Original research

Int J Gynecol Cancer: first published as 10.1136/ijgc-2019-000863 on 2 December 2019. Downloaded from http://ijgc.bmj.com/ on August 7, 2020 at University of N S Wales 1247645.
Comparison of postoperative complications
and quality of life between patients
undergoing continent versus non-­continent
urinary diversion after pelvic exenteration for
gynecologic malignancies
Martina Aida Angeles,1 Estelle Mallet,2 Philippe Rouanet,3 Bastien Cabarrou,4 Pierre Méeus,5
Eric Lambaudie,6 Fabrice Foucher,7 Fabrice Narducci,8 Cécile Loaec,9 Sebastien Gouy,10
Frederic Guyon,11 Frédéric Marchal,12 Laurence Gladieff,13 Carlos Martínez-­Gómez,1,14
Federico Migliorelli,15 Alejandra Martinez,14,16 Gwenael Ferron16,17

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• Postoperative complication rates after continent versus non-­continent urinary reconstruction are similar.
• Continent versus incontinent urinary diversions after pelvic exenteration are equivalent in terms of quality of life.
• The main complications after anterior or total pelvic exenteration and urinary diversion are digestive and infectious
complications.
Abstract P=0.95), complications needing surgical (27.9% vs

Correspondence to
Dr Gwenael Ferron, Institut
Claudius Regaud, Toulouse,
Occitanie 31059, France; ​
ferron.​gwenael@​iuct-​oncopole.​
fr
MAA and EM are joint first
authors.
AM and GF are joint senior
authors.
Received 22 August 2019
Revised 26 September 2019
Accepted 1 October 2019
Published Online First
2 December 2019
© IGCS and ESGO 2020. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Angeles MA, Mallet E,
Rouanet P, et al. Int J Gynecol
Cancer 2020;30:233–240.
Background Pelvic exenteration and its reconstructive
techniques have been associated with high postoperative
morbidity and a negative impact on patient quality of
life. The aim of our study was to compare postoperative
complications and quality of life in patients undergoing
continent compared with non-­continent urinary diversion
after pelvic exenteration for gynecologic malignancies.
Methods We designed a multicenter study of patients
from 10 centers who underwent an anterior or total
pelvic exenteration with urinary reconstruction for
histologically confirmed persistent or recurrent gynecologic
malignancy after previous treatment with radiotherapy.
From January 2005 to September 2008, we included
patients retrospectively, and from September 2008 to
May 2009, patients were included prospectively which
allowed collection of quality of life data. Demographic,
surgical, and follow-­up data were analyzed. Postoperative
complications were classified according to the Clavien–
Dindo classification. Quality of life was assessed using
the European Organization for Research and Treatment of
Cancer (EORTC)-­QLQ-­C30 (V.3.0) and EORTC-­QLQ-­OV28
quality of life questionnaires. We compared patients who
underwent a continent urinary diversion with those who
underwent a non-­continent reconstruction.
Results We included 148 patients, 92 retrospectively
and 56 prospectively. Among them, 77.4% had recurrent
disease and 22.6% persistent disease after the primary
treatment. In 70 patients, a urinary continent diversion was
performed, and 78 patients underwent a non-­continent
diversion. Median age of the continent and incontinent
groups was 53.5 (range 33–78) years and 57 (26-79)
years, respectively. There were no significant differences
between the continent and non-­continent groups in
median length of hospitalization (28.5 vs 26 days, P=0.19),
postoperative grade III–IV complications (42.9% vs 42.3%,
Protected by copyright.
34.6%, P=0.39) or radiological (14.7% vs 12.8%, P=0.74)
intervention, and complication type (digestive (23.2% vs
16.7%, P=0.32) and urinary (15.9% vs 16.7%, P=0.91)).
There were no significant differences between the groups
in global health, global quality of life, and body image
perception scores 1 year after surgery.
Conclusion Continent and incontinent urinary
reconstructions are equivalent in terms of postoperative
complications and quality of life scores.
Introduction
Despite improvements in local control of gynecologic
malignancies treated with concomitant chemoradio-
therapy, pelvic exenteration can be a curative treat-
ment for almost 30% of non-­metastatic patients with
recurrent or persistent pelvic disease after prior radi-
ation therapy.1 Urinary diversion after anterior or total
pelvic exenteration represents an essential part of
surgical reconstruction. There has been a significant
evolution in surgical approaches to urinary diversion
in the field of gynecological oncology over the past 70
years; however, achieving successful long term func-
tion and adequate quality of life are still challenging.2
The goal of urinary diversion after cystectomy has
evolved from simple diversion—such as cutaneous
bilateral ureterostomy—to functioning and anatomic
reconstruction as close as possible to the physiologic
preoperative status.3 Many types of urinary diver-
sion have been developed. There are non-­continent
techniques, such as the Bricker ileal conduit,4 and
continent urinary diversions, such as the Koch pouch
with an ileal reservoir5 or the Miami pouch which is

