Clinical Study Received: July 16, 2013 Accepted after revision: February 2, 2014 Published online: June 7, 2014
Oncology 2014;86:303–307 DOI: 10.1159/000360294
The Incidence of Genitourinary and Gastrointestinal Complications in Open and Endoscopic Gynecologic Cancer Surgery Christopher R. Rettenmaier a Nicholas B. Rettenmaier a Lisa N. Abaid b John V. Brown b John P. Micha b Alberto A. Mendivil b Tomasz Wojciechowski b Bram H. Goldstein b Maurie Markman c
a
The Nancy Yeary Women’s Cancer Research Foundation and b Gynecologic Oncology Associates, Newport Beach, Calif., and c Cancer Treatment Centers of America, Philadelphia, Pa., USA
Abstract Objectives: The purpose of this study was to examine the incidence of genitourinary and intestinal tract injuries in an effort to identify which factors might predispose a patient to developing one of these surgical complications. Methods: We retrospectively evaluated the charts of gynecologic cancer patients who were treated at a single medical institution from January 2002 to February 2011. The following study variables were noted for evaluation: age, BMI, cancer origin, disease recurrence, a history of pelvic surgery, surgery type, operative approach and injury classification (genitourinary or gastrointestinal). Results: In our group of 1,618 patients, a total of 47 (2.9%) gastrointestinal and 18 (1.1%) genitourinary tract injuries were encountered. There were no intraoperative-related deaths but 2 patients expired 1 month after surgery. Logistic regression indicated that surgery type, undergoing an open procedure, cancerous involvement of the bowel or genitourinary tract and a history of pelvic surgery
© 2014 S. Karger AG, Basel 0030–2414/14/0866–0303$39.50/0 E-Mail [email protected] www.karger.com/ocl
were significant predictors of operative injury occurrence [χ2 (28) = 167.22; p < 0.001]. Conclusions: We ascertained a relatively low incidence of gastrointestinal and genitourinary complications. Nevertheless, undergoing an open procedure, a history of pelvic surgery and surgical involvement of the bowel or genitourinary tract were predictive of an increased risk for these aforementioned injuries. © 2014 S. Karger AG, Basel
Introduction
Iatrogenic injuries are an unfortunate outcome in patients undergoing surgical treatment. In gynecologic oncology, genitourinary and intestinal tract complications periodically occur because the disease is often extensive and proximal to relevant pelvic organs [1–3]. Gastrointestinal injuries that are incurred during gynecologic surgery have a reported incidence of 0.3–0.6% [4–6] and often coincide with pneumoperitoneum initiation or trocar employment during endoscopic procedures [7, 8]. Similarly, genitourinary complications (injuries involving the bladder or ureter) occur in approximately Bram H. Goldstein, PhD Gynecologic Oncology Associates 351 Hospital Road, Suite 507 Newport Beach, CA 92663 (USA) E-Mail bram @ gynoncology.com
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Key Words Pelvic surgery · Iatrogenic injuries · Genitourinary and gastrointestinal tract complications · Gynecologic cancer
Materials and Methods Inclusion and Exclusion Criteria Our retrospective study encompassed a chart review of all invasive gynecologic (e.g. ovarian, uterine, cervical and vaginal) cancer patients who were managed and under surveillance at a single, tertiary, nonacademic healthcare institution from January 2002 until February 2011. An evaluation of patient records from our clinic database identified 1,980 patients who comprised the subject of this investigation. Patients who did not undergo treatment for their gynecologic malignancy or follow-up by the same group of gynecologic oncologists (i.e. patients who were treated at multiple hospitals or for whom adequate operative and follow-up data were not available) were excluded from the analysis. Also if a patient had been referred or followed by a urologic or colorectal surgeon for a particular complication, their data were also not included due to potentially incomplete operative and follow-up data. An institutional review board approved the study before any patient data were reviewed. Study Variables Demographic and clinical data included age, BMI, cancer site, surgeon-specific performance, upfront surgery or surgery coinciding with disease recurrence, a history of pelvic surgery, surgery type [hysterectomy alone, hysterectomy and lymph node dissection (LND), radical hysterectomy (e.g. surgical removal of the uterus, cervix, ovaries, Fallopian tubes and a portion of the upper
304
Oncology 2014;86:303–307 DOI: 10.1159/000360294
vagina with possible pelvic and/or para-aortic LND)], cytoreductive procedure (e.g. surgical resection of the ovaries, uterus, cervix, Fallopian tubes and visible disease) or noncytoreductive surgical procedure (e.g. cystoscopy, pelvic-floor restoration and herniorrhaphy), operative approach (open procedure vs. endoscopic), cancerous involvement of the bowel or genitourinary tract and type of operative injury (gastrointestinal or genitourinary) were all noted for evaluation. Any endoscopic procedure that was eventually converted to a laparotomy was considered (i.e. analyzed or coded as) an open procedure. Complications Surgical injuries to the bladder, ureter or bowel were comprehensively documented. Genitourinary complications included ureteral or bladder injuries (e.g. incision, avulsion and transection). Bowel injuries encompassed a laceration to the bowel (colon or small intestine). An enterotomy or cystotomy to address tumor involvement of the bowel or bladder was not classified as a complication, and a bowel resection to address a fistula or anastomotic leak was not considered an operative injury. Statistical Analyses All statistical analyses were conducted using MedCalc statistical software for biomedical research (version 9.5.1 for Windows). The initial data analysis was conducted by employing a descriptive statistical approach, which underwent further examination via multinomial logistic regression and the Pearson’s χ2 test to discern any prognostic relationship amongst the various clinicopathologic variables.
