TECHNICAL NOTES
Pelvic Bladder Sling for Radiotherapy Raymond Yap, M.B.B.S., B.Med.Sc. • David Lloyd, M.B.B.S., F.R.A.C.S.(Gen.Surg.) Austin Hospital, Heidelberg, Victoria, Australia
Key Words: Rectal cancer; Colon and rectal surgery; General surgery; Radiation proctitis/enteritis.
I
n the past decade, rectal carcinoma has been increasingly treated with neoadjuvant chemoradiotherapy.1 Despite this, there is still a small subgroup of patients who present with perforated rectal cancer in whom treatment with neoadjuvant chemoradiotherapy is not possible. In addition, adjuvant radiotherapy may be considered in those patients in whom the preoperative staging underestimated the stage. However, significant complications can result, one of which is small-bowel radiation injury.2 Various methods are used to prevent this, including wedging of the radiation beams, careful pretherapy planning, and correct positioning of the patient.
FIGURE 2. Anterior surface of bladder fully mobilized from the anterior abdominal wall.
Despite these efforts, radiation enteritis is often a limiting factor to the delivery of effective adjuvant radiotherapy. Typically, this can be limited surgically by placing a sling to cover the pelvic brim and prevent the descent of the small bowel below the pelvic brim. Numerous techniques have been described using mesh through either open3 or laparoscopic methods4; these all carry the inherent complications of using mesh, especially if done at the original operation where the procedure is contaminated by the resection of large bowel. A separate sling operation incurs the risks of a second anesthetic, the challenges of entering a space that has been previously operated on, as well as a delay in treatment. We note that little research or
FIGURE 1. Lateral edges of bladder being mobilized from the peritoneum. abdo = abdominal.
Financial Disclosure: None reported. Correspondence: Raymond Yap, M.B.B.S., B.Med.Sc., Austin Hospital, Studley Rd, Heidelberg 3084, VIC, Australia. E-mail: Raymond.yap@ austin.org.au Dis Colon Rectum 2014; 57: 546–548 DOI: 10.1097/DCR.0000000000000102 © The ASCRS 2014
546
FIGURE 3. Small bowel being placed over the pelvic brim. Diseases of the Colon & Rectum Volume 57: 4 (2014)
Diseases of the Colon & Rectum Volume 57: 4 (2014)
FIGURE 4. Securing the small bowel over the pelvic brim with 2-0 Vicryl sutures. abdo = abdominal.
f ollow-up has been conducted on these patients regarding their complication rates. We would like to propose a different method of enclosing the small bowel within the abdomen that is simple, effective, and without many of the complications that come with mesh. The bladder is a highly pliable organ that can be safely mobilized from its attachments to the anterior abdominal wall, leaving it free to then act as a sling over the pelvic brim and provide an effective barrier against the descent of the small bowel. The authors have used this technique for several years, and our radiotherapy oncology colleagues attest that this is effective in reducing
547
small-bowel radiation injury. In addition, we have noted no significant urinary complications. Initially, a midline laparotomy incision is made from the pubic symphysis to below the umbilicus. Ideally, this incision already has been made as part of an open operation, or for retrieval of the specimen in a laparoscopic-assisted case. Mobilization of the bladder is then done from its attachments to the anterior abdominal wall. The peritoneum on each side of the bladder is incised, freeing the bladder from its attachments until the lateral pedicles (Fig. 1). Care is taken to ensure meticulous hemostasis and not to enter the muscle fibers of the bladder. Sharp dissection is then used to separate the bladder wall from the anterior abdominal wall until the pelvic brim (Fig. 2). Once sufficiently mobilized, the small bowel is retracted from the pelvis into the abdomen and the bladder is placed over the pelvic brim (Fig. 3). To secure the bladder to the retroperitoneal and lateral abdominal wall, 2-0 interrupted Vicryl sutures are used approximately 1 cm apart (Fig. 4). If large bowel is entering the pelvis, then the bladder is stitched directly to the large bowel with seromuscular sutures. The rest of the operation is completed in a standard fashion, with closure of the anterior abdominal wall wound. We have found no problems with urinary incontinence, retention, urgency, or frequency in our patients. Furthermore, the lack of foreign material allows this procedure to be performed at the initial operation, saving the patient an additional anesthetic. A CT scan demonstrating the result can be seen in Figure 5. In addition, the bladder can be filled
FIGURE 5. This figure refers to a patient who underwent a Hartmann procedure for perforated rectal cancer. The images on the left are approximately 2 years before the images on the right. A, These are preoperative images of the pelvis. The upper image is a MRI sagittal slice of the pelvis. The white arrow indicates the bladder, the brown arrow indicates the rectum, and the red arrow indicates the small bowel. As can be seen here, the small bowel has started to enter the pelvis, and there is nothing to prevent its further descent. B, These are CT coronal, sagittal, and axial slices of the postoperative pelvis. As can be seen, the red arrow points to the remaining rectal stump that has been isolated in the pelvis by the bladder (white arrow). The small bowel has been safely quarantined in the abdomen.
