title: Clinical algorithms for the diagnosis and management of urological leaks following pelvic exenteration.
abstract: BACKGROUND
  Urine leak following pelvic exenteration for locally advanced pelvic malignancy is a major complication leading to increased mortality, morbidity and length of stay. We reviewed our experience and developed a diagnostic and management algorithm for urine leaks in this patient population.
  
  
  METHODS
  Consecutive patients who underwent en bloc cystectomy and conduit formation as part of pelvic exenteration at a single quaternary referral centre from 1995 to 2012 were reviewed. Patients with urine leak were identified. Medical records were reviewed to extract data on diagnosis and management and a suggested clinical algorithm was developed.
  
  
  RESULTS
  Of 325 exenterations, there were 102 conduits, of which 15 patients (15%) developed a conduit related urine leak. Most (14/15) patients were symptomatic. Diagnosis was made by drain creatinine studies (12/15) and/or imaging (15/15). Management comprised of conservative management, radiologic urinary diversion, early surgical revision and late surgical revision in 3, 11, 2 and 1 patients respectively. Important lessons from our 17 year experience include a high index of suspicion in a patient who is persistently septic despite appropriate treatment, the importance of regular drain creatinine studies, CT (computer tomography) with delayed images (CT intravenous pyelogram) when performing a CT for investigation of sepsis and early aggressive management with radiologic urinary diversion to facilitate early healing.
  
  
  CONCLUSIONS
  Urine leak after pelvic exenteration is a complex problem. Conservative management usually fails and early diagnosis and intervention is the key. It is hoped that our algorithms will facilitate diagnosis and subsequent management of this group of patients.
authors.affiliation: Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & Sydney School of Public Health, University of Sydney, Sydney, Australia.
authors.forename: K G M
authors.initials: KG
authors.lastname: Brown
authors.affiliation: Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: C E
authors.initials: CE
authors.lastname: Koh
authors.affiliation: Department of Urology, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: A
authors.initials: A
authors.lastname: Vasilaras
authors.affiliation: Department of Urology, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: D
authors.initials: D
authors.lastname: Eisinger
authors.affiliation: Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; University of Sydney, New South Wales, Australia. Electronic address: professor.solomon@sydney.edu.au.
authors.forename: M J
authors.initials: MJ
authors.lastname: Solomon
mesh_terms: D000368:Aged; D000465:Algorithms; D015653:Cystectomy; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010385:Pelvic Exenteration; D011183:Postoperative Complications / Q000175:diagnosis* / Q000628:therapy*; D016896:Treatment Outcome; D014555:Urination Disorders / Q000175:diagnosis* / Q000628:therapy*
keywords: Algorithm; Ileal conduit; Pelvic exenteration; Urinary diversion; Urinary leakage