MISCELLANEOUS Urinary and Fecal Diversion Following Pelvic Exenteration: Comparison of Double-Barrelled and Plain Wet Colostomy Sertac Yazici1*, Senol Tonyali1, Ali Cansu Bozaci1, Hakan Bahadir Haberal1, Erhan Hamaloglu2, Haluk Ozen1 Purpose: To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simulta- neous fecal and urinary diversion with plain wet colostomy (PWC) or double-barrelled wet colostomy (DBWC). Materials and Methods: The medical records of all patients who had undergone pelvic exenteration and urinary diversion between 2006 and 2017 at our hospital were reviewed retrospectively. Results: In total, 15 patients with a mean age of 56 ± 13 years were included in the study. Simultaneous urinary and fecal diversions were carried out as PWC (n = 8), or DBWC (n = 7). No significant differences were found between PWC and DBWC groups in terms of operation time (373.7 ± 66.5 versus 394.2 ± 133.2 min, P = .955), estimated blood loss (862.8 ± 462.4 versus 726.2 ± 489.4 mL, P = .613), length of hospital stay (13.2 ± 9.1 versus 14.1 ± 6.9 days), early complications (25% versus 28.6%, P = 1.0) and late term complications (37.5% versus 42.9%, P = 1.0). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically significant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618). Conclusion: PWC and DBWC are valid options for creating simultaneous urinary and fecal diversion after exten- sive pelvic surgery in patients with short life expectancy. DBWC might be superior to PWC in terms of decreased risk of recurrent pyelonephritis. Keywords: pelvic exenteration; wet colostomy; double-barreled; urinary diversion INTRODUCTION Due to recent advancements in anesthesiology, sur-gical techniques and surgical tools, surgeons are able to perform more complicated, risky and long-last- ing operations. “Pelvic exenteration” is one of these complex procedures that is commonly used in the treat- ment of locally advanced pelvic tumors, organ injury secondary to radiotherapy, and benign but locally de- structive pathologies. Pelvic exenteration was first described by Alexander Brunschwig in 1948(1) in the treatment of pelvic tumors. Besides rectosigmoid colon, pelvic peritoneum, drain- ing lymph nodes, reproductive organs, urinary bladder and distal ureters are also excised necessitating recon- structions for urinary and intestinal diversions in these procedures. To date many researchers developed different tech- niques to store urine in pressures safe for upper urinary tract without causing an electrolyte imbalance(1-4). How- ever, in addition to aforementioned principles, opera- tion time, postoperative course/complications and pa- tient quality of life (QoL) must be considered. In this study, we aimed to report the outcomes of pa- tients who had undergone simultaneous fecal and uri- nary diversion after pelvic exenteration, comparing plain wet colostomy (PWC) with double-barrelled wet colostomy (DBWC) technique. To our knowledge, this 1Departments of Urology Hacettepe University School of Medicine, Ankara, Turkey . 2Departments of General Surgery Hacettepe University School of Medicine, Ankara, Turkey. *Correspondence: Hacettepe University School of Medicine, Department of Urology, Sihhiye, Ankara 06100, Turkey. Tel: +90-312-305 1885. Fax: +90-312-311 2262. E-mail: msertacyazici@yahoo.com. Received March 2018 & Accepted April 2018 is the first retrospective study that compares PWC with DBWC. PATIENTS AND METHODS Study Population The medical records of all patients who had undergone pelvic exenteration and urinary diversion for primary or recurrent pelvic malignancies at the Hacettepe Uni- versity Hospital between 2006 and 2017 were reviewed retrospectively. The surgeries were performed under the collaboration of General Surgery and Urology De- partments. Surgical Technique All patients had undergone abdominoperineal resection (APR), which included resection of rectum, anus, uri- nary bladder, and pelvic lymph nodes accompanied by total prostatectomy in male patients and total abdom- inal hysterectomy, bilateral salpingo-oopherectomy, and total vaginectomy in female patients. In 8 patients, fecal and urinary diversions were carried out with plain wet colostomy (PWC), while 7 patients had undergone double-barrelled wet colostomy (DBWC). The choice of urinary diversion was based on perioperative deci- sion of general surgeon and urologist, depending on the length of the mesocolon. If the mesocolon was long enough DBWC was preferred. DBWC was constructed as described previously by Miscellaneous 290 Vol 15 No 05 September-October 2018 291 Carter et al(5). Rectosigmoid or descending colon was used for loop