Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer

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Abstract

Background

Multi-visceral resection, including parts of the urinary tract, is sometimes warranted to achieve cancer clear resection margins and optimize survival in patients with locally advanced colorectal and anal cancer. The aim of this study was to assess morbidity after urinary tract reconstruction dictated by colorectal and anal malignancy and to identify potential predictors of urological complications.

Methods

All patients undergoing surgery for colorectal or anal malignancy, including urinary tract resection and synchronous reconstruction, performed at the Karolinska University Hospital during 2004–2015 were included in this retrospective cohort study. Data was collected from medical records with follow-up until at least one year after the index surgery. Complications were graded according to the Clavien-Dindo classification system of surgical complications.

Results

The study included 189 patients; 121 underwent cystectomy and 68 partial ureter resection. The rate of high grade urological complications was 22%. The risk of major urological complications was significantly higher in patients subjected to ureter resection compared to after cystectomy (OR 2.60, 95% CI 1.23–5.49). Also, preoperative radiotherapy and intestinal anastomotic dehiscence significantly increased the risk of high grade urological complications.

Conclusion

To achieve potentially curative resections with uninvolved margins in patients with locally advanced colorectal and anal cancer, multi-visceral resection including urinary tract reconstruction can be performed with reasonable morbidity.

Introduction

In at least 5–10% of patients with colorectal cancer the tumour invades one or more adjacent organ at the time of diagnosis. According to the 7th ed. UICC/TNM staging system these tumours are defined as T4b [1], [2]. The exact prevalence of tumour invasion of the urinary tract is uncertain but bladder involvement has been reported in 17% of patients after multivisceral resection [3]. In an unselected series of resected colorectal cancers, bladder involvement was reported in 3% of specimens [4].

Surgery resulting in specimens with margins uninvolved by tumour (R0 resection) is the most important prognostic factor in determining treatment outcomes in locally advanced and locally recurrent colorectal cancer [5]. To achieve an R0 resection, partial or complete cystectomy or resection of part of the ureter/s may be necessary, as part of multivisceral en bloc surgery. Urinary tract reconstruction after both cystectomy and partial ureter resection has proven more prone to complications when performed in the context of colorectal cancer surgery as compared to surgery for primary urothelial cancer or benign conditions [6], [7]. Prior pelvic irradiation, the extent of the surgical resection and major intraoperative blood loss are factors suggested to contribute to the increased urological morbidity. However, evidence in contemporary literature is diverging [6], [8]. In addition, comparison of results is difficult due to disparity in how surgical complications are reported [9]. Systematic classifications of surgical complications, for example by the Clavien-Dindo (CD) system, has been sparsely implemented to describe urological morbidity following malignant colorectal and anal cancer surgery [10].

The aim of this retrospective cohort study was to assess morbidity related to urinary tract reconstruction after multivisceral resection of colorectal and anal cancer. Furthermore, potential patient and surgical factors predicting urological complications were investigated.

Section snippets

Methods

All patients in whom an en bloc resection of a part of the urinary tract was performed for a locally advanced or locally recurrent colorectal or anal cancer at Karolinska University Hospital between 2004 and 2015 were identified using an in-hospital, prospective database of all operative procedures. The inclusion criterion for this study was surgery for a colorectal or anal cancer requiring reconstruction of part of the urinary tract with a synchronous ureteric anastomosis to ureter, bladder or

Results

In total, 191 patients fulfilled the inclusion criterion during the study period. Two patients were lost to follow up, leaving 189 patients in the study.

Discussion

In this large retrospective single centre cohort study on patients undergoing urological reconstruction following resectional surgery for locally advanced colorectal and anal cancer the overall rate of high grade urological complications amounted to 22% which is comparable to the complication rates of 16–59% that have previously been reported [6], [7], [8], [18], [19]. However, heterogeneous cohorts and differences in registration and classification of urological complications makes direct

Conclusion

Multivisceral resection and reconstruction of the urinary tract can be performed with reasonable morbidity in patients with locally advanced and locally recurrent colorectal and anal cancer in order to achieve an R0 resection and potential cure. When complications occur, some urological reconstructions can be salvaged by operative or conservative measures, however, a proportion of reconstructions fail. Type of reconstruction, prior pelvic radiotherapy and intestinal anastomotic dehiscence are

Conflict of interest

None.

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