Ileal Conduit and Continent Ileocecal Pouch for Patients Undergoing ...

Ileal Conduit and Continent Ileocecal Pouch for Patients
Undergoing Pelvic Exenteration
Comparison of Complications and Quality of Life
Dirk Michael Forner, MD and Björn Lampe, MD, PhD
Objectives: Creating a continent urinary pouch has become an alternative to the ileal
conduit for patients undergoing exenteration for advanced gynecologic malignancies. The
objective of this study was to compare clinical outcomes for the 2 methods.
Methods: In this retrospective study, we compared intraoperative and postoperative
complications and quality-of-life scores for the modified ileocecal pouch and the ileal
conduit in anterior or total pelvic exenteration.
Results: In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by
an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes
compared to an IC (IC, 453 minutes vs IP, 550 minutes; P = 0.009). Overall complication
rates were similar, but patients with an IP had significantly more complications of urinary
diversion (48%) than patients with an IC (31%; P = 0.03). Follow-up showed urinary loss
and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal
complications (n = 2) and treatment of bladderstones were necessary more frequently
(n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire
was similar in both groups.
Conclusion: A continent IP is an alternative to the IC in cases of pelvic exenteration. Early
complications are more frequent with an IP than with an IC. The mode of urinary diversion
has little influence on the quality of life in patients with advanced genital cancer.
Key Words: Pelvic exenteration, Urinary reservoirs, Genital neoplasms, Ileal conduit,
Continent pouch
Received November 2, 2010, and in revised form December 8, 2010.
Accepted for publication December 9, 2010.
(Int J Gynecol Cancer 2011;21: 403Y408)
esides cancer of the bladder, pelvic exenteration (PE) for
B advanced gynecologic carcinoma is the main indication
for urinary diversion. The ileal conduit (IC), for a long time
the standard of care in exenterative surgery, was first described
by Seifert 1 back in the 1930s but introduced mainly
Kaiserswerther Diakonie, Florence Nightingale Hospital, Duesseldorf,
Germany.
Address correspondence and reprint requests to Dirk Michael
Forner, MD, Sana Klinikum Remscheid, Burger Str. 211,
D-42859 Remscheid, Germany. E-mail: dr.forner@gmx.de.
The results were presented at the meeting of the German Society
of Obstetrics and Gynaecology (DGGG) in Munich in
October 2010.
Copyright * 2011 by IGCS and ESGO
ISSN: 1048-891X
DOI: 10.1097/IGC.0b013e31820aab17
ORIGINAL STUDY
by Bricker. 2 For a long time, IC has been the standard of care
in bladder replacement after PE, but as continence is not
achieved by a conduit, patients need lifelong stoma care. An
IC is technically simple and well tolerated by most patients,
so until today many authors see it as the ideal reconstruction
after cystectomy. However, in long-term followups
of more than 5 years, 66% of patients developed late
complications such as renal failure, stoma failure, bowel
complications, and symptomatic urinary tract infections. 3
The various techniques of a continent pouch are an alternative
for patients, offering a higher quality of life. The
first continent cecal reservoir was described in 1908 by
Verhoogen, 4 and in 1975, Kock 5 described a procedure for
a continent ileal reservoir. However, implantation of ureters
was complex and problematic in this procedure. Further
developments in the form of the Indiana, Miami, and Mainz
pouches 6Y8 helped to solve this problem and established the
International Journal of Gynecological Cancer & Volume 21, Number 2, February 2011 403
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Forner and Lampe International Journal of Gynecological Cancer & Volume 21, Number 2, February 2011
continent bladder replacement in the 1990s. Both the Miami
and Mainz pouches use the ileocecal segment, creating a
reservoir by detubulizing it and diverting the urine via an
ileal segment or the appendix. Since then, several other
techniques using various ileal or colonic segments have been
developed, but still the ileal conduit is more widely used in
cancer surgery than its continent alternatives.
Farnham 9 did not find any significant differences in
the frequency of surgical complications for the various
methods of urinary diversion. He concluded that as long as
there are no contraindications against one method or the
other, the appropriate procedure should be chosen individually
according to the underlying disease, quality of life,
and patient’s personal preference.
In this study, we compared intraoperative and postoperative
complications and quality-of-life scores of the modified
ileocecal pouch and the ileal conduit as described by
Wallace 10 in anterior or total PEs.
MATERIALS AND METHODS
Patients who had undergone exenterative surgery in our
department between July 2000 and June 2010 were identified,
their records were reviewed, and data were analyzed retrospectively.
Compilation and analysis of data were done by the
statistics program BiAS for Windows (Software, Version 9.2,
University of Frankfurt/ Main, Germany) using the Mann-
Whitney test for data without normal distribution and the
Fisher-Yates exact test with mid-P methods. The confidence
level was P = 0.05.