548
through a urinary catheter in a retrograde fashion at the time of radiotherapy to further push the small bowel out of the pelvis, expanding the existing radiation field. Over the past 5 years, there has been a total of 12 patients who had this procedure performed for perforated rectal cancer in conjunction with an abdominoperineal resection or Hartmann procedure. A chart review was performed with each of the patients with a mean follow-up of 20.4 months (range, 6–40 months). None of the patients have had presentations for symptoms of small-bowel enteritis. One patient required reoperation for adhesive small-bowel obstruction, which was made technically easier by the lack of the need to explore the pelvis. One patient had a prostate-rectal stump fistula resulting from the removal of a perforated rectal cancer adherent to the prostate; he had had external beam radiation 6 years earlier for prostate cancer, which required a gracilis flap, and he remained free of urinary symptoms after. The sling was created on consultation with our radiation oncologists who were considering further radiotherapy. One other patient had urinary frequency thought to be secondary to benign prostatic hypertrophy. The authors would suggest that this is an effective and simple method to exclude the small bowel from the pelvis. In addition, such a technique may lessen the risk of the
YAP AND LLOYD: PELVIC BLADDER SLING FOR RADIOTHERAPY
small bowel prolapsing through a perineal wound in an abdominoperineal resection where an extended resection including part of the pelvic floor complex has been taken. There is no reason why this method could not be used to exclude the small bowel for radiotherapy of other pelvic cancers, eg, prostate. The authors acknowledge that further studies with more detailed follow-up will be necessary to prove its efficacy, and that limitations exist in this technical note in relation to a relatively short follow-up period and the retrospective nature of the case series. REFERENCES 1. Sauer R, Becker H, Hohenberger W, et al; German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–1740. 2. Nguyen NP, Antoine JE, Dutta S, Karlsson U, Sallah S. Current concepts in radiation enteritis and implications for future clinical trials. Cancer. 2002;95:1151–1163. 3. Waddell BE, Lee RJ. Absorbable mesh sling prevents radiation-induced bowel injury during “sandwich” chemoradiation for rectal cancer. Arch Surg. 2000;135:1212–1217. 4. Joyce M, Thirion P, Kiernan F, et al. Laparoscopic pelvic sling placement facilitates optimum therapeutic radiotherapy delivery in the management of pelvic malignancy. Eur J Surg Oncol. 2009;35:348–351.
Pelvic Bladder Sling for Radiotherapy Raymond Yap, M.B.B.S., B.Med.Sc. • David Lloyd, M.B.B.S., F.R.A.C.S.(Gen.Surg.) Austin Hospital, Heidelberg, Victoria, Australia
Key Words: Rectal cancer; Colon and rectal surgery; General surgery; Radiation proctitis/enteritis.
I
n the past decade, rectal carcinoma has been increasingly treated with neoadjuvant chemoradiotherapy.1 Despite this, there is still a small subgroup of patients who present with perforated rectal cancer in whom treatment with neoadjuvant chemoradiotherapy is not possible. In addition, adjuvant radiotherapy may be considered in those patients in whom the preoperative staging underestimated the stage. However, significant complications can result, one of which is small-bowel radiation injury.2 Various methods are used to prevent this, including wedging of the radiation beams, careful pretherapy planning, and correct positioning of the patient.
FIGURE 2. Anterior surface of bladder fully mobilized from the anterior abdominal wall.
Despite these efforts, radiation enteritis is often a limiting factor to the delivery of effective adjuvant radiotherapy. Typically, this can be limited surgically by placing a sling to cover the pelvic brim and prevent the descent of the small bowel below the pelvic brim. Numerous techniques have been described using mesh through either open3 or laparoscopic methods4; these all carry the inherent complications of using mesh, especially if done at the original operation where the procedure is contaminated by the resection of large bowel. A separate sling operation incurs the risks of a second anesthetic, the challenges of entering a space that has been previously operated on, as well as a delay in treatment. We note that little research or
FIGURE 1. Lateral edges of bladder being mobilized from the peritoneum. abdo = abdominal.
Financial Disclosure: None reported. Correspondence: Raymond Yap, M.B.B.S., B.Med.Sc., Austin Hospital, Studley Rd, Heidelberg 3084, VIC, Australia. E-mail: Raymond.yap@ austin.org.au Dis Colon Rectum 2014; 57: 546–548 DOI: 10.1097/DCR.0000000000000102 © The ASCRS 2014
546
FIGURE 3. Small bowel being placed over the pelvic brim. Diseases of the Colon & Rectum Volume 57: 4 (2014)
Diseases of the Colon & Rectum Volume 57: 4 (2014)
FIGURE 4. Securing the small bowel over the pelvic brim with 2-0 Vicryl sutures. abdo = abdominal.