colostomy depending on the level of colectomy. Splenic flexure was mobilized to ensure a tension free position for the loop colostomy and the loop was constructed before the anastomosis of ureters to prevent twisting. The ureters were mobilized as much length as possible while taking care to preserve the pe- riureteral vascular supply. The opposite sided ureter was then transposed to the loop colostomy side through a tunnel at mesocolon. Each ureter was implanted individually into the distal, blind-ended limb of the loop colostomy. For prevention of reflux, ureters were anastomosed at the antimesen- teric region with 3-4 cm long submucosal tunnels(5, 6). A mammary implant was placed in the pelvic cavity in 9 cases to prevent prolapsus of intestines. To preserve the anastomosis, ureteral stents were placed bilaterally, fixed to colonic mucosa with absorbable sutures and removed after 3 weeks. The loop was exteriorized and fixed to the abdominal wall as double-barreled follow- ing the implantation of the ureters. The distal blind-end- ed part of the loop acts as a reservoir for urine to mini- mize contact of urine and feces in patients with DBWC (5,7-9). In case of plain wet colostomy, ureters were anas- tomosed to colostomy forming an ureterocolostomy. Outcome Assessment The examined parameters consisted of patient demo- graphics, primary pathology, type of surgery, operation characteristics, and post-operative follow-up including blood chemistry and imaging results. Complications such as pyelonephritis, urinary leak and fistulas, hy- dronephrosis and metabolic disturbances were also compared between the two groups. Renal functions of the patients were followed by plasma creatinine (Cr), blood urea nitrogen (BUN) and electrolytes. If the pa- tient’s clinical findings indicated urinary tract infection, urine analysis and culture were performed. The primary disease, surgical outcome and urinary system were ex- amined by abdominopelvic imaging [ultrasonography (USG), computed tomography (CT), or magnetic reso- nance imaging (MRI)] at necessary periods. All procedures performed in studies involving human participants were in accordance with the 1964 Helsin- ki declaration and its later amendments or comparable ethical standards. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, version 21.0, IBM, Chicago, IL, USA). Mean ± SD and range were used to express quantitative values, and number and percentage were given for qualitative values. Chi-square test, Fish- er’s exact test, Mann-Whitney U test and Student’s t test were applied to compare the two groups. Kaplan-Meier analysis was used for survival analysis. P values <0.05 were considered as statistically significant. Table 1. Patients Demographics, Characteristics, Intraoperative/Postoperative Features and Follow-up No Sex Age Primary Prior Prior Operation Type of Early Late term Electrolyte Overall Exitus- Pathology Surgery Radiotherapy Diversion Complication complication imbalance survival Alive (days) 1. F 48 Cervix Ca TAH+ BSO Yes APR+ PWC Intraabdominal No No 7 Ex cystectomy abscess 2. F 42 Cervix Ca None Yes APR+ PWC Ureterocolonic No No 87 Ex cystectomy+ Leakage TAH + BSO 3. F 70 Colon Ca None No APR+ PWC No No No 859 Ex cystectomy+ TAH + BSO 4. M 51 Rectum Ca Anterior Yes APR + CP+ PWC No Pyelonephritis No 418 Ex Resection sacrectomy 5. M 59 Rectum Ca Anterior Yes APR + CP PWC No Pyelonephritis No 503 Ex Resection 6. M 55 Prostate Ca None Yes APR + CP PWC No No No 43 Ex 7. M 65 Rectum Ca Anterior Yes APR + CP PWC No No No 89 Ex Resection 8. M 45 Rectum Ca Anterior Yes APR + CP PWC* No Pyelonephritis No 1313 Ex Resection 9. M 68 Rectum Ca Anterior Yes APR + CP DBWC No Pyelonephritis No 628 Ex Resection 10. M 49 Colon Ca Right hemi No APR + CP DBWC No No No 454 Ex colectomy 11. M 79 Rectum Ca+ None Yes APR + CP DBWC Right No No 260 Ex Prostate Ca Pneumothorax 12. M 55 Colon+ None No APR + CP DBWC No Hydronephrosis No 496 Ex rectum Ca 13. M 57 Colon Ca Colostomy No APR + CP + DBWC No Sacral abscess No 329 Ex sacrectomy 14. M 70 Prostate Ca None Yes APR + CP DBWC Ileus No No 222 Ex 15. F 28 Rectum Ca Anterior Yes APR + DBWC No No No 78 Ex Resection cystectomy + TAH + BSO Abbreviations: APR, Abdominoperineal resection; TAH, Total abdominal hysterectomy; BSO, Bilateral salphingo-oopherectomy; IL, Ileal loop; CP, Cystoprostatectomy; PWC, Plain Wet Colostomy; DBWC, Double-barrelled wet colostomy; F, Female; M, Male; Ca, Cancer; Ex, Exitus *Converted to colostomy plus ileal loop Urinary And Fecal Diversion Following Pelvic Exenteration-Yazici et al. RESULTS In total, 15 patients whom all data was available were included in the