To evaluate the quality of life, the patients were
asked to fill in the Short Form-12 Health Survey Questionnaire
(SF-12). 11 The SF-12 questionnaire uses 12 items to
describe a summary scale for quality of life. In addition, a
mental and physical summary scale is reported. The regression
weightings used for scoring the SF-12 come from a
general population. 11
Technique of Creating the Ileocecal Pouch
Continent ileocecal pouches were created using the
modified technique according to Hünlich and Egger. 12 An
ileocecal segment consisting of approximately 20 cm of
ileum and 15 cm of cecum was dissected and isolated.
Continuity was reestablished by side-to-side anastomosis.
The ileal and cecal parts of the isolated segment were then
joined side by side down to the Bauhins valve by a linear titan
stapler, thus detubulizing the segment by cutting the circular
musculature. The resulting pouch was approximately the
size of a fist. To be able to use the appendix as a neourethra,
its tip was cut off and widened with Hegars dilators to 5-mm
diameter. A urinary catheter (Charrière 14) was placed in the
neourethra. The appendix-urethra was then lead out through
the navel, and its mucosa was fixed to the skin. Both ureters
were implanted antirefluxively in the cecal wall and stented
for 14 days.
In all patients, a drain was placed in the pouch of
Douglas. Serum electrolytes including chloride and phosphate
were checked regularly during the hospital stay. All
patients were trained by a specialized stoma nurse in the care
of their ileal conduit or in self-catheterization of their ileal
pouch, respectively.
RESULTS
A total of 100 patients were identified who had undergone
anterior or total exenterative procedures with bladder
reconstruction between July 2000 and June 2010. The median
age of the patients was 56 years (range, 35Y81 years), postoperative
hospital stay was for a median of 34 days (range,
10Y147 days). On average, 4 units of packed red blood
cells (0Y20 units) and 2 units (0Y6 units) of fresh frozen
plasma were required. Median operating time was 490 minutes
(range, 237Y724 minutes). None of the patients died
intraoperatively or within the first 100 days after surgery.
Total exenteration was performed in 59 patients, and
anterior exenteration was performed in 35 patients. Six
patients with advanced ovarian cancer had a complete exenteration
according to Bristow III. 13 For 41 of 49 patients with
supralevatoric total exenteration, a deep rectal anastomosis
was created simultaneously, including a protective colostomy
in 25 cases.
Fifty-four patients had cervical cancer, 11 had endometrial
cancer, 20 had vulval cancer, and 6 had vaginal
cancer. Six patients presented with an advanced ovarian
malignancy, and 3 patients presented with other malignancies
in the pelvis. Fifty-four patients had a relapse, whereas
35 patients had undergone previous radiotherapy.
In 33 patients, an ileal pouch (IP) was created; the
other 67 patients were treated with an ileal conduit (IC), the
latter group being slightly older (IP, 52 years vs IC, 63 years;
P = 0.02). Creating an IP prolonged the procedure by
97 minutes compared to creating an IC (IC, 453 minutes vs
IP, 550 minutes; P = 0.009). In anterior exenteration, the
difference was 59 minutes (P = 0.01); in total PE, the difference
was 108 minutes. However, in total PE, rectal anastomoses,
which add to prolonging the procedure, were
significantly more frequent (IC, 20/37 [55%]; IP: 21/22
[95%]; P G 0.001). The 2 groups did not differ in the length of
postoperative intensive care or in the need for units of packed
red blood cells or fresh frozen plasma (Table 1).
Postoperative recovery was free of complications for 31
patients with IC (46%) and for 9 patients with IP (27%). In 22
patients with IC (33%) and in 12 patients with IP (36%),
minor complications occurred, which were treated conservatively.
Surgical treatment of complications was necessary
in 14 patients with IC (21%) and 12 patients with IP (36%,
not significant; Table 2).
Overall, complications of urinary diversion were significantly
more frequent in patients with IC (21 patients
[31%]) than in patients with IP (16 patients [48%]; P = 0.03).
The frequency of the different types of complications was
similar in both groups and did not change over the years
(Table 3). Complications of urinary diversion requiring surgical
treatment occurred in 7 patients with IC (10%). Those
consisted of 4 leaks of the ureteroileal anastomosis, one
necrosis of the ureter and 2 leaks of the intestinal anastomosis.
