Long-term results of ileocecal continent urinary diversion in patients treated with or without previous pelvic irradiation

Abstract

Purpose: Patients who receive pelvic irradiation may require urinary diversion to manage complications resulting from progressive malignancy or radiotherapy. The choice of urinary diversion is an important issue and remains controversial. We characterized the long-term outcome of urinary diversion with a continent ileocecal reservoir in patients who received pelvic irradiation versus those who underwent urinary diversion without previous irradiation. Materials and Methods: Continent urinary diversion with an ileocecal reservoir (Mainz pouch 1) was performed in 36 irradiated patients in a 9-year period. Morbidity, mortality, the reoperative rate and parameters associated with the surgical procedure were determined at a median followup of 57 months. Results were compared with those in 385 nonirradiated patients who received the same type of continent diversion after cystectomy for bladder cancer. Results: Irradiated patients had a significantly higher rate of serious complications after ileocecal urinary diversion than nonirradiated controls. Continence mechanism failure occurred in 25% of patients in the irradiated group and 5.7% in nonirradiated patients, stomal complications were noted in 38.8% and 10.6%, and ureteral complications developed in 22.2% and 6.5%, respectively. Conclusions: In patients who have received pelvic radiotherapy, ileocecal Mainz pouch 1 continent urinary diversion is associated with a high rate of serious complications and should be avoided. Patients with a history of pelvic irradiation may require urinary diversion to manage complications resulting from progressive malignancy or radiotherapy. Incontinent urinary diversion, such as conduits of ileum, ascending, transverse, descending and sigmoid colon, have been described and the most appropriate technique remains controversial. Most investigators prefer transverse colon conduits to avoid the use of irradiated bowel and extensively damaged ureters.1, 2 However, noncontinent conduit diversions are associated with stomal problems and the need to wear constantly an external appliance. These aspects may be psychologically unfavorable in terms of a positive body image, especially in young women with gynecologic tumors. 3 Thus, continent urinary pouches have been popularized in gynecologic oncology. When continent urinary reconstruction must be performed in patients who underwent extensive radiotherapy, most surgeons use operative techniques that they are familiar with and otherwise use in nonirradiated patients. An ileocecal pouch, termed the Mainz pouch 1, has been the method of choice for continent urinary diversion in patients with bladder cancer at our institution since 1983. It has proved to be a reliable and technically standard technique that can be applied to various intestinal urinary replacement strategies.4 We characterized the long-term outcome of this continent ileocecal pouch in patients who received pelvic irradiation compared to nonirradiated controls who underwent the same type of urinary diversion.