Our Summary

Pelvic exenteration is a major surgery that involves removing several organs in the pelvic area, often used to treat advanced cancers. One of the challenges is reconstructing the urinary system after surgery. This review paper looks at the different techniques for urinary reconstruction, their pros and cons, and their impact on patients’ lives.

There are a few common methods for urinary reconstruction. The Bricker ileal conduit (a way to reroute urine using a piece of the small intestine) is used often, followed by creating a self-catheterizable pouch and replacing the bladder entirely. Each method comes with potential complications, such as urinary tract infections, blockages in the ureter (tube that carries urine from kidneys to bladder), formation of stones, urine leakage, and rarely, vitamin B12 deficiency and metabolic acidosis (a condition that happens when the body produces too much acid).

There are also complications specific to each technique. For example, half of the patients who get a new bladder (ileal orthotopic neobladder) experience urinary incontinence, 24% of patients with a Bricker ileal conduit face issues related to the stoma (a hole made in the body to get rid of waste), and 18% of patients with a self-catheterizable pouch have difficulty with self-catheterization.

The self-catheterizable pouch and bladder replacement techniques require more training from the surgical team and adjustments from the patient compared to the ileal conduit. The impact of these techniques on the patients’ quality of life is still up for debate, although it seems younger patients might benefit more from techniques that allow them to control their urine flow (continent diversions).

The authors recommend that pelvic exenteration surgery should be centralized in referral centers to improve both cancer-related and functional outcomes of this complex surgery.

FAQs

  1. What is urinary diversion surgery and when is it typically used?
  2. What are the most common complications that can occur after urinary diversion surgery?
  3. How does the choice of urinary reconstruction technique affect a patient’s quality of life after surgery?

Doctor’s Tip

One helpful tip a doctor might tell a patient about urinary diversion surgery is to closely follow the post-operative care instructions provided by the medical team. This may include proper stoma care, monitoring for signs of infection or complications, and adhering to any dietary or lifestyle recommendations to optimize recovery and prevent complications. It is important for patients to communicate any concerns or changes in symptoms to their healthcare provider promptly.

Suitable For

Patients who may be recommended for urinary diversion surgery typically include those undergoing pelvic exenteration for gynecologic or urologic malignancies, such as bladder or cervical cancer. These patients may require urinary diversion due to the removal of the bladder or other pelvic organs during surgery. The choice of urinary diversion technique will depend on various factors, including the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. Continent techniques, such as the self-catheterizable pouch or orthotopic bladder replacement, may be considered for younger patients who may benefit from improved quality of life compared to non-continent diversions like the Bricker ileal conduit. Complications following urinary diversion surgery can include lower tract urinary infections, ureteral stricture, urolithiasis, urinary fistula, and other technique-related issues. Centralization of pelvic exenteration in specialized centers may help optimize oncologic and functional outcomes for patients undergoing complex ablative reconstructive surgery.

Timeline

Before urinary diversion surgery, a patient will typically undergo a series of diagnostic tests and consultations with their healthcare team to determine the need for surgery and the most appropriate technique for their individual case. This may include imaging studies, blood tests, and discussions about the potential risks and benefits of the procedure.

After urinary diversion surgery, the patient will likely experience a period of recovery in the hospital, during which they will be closely monitored for any complications. They will receive instructions on how to care for their surgical incisions and stoma if applicable, as well as guidance on managing any potential side effects such as urinary leakage or infections.

Over time, the patient will gradually adjust to life with a urinary diversion, learning how to properly empty their pouch or catheterize their stoma. They will also have regular follow-up appointments with their healthcare team to monitor their overall health and address any concerns that may arise. It is important for patients to maintain good communication with their healthcare providers and adhere to any recommended lifestyle changes to optimize their long-term outcomes and quality of life.

What to Ask Your Doctor

  1. What are the different types of urinary diversion surgeries available for me?
  2. What are the advantages and disadvantages of each type of urinary diversion surgery?
  3. How will my choice of urinary diversion surgery impact my quality of life in the long term?
  4. What are the potential complications associated with the urinary diversion surgery I am considering?
  5. How long is the recovery process expected to be after the surgery?
  6. Will I need additional procedures or ongoing care after the urinary diversion surgery?
  7. How experienced are you in performing the specific type of urinary diversion surgery I am considering?
  8. Are there any lifestyle changes or restrictions I will need to follow after the surgery?
  9. Can you provide me with information or resources for support groups or counseling related to urinary diversion surgery?
  10. What is the success rate of the urinary diversion surgery in terms of controlling the disease and maintaining urinary function?

Reference

Authors: Martínez-Gómez C, Angeles MA, Martinez A, Malavaud B, Ferron G. Journal: Int J Gynecol Cancer. 2021 Jan;31(1):1-10. doi: 10.1136/ijgc-2020-002015. Epub 2020 Nov 23. PMID: 33229410