In the early stage, no complication of the stoma
was seen. One patient with IC had an acute anterenal failure
requiring transient hemodialysis. No other patient of either
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International Journal of Gynecological Cancer & Volume 21, Number 2, February 2011 Ileal Conduit and Ileocecal Pouch
TABLE 1. Characteristics of patients with Ileal conduit or ileocecal pouch and significant differences according to
Mann-Whitney or Fisher-Yates exact test
Ileal Conduit Ileocecal Pouch
Median Range Median Range P*
Age, yrs 63 35Y81 52 35Y74 0.02
Duration of procedure, min 453 237Y724 550 308Y653 0.009
Days in hospital 32 10Y147 38 16Y117 0.02
Days on intensive care 3 1Y40 4 1Y13 0.32
Packed red blood cells, 500 cc 4 0Y20 4.5 4Y10 1.00
Fresh frozen plasma, 500 cc 2 0Y6 2 0Y60.96 Quality-of-life score 56 38Y92 81 38Y92 0.10
n=67 % n=33 % P†
Preceding radiotherapy 24 35.8 11 33.3 0.82
Recurrence 39 58.2 14 42.4 0.17
Total Exenteration 37 55.2 22 66.7 0.24
Rectal anastomosis 20 55 21 95 0.001
Rectal anastomosis was more frequently needed in patients with ileal pouch.
*Mann-Whitney test.
†Fisher-Yates exact test.
group showed a rise in creatinine, and there was no case of
hypochloremic acidosis. Six patients with IP (18%) needed
surgical intervention owing to complications of urinary
diversion: In 4 patients, there was a leak at the pouch or at
the implantation of the ureter; 2 patients had complications
of the appendix stoma, requiring transformation into a wet
stoma. There were no leaks at the ileo-ascendostomies. Of
the 31 patients with IP without resurgery for stoma complications,
29 (94%) were continent and able to empty their
IP by self-catheterization at discharge from hospital.
Overall, 35 patients had prior irradiation, 24 of which
were treated with an IC and 11 with an IP. In the IC group, of
TABLE 2. Morbidity and mortality according to the classification of postexenterative complications
Category No. Patients Complications No. Patients Affected*
Without complications 40
Minor complications
without surgical intervention
Major complication requiring
surgical intervention
*Several complications possible in same patient.
34 Urinary tract infection 10
Urinary tract obstruction 7
Seroma/Lymphocele 8
Fever 938 h 6
Failure of wound healing 5
Nerve lesion 2
Pleural effusion requiring drainage 1
Thrombosis 1
Ileus 1
Retracted colostomy 1
26 Leak of intestinal anastomosis 8
Leak of ureteric anastomosis 9
Intraperitoneal abscess 2
Complete wound dehiscence 2
Bleeding after disseminated intravascular coagulation 2
Colostomic tear-out 1
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Forner and Lampe International Journal of Gynecological Cancer & Volume 21, Number 2, February 2011
TABLE 3. Urinary diversionYrelated early complications of Ileal conduit and Ileocecal pouch show no significant
differences in Fisher-Yates exact test
Ileal Conduit Ileocecal Pouch
n = 67 % n = 33 % P*
Renal failure 1 1.4 0 0 0.67
Urinary tract infection 9 13.4 5 15.1 0.51
Urinary tract obstruction 3 4.4 4 12.1 0.16
Leak of ureter anastomosis 4 6.0 4 12.1 0.24
Ureter necrosis 1 1.4 0 0 0.67
Stomal complication 0 0 2 6.1 0.11
Leak of ileal anastomosis 2 3.0 0 0 0.44
Several complications are possible in same patient.
*Fisher-Yates exact test.
the 5 patients that had a leakage, one had had prior irradiation.
In the IP group, 2 of 4 patients with a leakage had prior
irradiation. A correlated cause could not be determined. The
incidence of complications was neither correlated to negative
or positive margins nor to lymph node status.
Regarding complications other than urinary diversion,
3 patients in each group needed revision surgery for failure of
wound healing or complete wound dehiscence. Leaks of the
colonic anastomosis occurred in 5 patients with IC and 3
patients with IP (nonsignificant). No patient had an ileus.
Postoperative hospital stay was longer for patients with IP
than for patients with IC (38 vs 32 days, P = 0.02).
Of 100 patients, 97 were followed up for a median of
37 months. Thirty-seven patients are still alive (34 of them
free of disease). Twenty-two of these patients have an IC, and
15 have an IP. Two patients with IC (9%) and one patient with
IP (7%) experience an involuntary loss of urine. Seventy-five
percent and 78% of the patients, respectively, need to empty
their stomal bag or IP no more than twice per night, the others
more frequently. In both groups, 2 patients needed resurgery
for stomal complications. Bladder stones were only seen in 3
patients with IP. Patients with IP needed treatment for urinary
tract infection (33%) significantly more frequently than
patients with IC (4%, P = 0.02). Quality of life was tested
with the SF-12 questionnaire, and results were not statistically
different between the groups (Table 4). Both groups had
the same frequency of colonic anastomoses and colostomies,
hence not biasing the quality-of-life score results.
