Urinary diversion after total pelvic exenteration for rectal cancer.
BACKGROUND
Total cystectomy is indicated for the treatment of bulky primary rectal cancers as well as previously treated, locally recurrent tumors that invade the bladder, prostate, seminal vesicle, or urethra. We review a 10-year Memorial Sloan-Kettering Cancer Center experience with urinary diversion in this setting.


METHODS
Between April 1988 and June 1998, 47 patients underwent urinary diversion during a total pelvic exenteration for rectal cancer. Charts and operative records were reviewed to determine pathological findings, short-term and long-term urological complications, and survival.


RESULTS
Forty-seven patients (25 males and 22 females; median age, 62 years; age range, 27-79 years) were included. Sixteen (34%) patients underwent cystectomy for a primary rectal tumor (including 1 for rectal sarcoma and 1 for synchronous invasive bladder cancer), and 31 (66%) patients underwent surgery for a locally recurrent rectal cancer. Thirty (64%) patients underwent preoperative, 18 (38%) underwent intraoperative, and 11 (23%) underwent postoperative radiotherapy. Twenty-six (55%) patients received preoperative and 16 (34%) underwent postoperative chemotherapy. Two patients had continent ileal cecal reservoirs, 1 a colonic conduit, and the remaining 45 had ileal conduits. The tumor invaded the bladder in 24 (51%) patients, the prostate in 5 (11%) patients, and the seminal vesicle in 5 (11%) patients. Complete resection was achieved in 42 (89%) patients. There were a total of eight complications in eight (17%) patients. There were three early complications, two of which were ileoureteral anastomotic leaks, one managed by reoperation, the second by percutaneous drainage, and one moderate hydronephrosis managed expectantly. There were five late complications; three patients had ureteral stricture/stenosis, leading to nephrectomy in one patient and percutaneous stenting in two patients. Two patients developed late hydronephrosis, so far managed expectantly. There was one perioperative death. After a median follow-up of 16.83 months, 20 patients were dead of the disease, 6 were alive with disease recurrence, 2 were dead of other causes, and 19 had no evidence of disease. Three-year actuarial disease-specific survival was 34%.


CONCLUSIONS
Complete resection of bulky primary or locally recurrent rectal cancer can be performed with acceptable urological morbidity. Complete resection was obtained in 89% of patients, with 72% having urological organ invasion. Overall urological complications of 17% are acceptably low despite intensive perioperative radiation and chemotherapy. Disease-specific survival in these patients remains limited.
Russo
P
P
Department of Surgery, Urology Services, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. russop@mskcc.org
Ravindran
B
B
Katz
J
J
Paty
P
P
Guillem
J
J
Cohen
A M
AM
D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010385:Pelvic Exenteration; D011183:Postoperative Complications / Q000453:epidemiology; D012004:Rectal Neoplasms / Q000601:surgery*; D014547:Urinary Diversion / Q000009:adverse effects; D016476:Urinary Reservoirs, Continent / Q000009:adverse effects