Angeles MA, et al. Int J Gynecol Cancer 2020;30:233–240. doi:10.1136/ijgc-2019-000863 233

Original research
Figure 1 Flowchart of patient participation and study
design. QoL, quality of life.
created with a segment of distal ileum and ascending colon.6 Chiva
et al proposed urinary reconstruction with a Y shaped neobladder
created with a detubularized ileum connected to the proximal
urethra for patients with cervical cancer after pelvic exenteration.7
Along with the increase in survival rates of these patients,
improving their quality of life has become a major issue. Some
studies showed that after a year, regardless of the type of urinary
reconstruction, patients had similar scores for global quality of life
and physical, cognitive, and social functioning.8 To our knowledge,
there are very few studies comparing postoperative complications
between continent and non-­continent urinary diversion after pelvic
exenteration for gynecologic malignancies, and most studies are
from urologic series. None has shown any significant differences,
except a higher risk of stone formation in patients undergoing conti-
nent reconstruction. Moreover, none of these studies compared
patients' quality of life.9–12
The aim of our study was to compare the complication rate
and quality of life of patients undergoing continent versus non-­
continent urinary diversion after pelvic exenteration for gynecologic
malignancies.
Methods
Patients and Study Design
We designed a multicenter French study (Soutien aux Techniques
Innovantes et Coûteuses (STIC) Pelvic Exenteration) of patients from
10 centers who underwent an anterior or total pelvic exenteration
with urinary reconstruction. From January 2005 to September
2008, we included patients retrospectively, and from September
2008 to May 2009, patients were included prospectively which
allowed collection of quality of life data. Patients meeting the
following inclusion criteria were included in our study: diagnosis of
a persistent or recurrent gynecologic malignancy after prior radio-
therapy confirmed by biopsy; good performance status (score of 0
or 1 according to the World Health Organization classification); no
extra pelvic disease on positron emission tomography–computed
tomography; pelvic exenteration performed with a curative purpose;
and urinary diversion performed at the time of surgery. The type of
pelvic exenteration was classified according to the Magrina classi-
fication: type I (supralevator), type II (infralevator), and type III (with
vulvectomy). The type of urinary reconstruction was classified as
continent diversion if a Kock,5 13 Indiana,6 or Miami14 pouch was
234
Int J Gynecol Cancer: first published as 10.1136/ijgc-2019-000863 on 2 December 2019. Downloaded from http://ijgc.bmj.com/ on August 7, 2020 at University of N S Wales 1247645.
performed, or as non-­continent diversion if a colonic conduit, ileal,
or jejunal Bricker4 or bilateral ureterostomy10 (online supplemen-
tary file 3) was performed. None of our patients underwent urinary
reconstruction with an ileal orthotopic neobladder as this technique
was not used during the study period.
Informed consent was obtained from all patients prospectively
included. Institutional review board approval was obtained from all
centers.
Study Data
The following data were retrieved from records for retrospec-
tively included patients and were prospectively collected for the
remaining patients: age at diagnosis, American Society of Anesthe-
siologists score, medical comorbidity, previous abdominal surgery,
site of primary gynecologic tumor, histologic subtype, previous
surgical treatment or chemotherapy, age at the time of exenter-
ation, surgical indication for exenteration, interval between last
radiotherapy and exenteration, type of exenteration, surgical data,
hospitalization data, postoperative complications (according to the
Clavien–Dindo classification), and the need for surgical or radiolog-
ical procedures.15
Quality of Life Assessment
Quality of life was assessed using the European Organization for
Research and Treatment of Cancer (EORTC) QLQ-­C30 (V.3.0) and
the EORTC QLQ-­OV28 quality of life questionnaires before, and at 1,
Protected by copyright.
3, 6, and 12 months after surgery. Patients who experienced recur-
rence stopped completing the quality of life questionnaires.16–18
Statistical Analysis
Data were summarized by frequency and percentage for categorical
variables and by median (range) for continuous variables. Quality of
life scores were presented before (initial) and at each follow-­up
visit after surgery (at 1, 3, 6, and 12 months) using median (range)
values. Comparisons between groups were performed using the
χ2 or Fisher’s exact test for categorical variables and the Mann–
Whitney test for continuous variables. All reported P values were
two sided. For all statistical tests, differences were considered
significant at the 5% level. Statistical analyses were conducted
using STATA 13 software (StataCorp, Texas, USA).
Results
A total of 148 patients were included in our study, 92 retrospectively
and 56 prospectively (Figure 1). All patients had previously been
treated with radiation therapy. Pelvic exenteration was performed
for persistent or recurrent disease in 22.6% and 77.4% of patients,
respectively. Among these, 70 patients underwent a urinary conti-
nent diversion and 78 patients a non-­continent diversion. In those
who underwent a continent diversion, 45 (30.4%, 45/148) had a
Miami pouch, 23 (15.5%, 23/148) an Indiana pouch, and 2 (1.4%,
2/148) a Koch pouch. In those who underwent a non-­continent
diversion, in 74 (50%, 74/148) a urinary conduit was performed
(66 patients underwent an ileal Bricker, 5 a colonic conduit, and 3 a
jejunal Bricker) while 4 (2.7%, 4/148) patients underwent a bilateral
cutaneous ureterostomy.
Median age at the primary diagnosis for the 148 patients was
50 years (range 24–78). Regarding medical comorbidities, 8.2%
Angeles MA, et al. Int J Gynecol Cancer 2020;30:233–240. doi:10.1136/ijgc-2019-000863
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Int J Gynecol Cancer: first published as 10.1136/ijgc-2019-000863 on 2 December 2019. Downloaded from http://ijgc.bmj.com/ on August 7, 2020 at University of N S Wales 1247645.
Table 1 Patient characteristics
Variable Overall (n=148) Continent (n=70) Non-­continent (n=78) P value
Age at diagnosis (years) (median (range)) 50 (24–78) 49.5 (30–77) 52 (24–78) 0.511
ASA score (n (%))
 I 41 (28.3) 26 (37.7) 15 (19.7) 0.052
 II 80 (55.2) 34 (49.3) 46 (60.5)
 III 24 (16.6) 9 (13.0) 15 (19.7)
 Missing 3 (–) 1 (–) 2 (–)
Obesity (n (%)) 12 (8.2) 5 (7.2) 7 (9.0) 0.703
 Missing 1 (–) 1 (–) 0 (–)
Diabetes (n (%)) 8 (5.4) 3 (4.3) 5 (6.4) 0.723
 Missing 1 (–) 1 (–) 0 (–)
High blood pressure (n (%)) 35 (23.8) 16 (23.2) 19 (24.4) 0.868
 Missing 1 (–) 1 (–) 0 (–)
Hypercholesterolemia (n (%)) 9 (6.1) 5 (7.2) 4 (5.1) 0.735
 Missing 1 (–) 1 (–) 0 (–)
Smokers (n (%)) 43 (30.7) 22 (32.8) 21 (28.8) 0.602
 Missing 8 (–) 3 (–) 5 (–)
Previous abdominal surgery (n (%)) 52 (35.6) 25 (35.7) 27 (35.5) 0.981
 Missing 2 (–) 0 (–) 2 (–)
Origin of primitive tumor (n (%)) 0.238

