Urinary diversion in gynecologic malignancies

A variety of methods for urinary diversion are employed in patients with gynecologic malignancies depending on whether there is an obstruction or fistula formation due to either tumor growth or radiotherapeutic injury. Percutaneous nephrostomy (PCN) has a low complication rate and is a good method for palliative urinary diversion or may precede some form of permanent diversion to restore the kidney function first. Indication for palliative diversion in tumor obstruction depends on many individual factors. A relative contraindication is tumor progression during therapy. 6-month survival was about 70% in patients with previously untreated tumors or recurrences. This rate is far better than reported in earlier studies, so that a palliative diversion has to be considered for these patients. Also a high rate of recanalization after therapy could be observed in the untreated group, allowing the PCN to be removed. However, this has not been shown to be a prognostic factor. In the individual patient some other aspects, such as quality of life and social status, have to be taken into account before a final decision can be made. Ureteral obstruction after radiotherapy is a rare finding and often mistaken for a more likely recurrence. Different methods to restore the urinary tract, such as reimplantation of the ureter, should be used as a first choice. When the stenosis is due to radiocystitis, enterocytoplasty will often be indicated. Diversion has then to be omitted. The poor quality of life because of permanent incontinence due to fistula formation makes diversion mandatory even if life expectancy is very short. Surgical closure of a large radiogenic fistula is rarely successful. In this situation, ileal conduit has proven its efficacy for long-term urinary diversion.     

Laparoscopy in gynecologic oncology

Using technological progress, laparoscopic lymphadenectomy is becoming a standard for staging of pelvic cancer. In the same way more extensive procedures such as para-aortic lymph nodes dissection and radical hysterectomy have been demonstrated to be feasible by laparoscopy. In the future, because of its well known advantages, laparoscopic surgery may appear as a way to decrease the consequences of oncologic treatments in patients with low risk tumors and to propose more aggressive treatments of patients with bad prognosis tumors.     

Urinary diversion

Although the ileal conduit must be regarded as the "gold standard" technique of urinary diversion, many long-term complications result and patients must wear urinary collection devices with their associated psychological and social limitations. The recent interest in continent diversions was primarily an attempt to improve the quality of life rather than improve survival or reduce renal and metabolic complications. Although continent stomas can be achieved with low pressure reservoirs fashioned from detubularised or augmented bowel, many operations may be required to perfect the continent stoma. Long-term results using continent reservoirs are awaited. It seems that a bladder substitute using reconfigurated bowel is preferable to a continent reservoir but continence remains a problem and all of the techniques lack long-term follow-up. The use of bladder substitutes in females is limited by the need to use a prosthetic sphincter to achieve continence.     

Urinary diversion

The various operative and nonoperative methods of urinary diversion, their indications, contraindications and complications have been briefly presented. Technics found in the author's experience to be consistently satisfactory in practice have been described. Certain innovations not evaluated by the author but of seeming merit are offered for trial.     

Neoadjuvant chemotherapy in gynecologic oncology

The use of neoadjuvant chemotherapy in conjunction with surgery in squamous carcinoma of the uterine cervix can reduce the surgical treatment extent (to be confirmed) in small-volume tumors (diameter < 4 cm) and increase overall survival and disease-free interval in localized median-volume tumors (< or = 8 cm) and improve the quality of life of patients with large, locally advanced tumors, due to longer disease-free period. These issues have yet to be completely resolved (three randomized trials have confirmed these data), but in the meantime, neoadjuvant chemotherapy could be used as an alternative treatment in locally advanced tumors or large localized tumors. It is necessary to use high-dose chemotherapy to achieve a good tumor response and satisfactory "down-staging." Surgical treatment after neoadjuvant chemotherapy seems to be the most appealing option, especially in patients with poor response to chemotherapy. The proper extension of surgery after neoadjuvant chemotherapy is an unexplored matter for the gynecologic oncologist, and no trial has been developed to address this issue, but it seemingly must be performed according to the initial size and extension of the tumor (prior to neoadjuvant chemotherapy) despite the tumor response to it.     

Urinary diversion in infants

The article generalizes the experience in the treatment of over 500 children, aged from hours to 5 months, with various developmental anomalies of the urinary system. Different variants for draining off the urine were applied in 142 patients. Urethral, vesical, and supravesical methods are characterized. The indications for their use in the newborns and infants are formulated. Preference is given to the supravesical methods, among which T-ureterocutaneostomy and suspended ureteropyelostomy are optimal. The operative techniques are described. Complications occurred in 10 children: urinary dermatitis (3), cicatrization of the stoma (2), separation of the sutures of the main wound (2), stenosis of the stoma (1). The author concludes that draining off urine in the newborn with obstructive uropathy is advisable before radical correction of the anomaly.     

Laparoscopic surgery in gynecologic oncology

Laparoscopy found its first application in the field of gynecology. Today, laparoscopy benefits the general gynecologist because of its minimally invasive nature. Benign procedures, such as oophorectomies and hysterectomies, have become practically outpatient procedures. The learning curve for laparoscopy in gynecologic cancer operations is obviously steeper, more time consuming, and training-dependent. With increased operative time, cost, and the questions of safety in malignant conditions, laparoscopy has quite a burden of proof before it becomes widely accepted. This article reviews the current applications of laparoscopy in gynecologic oncology with available data and offers future directions best suited for laparoscopy in this subspecialty.     