Results
Following a review of chart data, 1,618 subjects who met the inclusion criteria were identified. The patients had cancer of the uterus (n = 709/43.8%), ovary (672/41.5%), cervix (n = 183/11.3%) and vagina (n = 54/3.4%). The subjects’ median age was 60 years (range 30–89) and BMI was 27.21 (range 15.27–55.08). The most common surgical procedure was hysterectomy and lymphadenectomy (n = 423/26.1%). The remaining subjects were treated via hysterectomy alone (n = 352/21.8%), a cytoreductive procedure (n = 325/20.1%), radical hysterectomy (n = 128/7.9%) or a noncytoreductive surgical procedure (n = 390 or 24.1%); of the aforementioned operations, 1,212 (74.9%) were performed via an open procedure and 406 (25.1%) were conducted endoscopically. Management for disease recurrence occurred in 189 (11.7%) of the surgeries performed. Sixty-five (4.0%) gastrointestinal or genitourinary complications were encountered, 4 of which were identified postoperatively. In the study group, 47 (2.9%) patients had an injury to the colon (n = 18) or small intestine (n = 29). There were 18 (1.1%) genitourinary complicaRettenmaier et al.
Downloaded by: UCONN Storrs 198.143.38.1 - 1/26/2016 1:13:04 PM
0.79–8.3% of gynecologic operations and primarily involve the bladder [9–11]. The incidence and severity of genitourinary and gastrointestinal operative injuries vary in accordance with the complexity of surgery. Therefore, one would surmise that gynecologic oncology complication rates are higher than in general gynecology [12, 13]. In particular, when treating gynecologic cancer, the pelvic anatomy may be distorted or obstructed, complicating surgical access and manipulation [14]. There are also issues related to previous radiotherapy and chemotherapy which further predispose a patient to an operative injury [15]. An appreciation of the conditions inherent in iatrogenic gynecologic oncology-related gastrointestinal and genitourinary injuries could decrease the corresponding surgical complication rates [5]. Consequently, the purpose of this retrospective study was to discern the potential determining factors and frequency of these specific complications encountered at a single medical institution by the same group of gynecologic oncologists. Prior to initiating the review, we speculated that undergoing an open procedure, surgical management for recurrent disease and cytoreductive surgery would significantly contribute to the risk for developing a gastrointestinal or genitourinary injury.
Operative Injuries in Gynecologic Oncology
Table 1. The number of GI and GU operative injuries in accordan-
ce with surgical approach and specific clinical risk factors in 1,618 patients Open procedures (total = 1,212) Cancerous involvement of the GI tract Yes 549 (45.3) No 663 (54.7) Cancerous involvement of the GU tract Yes 222 (18.3) No 990 (81.7) Recurrent disease Yes 157 (12.9) No 1,055 (87.1) History of pelvic surgery Yes 768 (63.4) No 444 (36.6) GI Hysterectomy Hysterectomy with LND Radical hysterectomy Cytoreductive procedure Noncytoreductive procedurea
Endoscopic (total = 406) 51 (12.6) 355 (87.4) 17 (4.2) 389 (95.8) 28 (6.9) 378 (93.1) 171 (42.1) 235 (57.9)
GU
GI
GU
8 (3.6) 3 (1.3) 1 (0.9)
3 (1.3) 3 (1.3) 4 (3.6)
0 (0) 2 (1.0) 1 (5.6)
0 (0) 1 (0.5) 1 (5.6)
17 (5.4)
3 (0.9)
1 (0.8)
0 (0)
14 (4.2)
3 (0.9)
0 (0)
0 (0)
Figures represent the number (%) of injuries. GI = Gastrointestinal; GU = genitourinary. a Including cystoscopy, pelvic-floor restoration and herniorrhaphy.