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 Cervix–vagina 126 (85.1) 63 (90.0) 63 (80.8)
 Uterus 21 (14.2) 7 (10.0) 14 (17.9)
 Other 1 (0.7) 0 (0) 1 (1.3)
Histological type (n (%))
 Squamous cell carcinoma 98 (67.6) 47 (70.1) 51 (65.4) 0.714
 Adenocarcinoma 36 (24.8) 16 (23.9) 20 (25.6)
 Sarcoma 5 (3.4) 1 (1.5) 4 (5.1)
 Other 6 (4.1) 3 (4.5) 3 (3.8)
 Missing 3 (–) 3 (–) 0 (–)
Previous surgical treatment (n (%)) 109 (73.6) 48 (68.6) 61 (78.2) 0.184
Previous chemotherapy (n (%)) 93 (62.8) 49 (70.0) 44 (56.4) 0.088
ASA, American Society of Anesthesiologists.

of patients were obese, 5.4% had diabetes mellitus, 23.8% had
hypertension, and 6.1% had hypercholesterolemia. The most
common primary tumor site was the cervix or the vagina in 126
(85.1%) patients and 98 (67.6%) patients had squamous cell carci-
noma. There were no significant differences in baseline character-
istics between patients with continent and non-­continent urinary
reconstruction. Patient characteristics are summarized in Table 1.
Median age at exenteration was 55 years (range 26–79). A total
pelvic exenteration was performed in 76 (51.4%) patients and 72
(48.6%) patients underwent an anterior pelvic exenteration. In the
non-­continent group, 60.3% of patients underwent a total exentera-
tion while in the continent group a total exenteration was performed
in 41.4% of patients (P=0.02). Following the Magrina classifica-
tion, 100 (68.5%) patients underwent a type I, 28 (19.2%) a type
II, and 18 (12.3%) a type III exenteration (data were missing for 2
patients). There were no significant differences between the conti-
nent and incontinent groups. Vaginal reconstruction was performed
in 70 (47.9%) patients, 39 patients in the continent group and 31
patients in the non-­continent group, and in 90% of patients vaginal
reconstruction was a myocutaneous flap (vertical rectus abdominis
myocutaneous flap or gracilis myocutaneous flap).
Median length of hospitalization (including stoma education
program) was 27 days (range 6–144) and 69.4% of patients where
admitted to the intensive care unit during the immediate postoper-
ative period. There were no significant differences between the two
groups in hospitalization length or admission to the intensive care unit.
Sixty-­three patients developed a grade III–IV postoperative complica-
tion according to the Clavien–Dindo classification, 33 (42.3%) patients
in the non-­continent urinary diversion group and 30 patients in the
continent group (42.9%) (P=0.95). Digestive and infectious complica-
tions were the most frequent overall (19.7% and 19.0%, respectively),
with no significant differences between the two groups. In addition,
there were no significant differences between the continent and non-­
continent groups regarding urinary complications (15.9% vs 16.7%,

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Table 2 Surgical data and postoperative outcomes
Non-­continent
Variable Overall (n=148) Continent (n=70) (n=78) P value
Age at time of exenteration (years) (median 55 (26–79) 53.5 (33–78) 57 (26–79) 0.466
(range))
Indication for exenteration (n (%)) 0.341
 Persistent disease 33 (22.6) 18 (26.1) 15 (19.5)
 Recurrent disease 113 (77.4) 51 (73.9) 62 (80.5)
 Missing 2 (–) 1 (–) 1 (–)
Interval between last radiotherapy and 14.0 (0.8–396.5) 15.9 (0.8–396.5) 11.3 (1.7–154.1) 0.774
exenteration (months) (median (range))
 Missing 17 3 14
Pre-­existing fistulae (n (%)) 27 (18.4) 15 (21.4) 12 (15.6) 0.361
 Missing 1 (–) 0 (–) 1 (–)
Type of exenteration (n (%)) 0.022
 Anterior 72 (48.6) 41 (58.6) 31 (39.7)
 Total 76 (51.4) 29 (41.4) 47 (60.3)
Magrina type exenteration (n (%)) 0.854
 I 100 (68.5) 45 (66.2) 55 (70.5)
 II 28 (19.2) 14 (20.6) 14 (17.9)
 III 18 (12.3) 9 (13.2) 9 (11.5)
 Missing 2 (–) 2 (–) 0 (–)

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Intraoperative radiotherapy or interstitial 8 (5.4) 6 (8.6) 2 (2.6) 0.152
brachytherapy (n (%))
 Missing 1 (–) 0 (–) 1 (–)
Vaginal reconstruction (n (%)) 70 (47.9) 39 (55.7) 31 (40.8) 0.071
 Missing 2 (–) 0 (–) 2 (–)
Vaginal reconstruction type (n (%)) 1.000
 Myocutaneous flap 54 (90.0) 31 (88.6) 23 (92.0)
 Omental flap 6 (10.0) 4 (11.4) 2 (8.0)
 Missing 10 (–) 4 (–) 6 (–)
Margins (n (%)) 0.795
 In sano 113 (78.5) 54 (79.4) 59 (77.6)
 Non-­in sano 31 (21.5) 14 (20.6) 17 (22.4)
 Missing 4 (–) 2 (–) 2 (–)
Hospitalization length (days) (median (range)) 27 (6–144) 28.5 (6–144) 26 (9–138) 0.194
 Missing 1 (–) 0 (–) 1 (–)
ICU hospitalization (n (%)) 102 (69.4) 44 (62.9) 58 (75.3) 0.101
 Missing 1 (–) 0 (–) 1 (–)
Postoperative grade III–IV complications* (n
(%))
 Total 63 (42.6) 30 (42.9) 33 (42.3) 0.946
 Grade IIIa 10 (6.8) 6 (8.7) 4 (5.1) 0.702
 Grade IIIb 38 (25.9) 16 (23.2) 22 (28.2)
 Grade IVa 6 (4.1) 4 (5.8) 2 (2.6)
 Grade IVb 8 (5.4) 3 (4.3) 5 (6.4)
 Missing 1 (–) 1 (–) 0 (–)
Continued

