Gas J, Beauval J B, Chalret du Rieu M, Bou Nasr E, Philis A, Kirzin S, Thoulouzan M, Soulié M, Ghouti L
Département d'urologie, d'andrologie et de transplantation rénale, CHU Toulouse Rangueil, 1, avenue du Pr-Jean-Poulhes, 31000 Toulouse, France.
Département d'urologie, d'andrologie et de transplantation rénale, CHU Toulouse Rangueil, 1, avenue du Pr-Jean-Poulhes, 31000 Toulouse, France.
Prog Urol. 2015 May;25(6):348-54. doi: 10.1016/j.purol.2015.02.005. Epub 2015 Mar 21.
Pelvic exenteration for rectal cancer is indicated in locally advanced rectal tumors or pelvic recurrence invading adjacent organs. The oncologic goal being a complete R0 resection. Our aim was to study the urinary complications resulting from pelvic exenterations with urinary reconstruction in order to obtain a complete local control of the disease.
Between April 2004 and June 2013, 42 patients who underwent pelvic exenteration for primary or recurrent rectal adenocarcinoma with urinary tract reconstruction were included. The urinary reconstruction was performed based on preoperative imaging and intraoperative findings. We studied early (within 30 postoperative days) and late urinary morbidity, as well as postoperative carcinologic control.
Forty-two exenterations were performed for primary rectal cancer (n=15) or pelvic recurrence (n=27). R0 complete resection was achieved in 64% of patients. The resection was incomplete (R1) on the urinary tract in 9.5% of patients. The urinary reconstruction methods used were: 31 transileal ureterostomies after total exenteration (bricker procedure), 6 ureteral reimplantations on psoic bladder, 2 ureteroileoplasties, 2 partial cystectomies and one ureteral resection with simple ligation. The median follow-up was 20 months. The perioperative mortality was 2.3% (n=1) and postoperative overall morbidity was 64%. Early and late urinary morbidity was 23.8% and 21.4% respectively. Six patients developed major urinary complications (≥ Clavien IIIb).
Pelvic exenteration with urinary resection resulted in our experience, in a local disease control of 64% (including a 90.5% for the urinary tract) at the price of an acceptable early specific morbidity and a low mortality that seems to justify an aggressive surgical approach.
对于局部晚期直肠癌肿瘤或侵犯邻近器官的盆腔复发癌，可行盆腔脏器清除术治疗直肠癌。肿瘤学目标是实现R0根治性切除。我们的目的是研究盆腔脏器清除术联合尿路重建术后的泌尿系统并发症，以实现对疾病的完全局部控制。
纳入2004年4月至2013年6月间42例行盆腔脏器清除术治疗原发性或复发性直肠腺癌并进行尿路重建的患者。根据术前影像学检查和术中发现进行尿路重建。我们研究了早期（术后30天内）及晚期泌尿系统发病率以及术后肿瘤学控制情况。
42例盆腔脏器清除术用于治疗原发性直肠癌（n = 15）或盆腔复发癌（n = 27）。64%的患者实现了R0根治性切除。9.5%的患者尿路切除不完全（R1）。所采用的尿路重建方法包括：全盆腔脏器清除术后31例行经髂骨输尿管造口术（Bricker术式），6例行输尿管在腰大肌膀胱上再植术，2例行输尿管回肠成形术，2例行部分膀胱切除术，1例行输尿管切除并单纯结扎术。中位随访时间为20个月。围手术期死亡率为2.3%（n = 1），术后总体发病率为64%。早期和晚期泌尿系统发病率分别为23.8%和21.4%。6例患者出现严重泌尿系统并发症（≥Clavien IIIb级）。
根据我们的经验，盆腔脏器清除术联合尿路切除实现了64%的局部疾病控制（尿路局部疾病控制率为90.5%），代价是早期特定发病率可接受且死亡率低，这似乎证明了积极手术方法的合理性。