DISCUSSION
In this study, we present the ileocecal pouch as modified
by Hünlich and Egger 12 and compare its intraoperative
and early postoperative data with the ileal conduit in the
setting of an exenteration. The IP requires a considerably
higher surgical effort, with an anterior exenteration taking an
average of 97 minutes longer. Also, the overall rate of complications
related to urinary diversion is higher for the IP (IC,
21/67 [31%] vs IP, 16/33 [48%]; P = 0.10). The rate of
complications requiring surgical intervention, however, is not
significantly different (10% vs 18%).
Similar rates were reported for other types of urinary
diversion. Of 396 patients with a Mainz I pouch and appendix-stoma,
93 patients (23.5%) needed surgical intervention
for complications of the stoma. 14 Twelve of 77 patients
(15.8%) supplied with a Miami pouch needed another intervention,
4 of them for stoma complications (5.1%). 15 Two of
our patients (6%) with IP needed intervention for stoma
complications; in another 2 patients (6%), problems of
catheterization could be treated conservatively.
In another study on the Mainz pouch, the frequency of
stomal failure was 11%, and the frequency of stomal stenosis
TABLE 4. Quality of life as measured by SF-12 questionnaire for patients treated by ileal conduit and ileocecal
pouch shows no significant difference between the 2 groups
Ileal Conduit Ileocecal Pouch
Mean SD Mean SD P*
Quality-of-life score 60 22.0 71 14.6 0.18
Physical component summary score 48 10.5 43 11.0 0.38
Mental component summary score
*Mann-Whitney test.
49 10.8 45 13.7 0.46
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International Journal of Gynecological Cancer & Volume 21, Number 2, February 2011 Ileal Conduit and Ileocecal Pouch
13%. 16 Stomal complications occurred in 22.1% of the
patients with the Miami pouch 15 and in 14.7% of patients
with Rome pouches. 17
We did not find a significant difference in the leakage
rate between IC and IP: In 4 patients with IP (12%) and
4 patients with IC (6%), repeat intervention was required for
leaks of the pouch or of the implantation site of the ureter.
Goldberg, 18 too, did not find any significant difference in the
rate of ureteric anastomosal leak between IC and a continent
pouch (14% vs 13%). For the Miami pouch, Mirhashemi 19
found these complications in 6.5% of patients (5/77),
Penalver 20 reports a rate of 12.1% (8/66). Chang 21 describes
fistulae of the Miami pouch in 4 of 21 patients (19.0%). With
1 in 40 patients (2.5%), Ramirez 22 saw a lower rate of
leakages. For the Rome pouch, a similar rate of 5.7% (2/35)
was reported. 23
Whereas studies on the conduits of the ileum or colon
report a permanent loss of renal function in 12% 24 and 17%
of patients, 25 respectively, this has not been seen in continent
urinary diversions. 15 In our own group of patients, no postrenal
complications occurred, which is in line with the findings
of Goldberg. 18 However, an 81-year-old patient with
an IC developed a transient anterenal failure early after
operation.
Wilkin et al 26 report that complications are more frequent
in patients with antecedent radiotherapy. In our group,
35 of 100 patients had been previously irradiated. We did
not find a correlation with early complications. Whereas in
the study by Panici et al, 17 the proportion of previously
irradiated patients was similar (15/35 [42.8%]), Ramirez 19
had 98% and Angioli had 92%. 15 The reason for these discrepancies
is mainly that in Germany, exenteration is seen
as a treatment option besides radiotherapy for primary cervical
cancer, whereas in the US, this is not the case. 27
In our study, we found no difference in the qualityof-life
scores for patients with a continent ileal pouch
compared with those with a wet ileal conduit stoma. In the
course of the past decades, several studies on the quality of
life after cystectomy came up with various results: Many of
these studies were limited by small patient numbers and
heterogeneous treatment groups with respect to age or
comorbidities. 28Y30 Most have shown that the overall quality
of life after cystectomy remains satisfactory for most
patients. The current body of published literature is insufficient
to conclude that one form of urinary diversion is
superior to another based on quality-of-life outcomes. 31
Quality-of-life might be improved by orthotopic bladder
replacement in selected cases. 32
CONCLUSION
The continent urinary pouch is an alternative to the
wet ileal conduit in patients in need of a bladder replacement
due to PE. Owing to the higher surgical complexity of the
procedure, early complications are more frequent with the
urinary pouch than with an ileal conduit. Conservative
management is sufficient for most of the complications.
The rate of complications requiring repeat intervention is
acceptable but higher than with an IC. Furthermore, our study
did not confirm the increase in the quality of life postulated
for all forms of continent urinary diversion.
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