Robot-assisted laparoscopy in gynecologic oncology

Objectives  The aim of this prospective study was to evaluate the feasibility and the outcome of gynaecological cancer surgery with the Da Vinci S surgical system (Intuitive Surgical). Methods  From February 2007 to September 2007, 28 patients underwent 32 gynaecological procedures in a single centre. Surgical procedures consisted of total hysterectomy, bilateral oophorectomy, and pelvic and/or lombo-aortic lymphadenectomy. In all cases, surgery was performed using both laparoscopic and robot-assisted laparoscopic techniques. In this heterogeneous series, a subgroup of 12 patients treated for advanced cervical cancer was compared with a retrospective series of 20 patients who underwent the same surgical procedure by laparotomy. Results  Mean age of the entire population was 52.5 years (range 25–72 years) and mean body mass index (BMI) was 25 kg/m² (range 18–40 kg/m²). Indications for surgery were cervical cancer in 21 cases, endometrial cancer in 7 cases, ovarian cancer in 1 case and cervical dysplasia in 3 cases. Median operating time was 180 min (mean 175.25 min, range 80–360 min) and median estimated blood loss was 110 cc (range 0–400 cc); no transfusions were necessary. No perioperative complications were observed and median time of hospitalisation was 3 days (mean 3.9 days, range 2–8 days). In the subgroup of 12 advanced cervical cancer a significant difference was observed in terms of hospital stay compared with laparotomy; no difference was observed concerning operative time. Fewer complications were observed with laparotomy (33% versus 25%) but more serious complications than with robot-assisted laparoscopy. Conclusion  As suggested in the literature, the use of robot-assisted laparoscopy leads to less intraoperative blood loss, less post operative pain and shorter hospital stays compared with those treated by more traditional surgical approaches. Despite the need for more extensive studies, robot-assisted surgery seems to represent a similar technological evolution as the laparoscopic approach 50 years ago.     

Urinary diversion in females

Permanent urinary diversions are performed in the majority of patients after cystectomy for bladder carcinoma. An ileal conduit is the most common incontinent stoma created but long-term follow-up shows that up to 80% of patients may develop deterioration in the upper renal tract, stomal problems, pyelonephritis, urolithiasis or electrolyte abnormalities. Continent stomas require intermittent self-catheterization to empty their reservoirs, which are created from detubularized ileal or colonic bowel segments. Long-term follow-up is awaited with continent urinary diversions but the absence of a continually worn collection device is of major benefit to patients. The risk of developing colonic carcinoma and metabolic disturbances has detracted from the use of ureterosigmoidostomy as a common form of diversion, but recently the augmented valved rectum and the sigma rectal pouch have been described to minimize the metabolic changes previously described.     

Urinary diversion 1989

Recent years have seen increasing of interest in enterocystoplasty owing to a considerable expansion of its applications for bladder reconstruction. The significantly improved outcome of enterocystoplasty in the past few years is the culmination of a long history of triumphs and failures, improvements in patient care and selection, proper bowel preparation, and use of antibiotics. There are various factors that can influence the outcome, such as choice, length, shape and size of bowel segment, protection of the upper tracts and urinary continence. Of the numerous bladder substitutes the ileal neobladder seems to be clearly the best, combining a large reservoir capacity, a low pressure system, guaranteed continence both day and night and simple and effective construction. Total bladder substitution in the female remains an unsolved problem. The functional rectal bladder (augmented and valved rectum) is a first step. The success that is possible with the Kock pouch, as with all other pouches, is tempered by the need for reoperations, mainly for repair to the efferent nipple; reoperation is a major surgical challenge in all bladder substitute procedures.     

Urinary diversion.

The patient facing cystectomy now has the opportunity to select various forms of urinary diversion. Although not all of the newer techniques have stood the test of time, preliminary results indicate that these continent diversions should be considered safe and effective. These procedures definitely alter the patient's lifestyle, resulting in a significantly better adjustment to the need for bladder removal. With experience, these procedures can be performed with morbidity rates very similar to those encountered with ileal conduit diversion. As with any procedures, however, appropriate patient selection and surgical training are imperative.     

Computer-enhanced robotic surgery in gynecologic oncology

Background This study aimed to report the computer-enhanced robotic surgery experience of the authors’ gynecologic oncology division. Methods From January 2001 to August 2006, 41 patients underwent laparoscopic surgery by our gynecologic oncology service using a computer-enhanced surgical robot. This report describes a retrospective review of these patients. Results The patients ranged in age from 27 to 77 years (mean, 44.2 years), in weight from 44 to 131 kg (mean, 72.1 kg), in operative time from 1 h and 50 min to 9 h (mean, 5 h and 2 min), and in estimated blood loss from 50 to 1,500 ml (mean, 253 ml). Of the 20 patients with gynecologic malignancies, 14 had cervical cancer. A total of 21 patients had benign indications for surgery. Complications included shoulder palsy, robot failure, colotomy, bradycardia, and intraabdominal bleeding requiring minilaparotomy and ligation of a bleeding pedicle. Conclusion This case series is one of the first to report the use of a computer-enhanced surgical robot in gynecologic oncology. This approach proved to be feasible and well tolerated in this series of patients and deserves further study for clarification of its indications, benefits, and safety.