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Table 2 Continued
Non-­continent
Variable Overall (n=148) Continent (n=70) (n=78) P value
Complications grade III–IV needing surgical 46 (31.5) 19 (27.9) 27 (34.6) 0.386
reintervention (n (%))
 Missing 2 (–) 2 (–) 0 (–)
Complications grade III–IV needing 20 (13.7) 10 (14.7) 10 (12.8) 0.741
interventional radiology procedures (n (%))
 Missing 2 (–) 2 (–) 0 (–)
Type of grade III–IV complication† (n (%))
 Digestive 29 (19.7) 16 (23.2) 13 (16.7) 0.321
 Urinary 24 (16.3) 11 (15.9) 13 (16.7) 0.906
 Parietal 4 (2.7) 0 (0) 4 (5.1) 0.123
 Infectious 28 (19.0) 10 (14.5) 18 (23.1) 0.186
 Hemorrhagic 3 (2.0) 1 (1.4) 2 (2.6) 1.000
 Medical 6 (4.1) 4 (5.8) 2 (2.6) 0.420
 Missing 1 (–) 1 (–) 0 (–)
*if more than one complication was present, grade was assigned according to the most severe complication.
†Percentages do not add up 100% as more than one complication could be present in the same patient.
ICU, intensive care unit.

P=0.91). Among the 63 patients with a grade III–IV complication, 46 of complication, there were no significant differences between the

needed a surgical reintervention and 20 an interventional radiology
procedure, with no significant differences between the continent and
non-­continent groups (Table 2).
Quality of life was assessed in 56 patients included prospec-
tively. The overall median global health and quality of life score was
58.3/100 just before surgery and 1 year after the intervention. No
significant differences were found for any item in the quality of life
questionnaires between patients with a continent and non-­continent
urinary reconstruction 1 year after surgery (Table 3). Regarding
global quality of life (Figure 2A), 1 month after surgery, patients
with a continent diversion had a lower median score (33.3/100)
than patients with non-­continent reconstruction (50/100). During
follow-­up, this difference was reversed, and 1 year after surgery,
continent patients had a higher median score (62.5/100) than non-­
continent patients (58.3/100), but this difference was not significant.
Regarding body image perception (Figure 2B), this was better in the
non-­continent group 1 month after surgery (66.7/100) compared
with the continent group (50/100). However, 3 months after surgery,
this difference was reversed, and body image median scores were
58.3/100 and 33.3/100 in the continent and non-­continent groups,
respectively. One year after surgery, body image median scores
were 33.3/100 and 16.7/100 in the continent and non-­continent
group, respectively, but this difference was not significant.
Discussion
In this study, we found that the rate of severe complications
was similar in the continent and non-­continent diversion groups
(approximately 43%). In addition, the rate of severe complications
requiring surgical reintervention and/or interventional radiology
procedures was not significantly different between the two groups
(approximately 30% and <15%, respectively). Regarding the type
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groups. In the continent group, the most frequent complication
was digestive and in the non-­continent group it was infectious. In
both groups, urinary complications were the second most common
type. However, in the non-­continent group, there was a significantly
higher proportion of patients undergoing total pelvic exenteration,
which carries a greater morbidity, and could have increased the
complication rate due to the exenterative procedure in this group.
Pelvic exenteration has been associated with a high rate of post-
operative complications, most likely increased by previous irradia-
tion, estimated at approximately 40–50% for major complications
and 80% for minor complications.19 This high morbidity remains an
important concern. Recently, Lago et al published a retrospective
study including patients who underwent pelvic exenteration with
incontinent urinary and/or digestive reconstruction for gyneco-
logic malignancies, and found a rate of grade III–IV complications
according to the Clavien-­Dindo classification of 48%, in line with
our results. In agreement with our study, they observed a similar
rate of urinary and digestive complications (approximately 17%
and 26%, respectively).20 Four previous studies have compared the
rate of complications between continent and incontinent urinary
diversion in patients with gynecologic cancers. Age and patient
baseline characteristics were comparable with our patients. None
of these four studies found significant differences in postoperative
complications.9–12 However, Urh et al reported a higher risk of stone
formation in patients undergoing continent reconstruction (34.8%
vs 2.3%, P=0.001).9 It is now well established that the use of auto-
matic non-­absorbable staplers is associated with an increased risk
of stone formation13; for this reason, absorbable staples should
be used when performing a continent urinary diversion.14 Houve-
naeghel et al described a non-­significant higher rate of overall
postoperative 12 week surgical complications in the incontinent
diversion group compared with the continent group (12.9% and

