Palliative Urinary Diversion

STEPHAN DEGENER

BURKHARD UBRIG

STEPHAN ROTH

The word palliative derives from the Latin palliare, which means “to cover with a coat.” The term palliative therapy implies the impossibility of cure. The main goal of palliative urinary diversion is the control or the prevention of symptoms caused by incurable diseases of the urinary tract, usually cancer. In addition to bladder and prostate cancer, advanced cervical, ovarian, breast, or colorectal cancer may interfere with the urinary tract.

INDICATIONS FOR SURGERY

There are no prospective studies that compare bladder-preserving strategies and palliative cystectomy in locally advanced bladder cancer. However, the clinical course of patients with advanced muscle-infiltrating bladder cancer under a bladderpreserving strategy is often dismal. In one study, 24 patients
with muscle-infiltrating bladder tumor not eligible for cystectomy (mean age 81 years) were treated with bladder preservation for a mean 22.6 months. All complained of frequency, urgency, and severe nocturia. The mean hospital readmission rate was 8 times per patient. Salvage cystectomy was required in 11 of 24 cases, in 7 solely because of recurrent macrohematuria. Major complications that might have been prevented with early cystectomy were ileus in three cases and an enterovesical fistula in one. All patients in whom the bladder was preserved complained of severe symptoms that reduced the quality of their remaining life (1).

Therefore, in most palliative patients with locally advanced pelvic cancer, cystectomy or complete pelvic exenteration is the standard option, unless it is a nonresectable tumor. There is some evidence that radical cystectomy itself, if performed efficiently and with minimal blood loss, does not decisively increase the morbidity of the palliative urinary diversion. By contrast, the high disease-related complication rate with explicit impairment of the remaining life span has to be considered in conservative strategy (1,2,3).

In a specific group of patients with high surgical risk, frozen pelvis, or a short residual life expectancy, supravesical diversion without exenteration may be a viable option that results in good symptom control (3). Indications are infrequent, and results of this strategy have rarely been reported. Further alternatives to radical cystectomy with urinary diversion are observation, repeated transfusions, or indwelling catheters depending on the underlying disease process.

Nevertheless, the decision will be made in individual cases by the urologic surgeon and the patient. Despite all surgical and anesthesiologic advances in some borderline cases, the risk of the surgical approach is considered too high. The American Society of Anesthesiologists (ASA) score has been described as one reliable decision criterion: ASA scores ≥3 is significantly associated with increased complication and reoperation rate, especially those related to the type of urinary diversion (4).

FIGURE 84.1 Supravesical urinary diversion. Cutaneous ureterostomy with (A) median or (B) lateral stoma, (C) transureteroureterostomy, and (D) pyeloureteral anastomosis. E and F: Transverse colon conduit, with (F) anastomosis to the pyelon; (G) ileal conduit.

SURGICAL TECHNIQUE AND OUTCOMES

Palliative urinary diversion will usually be performed with the lowest risk options that are acceptable to the patient. In general, conduits will often be preferred in palliative situations. Some patients for whom palliation is the goal may be very poor surgical candidates. Therefore, in these cases, less elaborate techniques such as cutaneous ureterostomy can be a safe and simple alternative. Nephrostomy placement should be considered in patients with extreme anesthetic or perioperative risks and in end-of-life situations.

Ileal Conduit

Assuming adequate surgical risk and life expectancy, an ileal conduit is the first choice of many urologists in a palliative situation. Ileal conduit can be performed despite previous abdominal surgery (e.g., enterostomy) in cases of impaired renal function and in patients with limited compliance because ostomy care is relatively easy. Patients may return to normal activity soon after discharge (Fig. 84.1). Postoperative complications such as metabolic acidosis or ureteroenteric
anastomotic stenosis are extremely rare, and increasing conduit-related complication rates are only seen in long-term survivors (5).

An ileal conduit should not be used in patients with short bowel syndrome, inflammatory small bowel disease, or in those who have had high-dose radiation to the ileum. The small intestine and ureters are usually within the radiation portals for treatment of pelvic malignancy which may cause long-term sequelae: impaired postirradiation healing of gut anastomosis, and scarring with stricture formation of the ureterointestinal anastomosis may occur. Strategies to prevent strictures are high ureter resection, prolonged anastomotic single-J ureteral stenting, and preservation of paraureteric blood supply with minimal use of electrocautery.

Sigmoid Colon Conduit

The sigmoid colon is a viable alternative to the ileum if the latter cannot be used for conduit construction (see earlier). However, it should not be used if it is diseased, has been exposed to radiation, or if the internal iliac arteries have been embolized (or ligated) with the rectum still in place. This last condition might lead to rectal sloughing because of compromised rectal blood supply (6). The stoma will usually be placed in the lower left abdominal quadrant (see Fig. 84.1).

Transverse Colon Conduit

In patients irradiated for urologic, gynecologic or intestinal malignancies, the use of the ileum and lower colon segments is associated with a higher early and late complication rate. In these cases, a transverse conduit can be indicated because this part of the colon is not within the common radiation portals (avoidance principle). The blood supply via the middle colic artery is usually ample. Indications for the use of transverse colon for conduit construction can be marked radiation fibrosis of the ureters or impaired ureteral mobilization because of frozen pelvis or periureteral lymph nodes. The ureterointestinal anastomosis can be accomplished with very short ureteral stumps. Also, anastomosis with the renal pelvis is feasible (see Fig. 84.1). The perioperative mortality rate has been reported at 3% (6).

Bilateral Cutaneous Ureterostomy with Single Stoma

In patients for whom major gut surgery is not advisable, cutaneous ureterostomy is a safe and simple alternative to transintestinal diversion (see Fig. 84.1); operative time is short, and renal function is not a selection factor, although the most common complication of all intestinal urinary diversion, mechanical or paralytic ileus, rarely occurs. A single stoma construction in the lateral or midline position is generally feasible and ensures easier care with minimal discomfort in patients without excessive obesity, extensive paraureteral lymph node involvement, previous radiation therapy, or frozen pelvis (3).

Ureterocutaneostomic Stomal Construction

Stomal construction is of critical importance. Stoma stenosis is the major problem with all forms of ureterocutaneostomies, although recent data show significantly better tube free rates of up to 80% to 100%. Stomal stenosis mainly results from ischemia of the distal ureteral end with consequent sloughing and fibrosis. Different strategies like an omentum wrapping or the preservation of the fascia between the spermatic cords and the ureters (2,7) have been described to prevent ischemia. Additionally, distal spatulation of the ureteral end and plastic augmentation with a V-shaped skin flap as proposed by Rodeck (8) or the split-cuff nipple should be considered. Therefore, the ureter is spatulated, folded back to form splitcuff nipple, and corners are sewn with small gap to prevent ureteral constriction (9).

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