Lima Pompeo
Department of Urology, Faculdade de Medicina do ABC (ABC Medical School), Av. Principe de Gales, 821 Santo Andre Sao Paulo CEP, Brazil
|Date of Submission||18-Oct-2011|
|Date of Acceptance||02-Mar-2012|
|Date of Web Publication||14-Feb-2013|
Felipe Brandao Correa de Araujo
Rua Machado Bittencourt, 379/44 Vila Clementina CEP, Sao Paulo
Source of Support: None, Conflict of Interest: None
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.
Keywords: Laparoscopic, pelvic malignancies, urinary Diversion
|How to cite this article:|
Tobias-Machado M, Lopes LS, de Araujo FB, Starling ES, Pompeo AC. Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies. J Min Access Surg 2013;9:3-6
|How to cite this URL:|
Tobias-Machado M, Lopes LS, de Araujo FB, Starling ES, Pompeo AC. Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies. J Min Access Surg [serial online] 2013 [cited 2020 Mar 29];9:3-6. Available from: http://www.journalofmas.com/text.asp?2013/9/1/3/107121
| ¤ Introduction|| |
In oncologic surgical practice, urinary diversion is a commonly performed procedure after pelvic exenteration or as palliation for untreatable advanced pelvic neoplasm. ,, In some cases, urinary diversion is an option for extrinsic obstruction or fistulas, usually caused by external beam radiation therapy. 
It is important for those who perform urologic reconstructive surgeries, to have the knowledge of a wide variety of urinary diversions. 
Laparoscopic surgery in urology has progressed significantly during the last decade and increasingly complex reconstructive procedures are being performed laparoscopically. ,
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. 
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.
- 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).
- Patients with indication of cutaneous ureterostomy (7 cases).
- Unilateral diversion with limited prognosis due to neoplasia.
- Patients with poor performance status were excluded.
Summarised surgical steps
- Candidates for urinary and faecal concomitant diversion (3 cases): actinic complex fistula including rectum, vagina and bladder that have failure after attempting to repair.
- 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. 
- 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. 
- 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 11 th costal rib, complete laparoscopic dissection and exteriorisation through the anterior incision). A double J stent is left completing the surgery.
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.
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 |
Click here to view
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. 
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. 
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.  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. 
Since Sanchez de Badajos et al. 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. ,,
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. ,,
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. 
Laparoscopic cutaneous ureterostomy or ileal conduits may be an option as a more permanent urinary diversion with the advantage of not using external catheters.  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. , 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. ,
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  are awaited to define advantages and to analyse long-term results of each alternative.
| ¤ References|| |
|1.||Martinez A, Filleron T, Vitse L, Querleu D,Mery E,Balague G, et al. Laparoscopic pelvic exenteration for gynaecological malignancy: Is there any advantage? Gynecol Oncol 2011;120:374-9. |
|2.||Schneider A, Kohler C, Erdemoglu E. Current developments for pelvic exenteration in gynecologic oncology. Curr Opin Obstet Gynecol 2009;21:4-9. |
|3.||Boustead GB, Feneley MR. Pelvic exenterative surgery for palliation of malignant disease in the robotic era. Clin Oncol (R Coll Radiol) 2010;22:740-6. |
|4.||Tobias-Machado M, Starling ES, Korkes F, da Silva MN, Appolonio PR, Wroclawski ER. Video-assisted colonic conduit: A new minimally invasive urinary diversion to patients after pelvic radiotherapy. Surg Laparosc Endosc Percutan Tech 2009;19:e119-22. |
|5.||Tobias-Machado M, Bicudo MC, Appolonio PR, Korkes F, Starling ES, Pompeu AC, et al. Video-assisted double-barreled wet colostomy: A new minimally invasive simultaneous diversion to patients after pelvic radiation therapy. J Laparoendosc Adv Surg Tech A 2009;19:803-6. |
|6.||Gupta NP, Gill IS, Fergany A, Nabi G. Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: Five cases with a 2-year follow-up. BJU Int 2002;90:391-6. |
|7.||Evans B, Montie JE, Gilbert SM. Incontinent or continent urinary diversion: How to make the right choice. Curr Opin Urol 2010;20:421-5. |
|8.||Shimko MS, Tollefson MK, Umbreit EC, Farmer SA, Blute ML, Frank I. Long-term complications of conduit urinary diversion. J Urol 2011;185:562-7. |
|9.||Kozminski M, Partamian KO. Case report of laparoscopic ileal loop conduit. J Endourol 1992;6:147-50. |
|10.||Potter SR, Charambura TC, Adams JB, 2 nd , Kavoussi LR. Laparoscopic ileal conduit: Five-year follow-up. Urology 2000;56:22-5. |
|11.||Sanchez de Badajoz E, del Rosal Samaniego JM, Gomez Gamez A, Burgos Rodriguez R, Vara Thorbeck C. [Laparoscopic ileal conduit]. Arch Esp Urol 1992;45:761-4. |
|12.||Haber GP, Crouzet S, Gill IS. Laparoscopic and robotic assisted radical cystectomy for bladder cancer: A critical analysis. Eur Urol 2008;54:54-62. |
|13.||Nix J, Smith A, Kurpad R, Nielsen ME, Wallen EM, Pruthi RS. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: Perioperative and pathologic results. Eur Urol 2010;57:196-201. |
|14.||Haber GP, Campbell SC, Colombo JR Jr, Fergany AF, Aron M, Kaouk J, et al. Perioperative outcomes with laparoscopic radical cystectomy: "Pure laparoscopic" and "open-assisted laparoscopic" approaches. Urology 2007;70:910-5. |
|15.||Pruthi RS, Nix J, McRackan D, Hickerson A,Nielsen ME, Raynor M, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol 2010;57:1013-21. |
|16.||Jalbani MH, Deenari RA, Dholia KR, Oad AK, Arbani IA. Role of Percutaneous Nephrostomy (PCN) in Malignant Ureteral Obstruction. J Pak Med Assoc 2010;60:280-3. |
|17.||Puppo P, Ricciotti G, Bozzo W, Pezzica C, Geddo D, Perachino M. Videoendoscopic cutaneous ureterostomy for palliative urinary diversion in advanced pelvic cancer. Eur Urol 1995;28:328-33. |
|18.||Rehman J, Sangalli MN, Guru K, de Naeyer G, Schatteman P, Carpentier P, et al. Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: Technique and outcomes. Can J Urol 2011;18:5548-56. |
[Table 1], [Table 2]