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Table 3 Quality of life from time of surgery at baseline, and at 1, 3, 6, and 12 months (n=56)
Continent
vs non-­
continent
at 12
Initial (before months (P
QLQ-­C30 surgery) 1 month 3 months 6 months 12 months value)
General health and 58.3 (0–100) 41.7 (0–83.3) 50 (16.7–83.3) 58.3 (8.3–100) 58.3 (0–100) 0.891
global quality of life
Functional scales
 Physical 80 (20–100) 46.7 (0–100) 73.3 (6.7–100) 80 (0–100) 86.7 (26.7–100) 0.195
 Role 83.3 (0–100) 33.3 (0–100) 75 (0–100) 83.3 (0–100) 83.3 (0–100) 0.322
 Emotional 58.3 (0–100) 66.7 (0–100) 75 (0–100) 79.2 (16.7–100) 75 (33.3–100) 0.172
 Cognitive 83.3 (0–100) 66.7 (0–100) 83.3 (33.3–100) 91.7 (0–100) 83.3 (16.7–100) 0.517
 Social 66.7 (0–100) 50 (0–100) 66.7 (0–100) 66.7 (0–100) 66.7 (0–100) 0.413
Symptom scales
 Fatigue 38.9 (0–100) 77.8 (11.1–100) 44.4 (0–100) 44.4 (0–100) 27.8 (0–100) 0.657
 Pain 33.3 (0–100) 33.3 (0–100) 33.3 (0–100) 16.7 (0–100) 16.7 (0–100) 0.517
 Insomnia 33.3 (0–100) 33.3 (0–100) 33.3 (0–100) 0 (0–100) 33.3 (0–100) 0.219
 Constipation 16.7 (0–100) 0 (0–100) 0 (0–100) 0 (0–66.7) 0 (0–100) 0.847
 Financial difficulties 16.7 (0–100) 0 (0–100) 0 (0–66.7) 0 (0–100) 0 (0–66.7) 0.432
 Nausea/vomiting 0 (0–83.3) 16.7 (0–83.3) 0 (0–83.3) 0 (0–66.7) 0 (0–50) 0.785
 Dyspnea 0 (0–100) 0 (0–100) 0 (0–33.3) 0 (0–66.7) 0 (0–33.3) 0.375

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 Loss of appetite 33.3 (0–100) 66.7 (0–100) 33.3 (0–100) 0 (0–100) 0 (0–33.3) 0.385
 Diarrhea 0 (0–100) 33.3 (0–100) 0 (0–100) 33.3 (0–100) 0 (0–66.7) 0.657
QLQ-­OV28
Abdominal complaints 22.2 (0–72.2) 33.3 (0–83.3) 25 (0–77.8) 22.2 (0–66.7) 16.7 (0–55.6) 0.973
Peripheral neuropathy 0 (0–100) 0 (0–100) 16.7 (0–66.7) 16.7 (0–66.7) 16.7 (0–50) 0.973
Menopausal 33.3 (0–100) 0 (0–83.3) 8.3 (0–66.7) 8.3 (0–83.3) 8.3 (0–100) 0.785
symptoms
Body image 33.3 (0–100) 50 (0–100) 50 (0–100) 33.3 (0–100) 33.3 (0–100) 0.277
Attitude towards 72.2 (0–100) 77.8 (0–100) 66.7 (0–100) 66.7 (11.1–100) 61.1 (0–100) 0.707
disease/treatment
Chemotherapy side 26.7 (0–93.3) 26.7 (0–73.3) 20 (0–60) 20 (0–60) 15 (0–60) 0.322
effects

Values are median (range).

QLQ, quality of life questionnaire.

