Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center

Our plain-English summary of Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center, by C.G. Trujillo, C. Domínguez, D. Robledo, et al (Acta Chirurgica Belgica, 2018).

The study

• Authors: C.G. Trujillo, C. Domínguez, D. Robledo, J.I. Caicedo, A. Bravo-Balado, J.G. Cataño, N. Cortés, L. Parra, W. Riaño, E. Londoño-Schimmer, J. Otero, G. Herrera, F. Arias, M. Plata
• Journal: Acta Chirurgica Belgica
• Published: 2018;118(6):348-353
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant manipulation of the urinary tract (UT). We aim to describe the urological events and their management in patients who underwent CRS-HIPEC.

Methods: Clinical records of patients who underwent treatment between 2007 and 2015 were reviewed. Urological events and their multidisciplinary management were analyzed. Descriptive statistics were calculated.

Results: A total of 103 patients were included. Mean age was 51 years (SD ± 11.8). Mean peritoneal cancer index (PCI) was 20.4 (SD ± 10.1). Primary tumors included appendicular (64%), gynecological (16%), colorectal (10%), and peritoneal mesotheliomas (9%). Ninety-three percent of patients had bilateral ureteral catheters inserted prior to surgery, without complications. Intraoperative UT injuries occurred in 7% of patients. In 5% of patients, tumor invasion of the bladder was evident at surgery and partial resection and primary repair of the bladder wall was performed. Urological complications included urinary tract infection (UTI) (21%) acute post-renal failure (4%), urinary fistulae (4%), and acute urinary retention (AUR) (1%).

Conclusions: In our study, intraoperative UT events and postoperative complications, although not neglectable, were infrequent. Due to the high complexity of these cases, a multidisciplinary approach is mandatory. However, randomized clinical trials are necessary to clarify current data on the need and efficacy of prophylactic ureteral catheterization in patients undergoing CRS-HIPEC.

In plain English

This was a descriptive retrospective study from a specialist center for peritoneal cancers at Hospital Universitario Fundacion Santa Fe de Bogota, Colombia. The authors reviewed the records of 103 patients who had cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) between November 2007 and December 2015. CRS-HIPEC is an extensive abdominal cancer operation combined with heated chemotherapy. The authors described problems involving the urinary tract. Nine patients (8.7%) had peritoneal mesothelioma, and most had appendix tumors. The article did not study asbestos exposure. Ninety-six patients (93.2%) had catheters placed in both ureters before surgery, with no complications from insertion. Urinary tract injuries during surgery occurred in 7 patients (6.8%): 5 bladder and 2 ureteral. After surgery, 22 patients (21.4%) had symptomatic urinary tract infections. Four (3.9%) had acute obstructive uropathy (blocked urine drainage) after catheter removal, 4 (3.9%) had urinary fistulae (abnormal passages), and 1 had acute urinary retention. The authors concluded these problems were infrequent and called for randomized trials on preventive ureteral catheterization. They named the retrospective, descriptive design and small sample as limitations.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Descriptive retrospective study of clinical records (single center)
• Who was studied: 103 patients (77 female, 26 male; mean age 51) who underwent CRS-HIPEC between November 2007 and December 2015 at the Clinical Care Center for Peritoneal Neoplasms, Hospital Universitario Fundacion Santa Fe de Bogota, Colombia. Primary tumors were appendix 66 (64.1%), gynecological 16 (15.5%), colorectal 10 (9.7%), peritoneal mesothelioma 9 (8.7%) and other 2 (1.9%).
• Exposure: No asbestos exposure was studied. What was studied was CRS-HIPEC surgery, usually with prophylactic ureteral catheterization. The intraperitoneal chemotherapy was a combination of cisplatin, doxorubicin, or mitomycin-c, circulated for 90 minutes at 41.0 to 42.9 degrees.
• Main results:
  • 96 of 103 patients (93.2%) had catheters in both ureters before surgery. One had a single catheter, 2 had double-J stents and 4 (3.9%) had no catheterization. There were no complications related to catheter insertion.
  • Intraoperative urinary tract injuries occurred in 7 patients (6.8%): 5 bladder injuries (4.9%) and 2 ureteral injuries (1.9%).
  • In another 5 patients (4.9%), tumor invasion of the bladder was found at surgery and was treated with partial resection and primary repair.
  • Ureteral and bladder complications occurred only in women. These patients had a higher peritoneal cancer index (28.0 vs. 20.3 for ureteral complications; 24.6 vs. 20.2 for bladder complications).
  • 22 patients (21.4%) had symptomatic urinary tract infection with positive urine cultures. All were treated with intravenous antibiotics, with no further complications.
  • 4 patients (3.9%) developed acute obstructive uropathy after catheter removal. These patients had received an average of 10.6 liters of crystalloids in the first 24 hours, and all were treated with double-J stenting.
  • 4 patients (3.9%) developed urinary fistulae, diagnosed at a median of 29.5 days (range 19 to 36).
  • One patient developed acute urinary retention.
  • All 99 patients (96.1%) whose urinary tract was instrumented had non-symptomatic visible blood in the urine, which was not counted as a complication. None of the 4 patients without catheterization developed gross hematuria or any complication.
  • On the Clavien–Dindo scale, 23 patients (74.2%) had grade II complications and 8 (25.8%) had grade IIIb complications.
• The authors' conclusion: The authors concluded that postoperative complications and intraoperative urinary tract injuries were infrequent and comparable to other high-volume centers. They concluded that a multidisciplinary approach is mandatory and that randomized trials are needed on the need for, and efficacy of, prophylactic ureteral catheterization.
• Limitations the authors state:
  • The retrospective, descriptive design and small sample made inferential analyses difficult.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Cancer Index (PCI), Peritoneal Mesothelioma, Bilateral, Multidisciplinary Team, Clinical Trial.

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