Pelvic exenteration and urinary reconstruction: A comparative analysis of surgical and oncologic outcomes

Pelvic exenteration (PE) performed for locally advanced or recurrent pelvic malignancies often required urinary reconstruction but associated with high postoperative morbidity (POM). The influence of urinary diversion type on outcomes remains uncertain.

This retrospective cohort study included 90 patients who underwent PE with urinary reconstruction between 2016 and 2023. Urinary diversions were classified as ileal conduit and alternative reconstructions (vesico-urethral anastomosis, Mitrofanoff procedure, ureteral implantation and enterocystoplasty). POM, quality of life (QoL; EQ-5D-5L questionnaire), bowel dysfunction (LARS and Wexner scores), and overall (OS) and disease-free survival (DFS) were analyzed. Statistical analyses compared outcomes between groups.

Sixty-two patients (69%) underwent an ileal conduit and 28 (31%) an alternative urinary reconstruction.The POM rate occurred in 66% of cases, including 34% experiencing major complications with no difference between groups (p = 0.86). Urologic complications were observed in 13% of patients, mainly urinary tract infections (10%); urine leaks (5%) occurred only after ileal conduit. Severe bowel dysfunction (major LARS) affected 30% and significant fecal incontinence (Wexner >10) 35% of patients, with a trend toward worse outcomes in the alternative reconstruction group. QoL was similar across most domains, except for the "usual activities" category, which were more limited after alternative reconstructions(p = 0.046). OS and DFS were comparable while primary cancer had significantly better outcomes than recurrent cancers (p < 0.001).

Ileal conduit remains the predominant urinary diversion following PE. Alternative reconstructions do not significantly impact morbidity, survival or QoL, except for a modest limitation in "usual activities". Shared decision-making is essential given the high morbidity and complex functional sequelae of PE.