6.25%, respectively).10 These last two studies reported a higher
rate of severe urinary complications than our study (approximately
30–40% compared with 16% in our study).9 10 Ramirez et al found
that infection was the most frequent complication after pelvic exen-
teration with the Miami pouch continent urinary reconstruction,
with a rate of 35%, twice the rate reported in our study.13
Some factors have been related to an increased rate of post-
operative complications after pelvic exenteration. Nahar et al
found that urinary diversion after radical cystectomy for bladder
cancer performed at a non-­academic center was an independent
predictor of 30 day readmission (odds ratio 1.19, P=0.010) and was
associated with a higher rate of 30 day mortality (odds ratio 1.27,
P=0.043).21 In our multicenter study, all patients were included in
the referral academic centers and this could explain our accept-
able rate of severe postoperative complications after these high
level salvage procedures. In another study, Leow et al showed that
there was an inverse relationship between the volume of surgeries
per surgeon and the occurrence of 90 day postoperative major
complications.22 For these reasons, urologic international recom-
mendations are to perform these types of procedures exclusively in
high volume hospitals with 40–50 cases per year.23 However, none
of the centers included in our study performed these numbers of
procedures per year for gynecologic malignancies.
Quality of Life Assessment
We did not find significant differences between the two groups
regarding quality of life 1 year after surgery for any of the items eval-
uated by the questionnaires. However, we observed lower median
scores in global health and global quality of life scores in the conti-
nent diversion group 1 month after surgery. One year after surgery,
this difference was reversed, and the median scores were higher in
the continent group. Nevertheless, this difference was not significant.

