Urinary diversion after total pelvic exenteration for rectal cancer

Background: Total cystectomy is indicated for the treatment of bulky primar y rectal cancers as well as previously treated, locally recurrent tumors th at invade the bladder, prostate, seminal vesicle, or urethra. We review a 1 0-year Memorial Sloan-Kettering Cancer Center experience with urinary diver sion in this setting. Methods: Between April 1988 and June 1998, 47 patients underwent urinary di version during a total pelvic exenteration for rectal cancer. Charts and op erative records were reviewed to determine pathological findings, short-ter m and long-term urological complications, and survival. Results: Forty-seven patients (25 males and 22 females; median age, 62 year s; 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 underw ent preoperative, 18 (38%) underwent intraoperative, and 11 (23%) underwent postoperative radiotherapy. Twenty-six (55%) patients received preoperativ e and 16 (34%) underwent postoperative chemotherapy. Two patients had conti nent ileal cecal reservoirs, 1 a colonic conduit, and the remaining 45 had ileal conduits. The tumor invaded the bladder in 24 (51%) patients, the pro state in 5 (11%) patients, and the seminal vesicle in 5 (11%) patients. Com plete resection was achieved in 42 (89%) patients. There were a total of ei ght complications in eight (17%) patients. There were three early complicat ions, two of which were ileoureteral anastomotic leaks, one managed by reop eration, the second by percutaneous drainage, and one moderate hydronephros is 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 hydronep hrosis, so far managed expectantly. There was one perioperative death. Afte r 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 recta l cancer can be performed with acceptable urological morbidity. Complete re section was obtained in 89% of patients, with 72% having urological organ i nvasion. Overall urological complications of 17% are acceptably low despite intensive perioperative radiation and chemotherapy. Disease-specific survi val in these patients remains Limited.