study. Characteristics of patients are summarized in Table 1. Mean age of the patients was 56 ± 13 years, ranging from 28 to 79. In all patients, urinary system was affected by the primary pathology. Eleven patients had previously received pelvic radio- therapy and 9 patients had undergone previous surgi- cal procedures. Mean operation time was 383 minutes (range 240 - 570). Mean hospitalization time after sur- gery was 13.6 ± 7.8 days. Preoperative and postoperative mean Cr level were 1,02 ± 0.32 mg/dL and 1,18 ± 0.52 mg/dL, respective- ly. Only one patient’s Cr level was above the normal, whose level was also abnormal preoperatively. No metabolic disturbances were encountered related with colonic/urinary conduit. Mean postoperative serum Na and K+ levels were 136.1 ± 4.7 mg/dL and 4.1 ± 0.43 mg/dL, respectively. At early postoperative period (within one month after the surgery), one ureterocolonic anastomosis leakage and one intraabdominal abscess in the PWC group; one unilateral pneumothorax and one ileus in the DBWC group were observed. Nephrostomy catheter was insert- ed to the kidney of the patient due to anastomosis leak- age and the catheter was removed after demonstration of no leakage at 2nd month on anterograde pyelography with minimal hydronephrosis in USG. Late-term (30 days or more after the surgery) compli- cations were observed in 6 patients including 3 pyelo- nephritis and 1 sacral abscess, which were managed by antibiotic treatment. In one patient with recurrent py- elonephritis, PWC was converted to ileal conduit for urinary diversion. In one patient with DBWC, unilat- eral grade 2-3 hydronephrosis caused by ureterocolonic stenosis was managed with percutaneous nephrostomy initially, which was replaced by indwelling stent sub- sequently. Pyelonephritis was observed only in one patient in the DBWC that was managed conservatively with antibiotics. One of the patients in the PWC group died 7 days after the surgery in the early postoperative period. She had multiple metastases due to cervix can- cer and postoperatively experienced pulmonary throm- boembolism which was treated with low molecular weight heparin. Comparison of patient outcomes of DBWC and PWC are summarized in Table 2. No significant differenc- es were found between the two groups in terms of age, operation time, estimated blood loss, length of hospital stay, early- and late-term complications (All p-values > .05). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically sig- nificant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618). DISCUSSION Pelvic exenteration is the standard choice of treatment for advanced or recurrent pelvic malignancies, which involves removal of all pelvic viscera. Besides being an extensive surgery, it also requires reconstruction for urinary and fecal diversions(10). In the first series of pel- vic exenteration, urinary diversion was carried out by anastomosing each ureter to ipsilateral colon segment and opening a terminal colostomy after the reconstruc- tion stage, which was called as “proximal wet colos- tomy” (1,2). However, high volume watery diarrhea, se- vere electrolyte imbalance and pyelonephritis resulting in poor life quality led the surgeons to investigate new diversion types. Besides, mixing up of urine and fec- es on intestinal surfaces was accused for the intestinal dysplasia and neoplasia diagnosed in long term follow up(2, 3,11). Due to the lack of an optimum type of diver- sion, Bricker et al. in 1949(4) described ileal segment to discard urine via a different way from feces, decreasing diarrhea and dysplasia. However, as majority of these patients had received radiotherapy, leakage from anas- tomosis was a major concern. Also, the presence of two stomas not only resulted in prolonged operation time but also negatively influenced patient’s quality of life. In 1989, Carter et al. first defined ‘Double-barrelled wet colostomy’ (DBWC) which is the lateral loop colosto- my that contains both urinary and intestinal diversions in the same segment and drains from a single stoma(5). It is a simple, safe and effective procedure to reconstruct urinary and fecal drainage after pelvic exenterations where orthotopic urinary or intestinal reconstructions are not possible(7-9,12-15). Besides, using the distal colon for loop colostomy enables formation of feces proxi- mally and prevents loss of excess fluid. In our patient cohort, we preferred PWC or DBWC for urinary and fecal diversion following pelvic ex- enteration depending on the length of mesocolon. To our knowledge, this is the first retrospective study that compares PWC with DBWC. Previously published ar- ticles usually