238 Angeles MA, et al. Int J Gynecol Cancer 2020;30:233–240. doi:10.1136/ijgc-2019-000863


Figure 2 (A) Global health and global quality of life evolution during the first year after pelvic exenteration and continent or
non-­continent urinary reconstruction. (B) Body image evolution during the first year after pelvic exenteration and continent or
non-­continent urinary reconstruction.
Regarding body image perception, the continent group attained the
highest median score later than the non-­continent group (58.3/100
at 3 months vs 66.7/100 at 1 month). One year after surgery, the
continent group maintained higher scores than the incontinent group,
although the difference was not significant. A possible explanation for
the initially lower median scores in global health, quality of life, and
body image in the continent group may be the learning process of
self-­catherization, which can be very difficult for half of the patients,
as reported in other studies.12 The higher median scores, even if not
significant, 1 year after surgery in the continent diversion group may
be explained by the absence of ostomies in patients undergoing a
continent urinary reconstruction after pelvic exenteration.
Controversial results can be found in the literature regarding
quality of life after continent and non-­continent urinary reconstruc-
tion. Recently, Ziouziou et al performed a meta-­analysis including four
studies which compared the health related quality of life between the
Bricker procedure—a non-­continent diversion—and continent orthot-
opic neobladder in patients undergoing an anterior pelvic exenteration
for bladder cancer. The results demonstrated better urinary func-
tion and urinary bother scores in the non-­continent diversion group
(urinary function scores referring to the frequency of these symptoms,
and urinary bother scores referring to the individual perception of
these symptoms). In contrast, sexual function was significantly better
in orthotopic neobladder patients. However, among these four studies,
only one evaluated quality of life prospectively, and all used the Bladder
Cancer Index to assess quality of life which is a non-­validated tool for
this purpose.24 Conversely, Dessole et al assessed quality of life in 96
patients undergoing a pelvic exenteration with urinary reconstruction
for gynecological cancer. It was a retrospective, multicenter study that
showed that non-­continent urinary reconstruction was an indepen-
dent predictor of poorer global health status scores and lower body
image.25 A review from the International Consultation on Urological
Diseases stated that there was no evidence of a better quality of life
when a continent reconstruction was performed after radical cystec-
tomy instead of a conduit diversion in patients with bladder cancer.26
In our series, 47% of patients underwent vaginal reconstruction with
Angeles MA, et al. Int J Gynecol Cancer 2020;30:233–240. doi:10.1136/ijgc-2019-000863
Original research
Int J Gynecol Cancer: first published as 10.1136/ijgc-2019-000863 on 2 December 2019. Downloaded from http://ijgc.bmj.com/ on August 7, 2020 at University of N S Wales 1247645.
similar rates in the continent and non-­continent groups. This type of
reconstruction may positively impact on the patient's quality of life,
body image perception, and sexuality.8 Parameters such as comor-
bidities, previous surgical and radiation history, obesity, baseline renal
Protected by copyright.
and hepatic function, sexual function, and ability to self-­catheterize
should be considered in the choice of urinary diversion.2
The main strengths of our study are its multicenter design,
comprising 10 referral academic centers, and the large number of
patients (n=148), which is particularly interesting as pelvic exen-
teration is not a frequent procedure. One of the limitations of our
study may be that we assessed quality of life in only 56 patients,
as the remaining 92 patients were included retrospectively. This
low number of patients may be the reason why we did not find
significant differences between the groups. Nevertheless, pelvic
exenteration in gynecologic malignancies is a salvage procedure,
and therefore it is not frequently performed. Another limitation
could be that complications were not chronologically classified
as early and late, which would have been relevant in the assess-
ment of postoperative morbidity. To our knowledge, this is the only
study comparing both complication rate and quality of life between
patients undergoing continent and non-­continent urinary recon-