f ollow-up has been conducted on these patients regarding their complication rates. We would like to propose a different method of enclosing the small bowel within the abdomen that is simple, effective, and without many of the complications that come with mesh. The bladder is a highly pliable organ that can be safely mobilized from its attachments to the anterior abdominal wall, leaving it free to then act as a sling over the pelvic brim and provide an effective barrier against the descent of the small bowel. The authors have used this technique for several years, and our radiotherapy oncology colleagues attest that this is effective in reducing
547
small-bowel radiation injury. In addition, we have noted no significant urinary complications. Initially, a midline laparotomy incision is made from the pubic symphysis to below the umbilicus. Ideally, this incision already has been made as part of an open operation, or for retrieval of the specimen in a laparoscopic-assisted case. Mobilization of the bladder is then done from its attachments to the anterior abdominal wall. The peritoneum on each side of the bladder is incised, freeing the bladder from its attachments until the lateral pedicles (Fig. 1). Care is taken to ensure meticulous hemostasis and not to enter the muscle fibers of the bladder. Sharp dissection is then used to separate the bladder wall from the anterior abdominal wall until the pelvic brim (Fig. 2). Once sufficiently mobilized, the small bowel is retracted from the pelvis into the abdomen and the bladder is placed over the pelvic brim (Fig. 3). To secure the bladder to the retroperitoneal and lateral abdominal wall, 2-0 interrupted Vicryl sutures are used approximately 1 cm apart (Fig. 4). If large bowel is entering the pelvis, then the bladder is stitched directly to the large bowel with seromuscular sutures. The rest of the operation is completed in a standard fashion, with closure of the anterior abdominal wall wound. We have found no problems with urinary incontinence, retention, urgency, or frequency in our patients. Furthermore, the lack of foreign material allows this procedure to be performed at the initial operation, saving the patient an additional anesthetic. A CT scan demonstrating the result can be seen in Figure 5. In addition, the bladder can be filled
FIGURE 5. This figure refers to a patient who underwent a Hartmann procedure for perforated rectal cancer. The images on the left are approximately 2 years before the images on the right. A, These are preoperative images of the pelvis. The upper image is a MRI sagittal slice of the pelvis. The white arrow indicates the bladder, the brown arrow indicates the rectum, and the red arrow indicates the small bowel. As can be seen here, the small bowel has started to enter the pelvis, and there is nothing to prevent its further descent. B, These are CT coronal, sagittal, and axial slices of the postoperative pelvis. As can be seen, the red arrow points to the remaining rectal stump that has been isolated in the pelvis by the bladder (white arrow). The small bowel has been safely quarantined in the abdomen.
548
through a urinary catheter in a retrograde fashion at the time of radiotherapy to further push the small bowel out of the pelvis, expanding the existing radiation field. Over the past 5 years, there has been a total of 12 patients who had this procedure performed for perforated rectal cancer in conjunction with an abdominoperineal resection or Hartmann procedure. A chart review was performed with each of the patients with a mean follow-up of 20.4 months (range, 6–40 months). None of the patients have had presentations for symptoms of small-bowel enteritis. One patient required reoperation for adhesive small-bowel obstruction, which was made technically easier by the lack of the need to explore the pelvis. One patient had a prostate-rectal stump fistula resulting from the removal of a perforated rectal cancer adherent to the prostate; he had had external beam radiation 6 years earlier for prostate cancer, which required a gracilis flap, and he remained free of urinary symptoms after. The sling was created on consultation with our radiation oncologists who were considering further radiotherapy. One other patient had urinary frequency thought to be secondary to benign prostatic hypertrophy. The authors would suggest that this is an effective and simple method to exclude the small bowel from the pelvis. In addition, such a technique may lessen the risk of the
YAP AND LLOYD: PELVIC BLADDER SLING FOR RADIOTHERAPY
small bowel prolapsing through a perineal wound in an abdominoperineal resection where an extended resection including part of the pelvic floor complex has been taken. There is no reason why this method could not be used to exclude the small bowel for radiotherapy of other pelvic cancers, eg, prostate. The authors acknowledge that further studies with more detailed follow-up will be necessary to prove its efficacy, and that limitations exist in this technical note in relation to a relatively short follow-up period and the retrospective nature of the case series. REFERENCES 1. Sauer R, Becker H, Hohenberger W, et al; German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–1740. 2. Nguyen NP, Antoine JE, Dutta S, Karlsson U, Sallah S. Current concepts in radiation enteritis and implications for future clinical trials. Cancer. 2002;95:1151–1163. 3. Waddell BE, Lee RJ. Absorbable mesh sling prevents radiation-induced bowel injury during “sandwich” chemoradiation for rectal cancer. Arch Surg. 2000;135:1212–1217. 4. Joyce M, Thirion P, Kiernan F, et al. Laparoscopic pelvic sling placement facilitates optimum therapeutic radiotherapy delivery in the management of pelvic malignancy. Eur J Surg Oncol. 2009;35:348–351.