focused on comparison of DBWC with ileal conduit plus colostomy. DBWC enables single sto- ma and shorter operation time compared to two stomas technique and also preserves intestinal integrity that prevents intestine related complications i.e. pouch leak and enteric fistulas(5,7-10,12-15). In some studies, DBWC has also been found to be superior to two stomas tech- nique in terms of hospital stay, pyelonephritis, sepsis, electrolyte imbalance, urinary leak and need of percu- Groups PWC (n=8) DBWC (n=7) P value Age (year) 54.3 ± 9.7 58 ± 16.7 0.463 Operation time (minutes) 373.7 ± 66.5 394.2 ± 133.2 0.955 Estimated blood loss (ml) 862.8 ± 462.4 726.2 ± 489.4 0.613 Length of stay (days) 13.2 ± 9.1 14.1 ± 6.9 0.613 Pyelonephritis 37.5% 14.3% 0.569 Early-term complication (%) 25% 28.6% 1.000 Late-term complication (%) 37.5% 42.9% 1.000 Overall Survival (days) 414 ± 165 352 ± 70 0.618 Table 2. Comparison of Patients’ Characteristics and Outcomes of DBWC and PWC Procedures. Urinary And Fecal Diversion Following Pelvic Exenteration-Yazici et al. Miscellaneous 292 Vol 15 No 05 September-October 2018 153 taneous nephrostomy. However, none of these studies showed the superiority of ileal conduit with colostomy in any evaluated parameters(10). Complications related to wet colostomy following the first series of pelvic exenteration were usually associ- ated with ascending urinary tract infections from reflux of intestinal contents, severe electrolyte imbalance, ob- struction at the uretero-intestinal anastomosis resulting in progressive hydronephrosis and impaired renal func- tion and development of fistulas from the anastomosis site(16). In a study focusing on urological complications after cystectomy, the urological complication rates was sig- nificantly higher after cystectomy as a part of pelvic ex- enteration (59%) compared to cystectomy alone (33%). Urinary leak was observed in 6% and 14% of the pa- tients who underwent pelvic exenteration for primary malignancies and recurrent malignancies, respectively. Major blood loss and previous pelvic radiotherapy was found to be an independent predictor of conduit-associ- ated complications(17). In our series most of the patients (9/14) underwent pelvic exenteration for recurrence. In another study comparing ileal versus colonic conduit after pelvic exenteration, colonic conduit was found to be associated with fewer complications (including sepsis, leak and pelvic collection) compared to ileal conduit (19% versus 40%, p < 0.01)(18). In our patient cohort, two complications (13.3%) (one leak and one intraabdominal abcess) were observed in concordance with aforementioned study. Despite these severe complications reported previous- ly, we have not encountered any severe electrolyte dis- turbance in our PWC serial. In the present study, three patients (37.5%) with PWC experienced recurrent py- elonephritis. Two patients were treated with antibiotic therapy and in the other patient urinary diversion was converted to ileal loop. Among patients with DBWC, only one patient (14.3%) experienced pyelonephritis. Although, it was not statistically significant (P = .569), we found DBWC superior to PWC in terms of upper urinary tract infection. Furthermore, none of the pa- tients required re-operation during the early postoper- ative period. As described in previous studies(1,19), preserving periu- reteral vascular supply while mobilizing and preparing the ureter is of critical importance to avoid necrosis leading strictures and anastomotic leaks. At our insti- tution, we are firmly committed to this principle and in our patient cohort, only one patient (6.6%) developed ureterocolonic leakage. In our series, not only patients with DBWC but also patients with PWC did not develop any secondary ne- oplasia due to mixing of urine and feces. We think this might be related to short survival period of our patients. The filling of pelvic cavity with intestinal loops fol- lowing pelvic exenteration can result in increased risk of complications such as intestinal obstruction, enter- ic fistulas and radiation enteritis especially in patients undergoing postoperative radiotherapy. To avoid this complication, we placed mammary implants in the pel- vic cavity of 9 patients, as described previously(20). No complications were observed related to the prosthetic implants in our series. This study has also some limitations. First of all, our sample size was relatively small and it was not possi- ble to compare the quality of life between patients with different type of diversions because of the retrospective nature of the study. 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