structions after a pelvic exenteration for gynecologic cancers. We
believe that pelvic exenteration and reconstructive procedures
are very complex interventions needing high level surgical skills.
It usually involves complex vaginal reconstruction with myocuta-
neous and perforator flaps3 27 as well as anorectal, perineal, and
vascular reconstructions.14 For this reason, all patients requiring
this type of salvage surgery should be referred to high volume
centers with multidisciplinary teams.28 This would allow patients to
have several options for reconstructive techniques. Currently, there
is a trend towards functioning and anatomic reconstructions, such
as orthotopic neobladder. However, improvement in quality of life in
these patients has yet to be evaluated.
In summary, continent and non-­continent urinary diversions after
pelvic exenteration for gynecologic malignancies seem to be equiv-
alent in terms of severe postoperative complications and quality of
239
Original research
life, even though there was a trend towards better long term quality
of life in patients with continent urinary reconstructions. The choice
of urinary reconstruction should be based on the surgeon's experi-
ence and the patient's preference.
Author affiliations
1
Surgical Oncology, Institut Claudius Regaud IUCT-­oncopole, Toulouse, Occitanie,
France
2 after pelvic exenteration for cervical cancer. Gynecol Oncol
Surgical Oncology, Centre Antoine-­Lacassagne, Nice, Provence-­Alpes-­Côte d'Azu,
France
3
Department of Surgical Oncology, Institut régional du Cancer de Montpellier,
Montpellier, France
4
Biostatistics Unit, Institut Claudius Regaud, Toulouse, Occitanie, France
5
Department of Surgical Oncology, Institut Léon Bérard, Lyon, France
6 after continent versus incontinent urinary diversion at the time of
Institut Paoli-­Calmettes, Marseille, France
7 pelvic exenteration for gynecologic malignancies. Gynecol Oncol
Department of Surgical Oncology, Centre Eugene Marquis, Rennes, Bretagne,
France
8
Gynecology, Centre Oscar Lambret, lille, France
9
Institut de Cancerologie de l'Ouest, Nantes, France
10
Institut Gustave-­Roussy, Villejuif, Île-­de-­France, France
11
Institut Bergonie, Bordeaux, France
12
Surgical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-­les-­Nancy,
Lorraine, France
13
Medical Oncology, Institut Claudius Regaud, Toulouse, Occitanie, France
14
INSERM CRCT 1, Toulouse, France
15
Department of Women, Children and Adolescents, Hopitaux Universitaires de
Geneve, Geneva, Switzerland
16
Institut Claudius Regaud, Toulouse, Occitanie, France
17
INSERM CRCT 19, Toulouse, France
Twitter Martina Aida Angeles @AngelesFite and Alejandra Martinez @Alejandra
Contributors MAA: conceptualization, data curation, methodology, and writing–
original draft. EM: conceptualization, data curation, methodology, and writing–
original draft. PR: conceptualization, project administration, and methodology
writing–review. BC: conceptualization, data curation, methodology, statistical
analyses, and writing–review. PM: conceptualization, project administration, and
methodology writing–review. EL: conceptualization, project administration, and
methodology writing–review. FF: conceptualization, project administration, and
methodology writing– review. FN: conceptualization, project administration, and
methodology writing–review. CL: conceptualization, project administration, and
methodology writing–review. SG: conceptualization, project administration, and
methodology writing– review. FG: conceptualization, project administration, and
methodology writing–review. FM: conceptualization, project administration, and
methodology writing–review. LG: conceptualization, project administration, and
methodology writing– review. CM-­G: conceptualization, data curation, methodology,
and writing–original draft. FM: conceptualization, data curation, methodology,
and writing–original draft. AM: conceptualization, project administration, and
methodology writing–review. GF: conceptualization, project administration, and
methodology writing– review.
Funding This study was supported by a grant from the French Ministry of Health
(STIC (support for innovative and expensive techniques), 2007, Exenteration
pelvienne).
Competing interests None declared.
Patient consent for publication Obtained.
Ethics approval Institutional review board approval was obtained from all centers.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request. All data
relevant to the study are included in the article or uploaded as supplementary
information.
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