Table 2. Significant prognostic indicators for the manifestation of a gastrointestinal or genitourinary operative injury in 1,618 patients
Variable
p value
Disease recurrence Surgery type Undergoing a laparotomy Having gastrointestinal or genitourinary surgery History of pelvic surgery Age
Oncology 2014;86:303–307 DOI: 10.1159/000360294
The Incidence of Genitourinary and Gastrointestinal Complications in Open and Endoscopic Gynecologic Cancer Surgery Christopher R. Rettenmaier a Nicholas B. Rettenmaier a Lisa N. Abaid b John V. Brown b John P. Micha b Alberto A. Mendivil b Tomasz Wojciechowski b Bram H. Goldstein b Maurie Markman c
a
The Nancy Yeary Women’s Cancer Research Foundation and b Gynecologic Oncology Associates, Newport Beach, Calif., and c Cancer Treatment Centers of America, Philadelphia, Pa., USA
Abstract Objectives: The purpose of this study was to examine the incidence of genitourinary and intestinal tract injuries in an effort to identify which factors might predispose a patient to developing one of these surgical complications. Methods: We retrospectively evaluated the charts of gynecologic cancer patients who were treated at a single medical institution from January 2002 to February 2011. The following study variables were noted for evaluation: age, BMI, cancer origin, disease recurrence, a history of pelvic surgery, surgery type, operative approach and injury classification (genitourinary or gastrointestinal). Results: In our group of 1,618 patients, a total of 47 (2.9%) gastrointestinal and 18 (1.1%) genitourinary tract injuries were encountered. There were no intraoperative-related deaths but 2 patients expired 1 month after surgery. Logistic regression indicated that surgery type, undergoing an open procedure, cancerous involvement of the bowel or genitourinary tract and a history of pelvic surgery
© 2014 S. Karger AG, Basel 0030–2414/14/0866–0303$39.50/0 E-Mail [email protected] www.karger.com/ocl
were significant predictors of operative injury occurrence [χ2 (28) = 167.22; p < 0.001]. Conclusions: We ascertained a relatively low incidence of gastrointestinal and genitourinary complications. Nevertheless, undergoing an open procedure, a history of pelvic surgery and surgical involvement of the bowel or genitourinary tract were predictive of an increased risk for these aforementioned injuries. © 2014 S. Karger AG, Basel
Introduction
Iatrogenic injuries are an unfortunate outcome in patients undergoing surgical treatment. In gynecologic oncology, genitourinary and intestinal tract complications periodically occur because the disease is often extensive and proximal to relevant pelvic organs [1–3]. Gastrointestinal injuries that are incurred during gynecologic surgery have a reported incidence of 0.3–0.6% [4–6] and often coincide with pneumoperitoneum initiation or trocar employment during endoscopic procedures [7, 8]. Similarly, genitourinary complications (injuries involving the bladder or ureter) occur in approximately Bram H. Goldstein, PhD Gynecologic Oncology Associates 351 Hospital Road, Suite 507 Newport Beach, CA 92663 (USA) E-Mail bram @ gynoncology.com
Downloaded by: UCONN Storrs 198.143.38.1 - 1/26/2016 1:13:04 PM
Key Words Pelvic surgery · Iatrogenic injuries · Genitourinary and gastrointestinal tract complications · Gynecologic cancer
Materials and Methods Inclusion and Exclusion Criteria Our retrospective study encompassed a chart review of all invasive gynecologic (e.g. ovarian, uterine, cervical and vaginal) cancer patients who were managed and under surveillance at a single, tertiary, nonacademic healthcare institution from January 2002 until February 2011. An evaluation of patient records from our clinic database identified 1,980 patients who comprised the subject of this investigation. Patients who did not undergo treatment for their gynecologic malignancy or follow-up by the same group of gynecologic oncologists (i.e. patients who were treated at multiple hospitals or for whom adequate operative and follow-up data were not available) were excluded from the analysis. Also if a patient had been referred or followed by a urologic or colorectal surgeon for a particular complication, their data were also not included due to potentially incomplete operative and follow-up data. An institutional review board approved the study before any patient data were reviewed. Study Variables Demographic and clinical data included age, BMI, cancer site, surgeon-specific performance, upfront surgery or surgery coinciding with disease recurrence, a history of pelvic surgery, surgery type [hysterectomy alone, hysterectomy and lymph node dissection (LND), radical hysterectomy (e.g. surgical removal of the uterus, cervix, ovaries, Fallopian tubes and a portion of the upper
304
Oncology 2014;86:303–307 DOI: 10.1159/000360294
vagina with possible pelvic and/or para-aortic LND)], cytoreductive procedure (e.g. surgical resection of the ovaries, uterus, cervix, Fallopian tubes and visible disease) or noncytoreductive surgical procedure (e.g. cystoscopy, pelvic-floor restoration and herniorrhaphy), operative approach (open procedure vs. endoscopic), cancerous involvement of the bowel or genitourinary tract and type of operative injury (gastrointestinal or genitourinary) were all noted for evaluation. Any endoscopic procedure that was eventually converted to a laparotomy was considered (i.e. analyzed or coded as) an open procedure. Complications Surgical injuries to the bladder, ureter or bowel were comprehensively documented. Genitourinary complications included ureteral or bladder injuries (e.g. incision, avulsion and transection). Bowel injuries encompassed a laceration to the bowel (colon or small intestine). An enterotomy or cystotomy to address tumor involvement of the bowel or bladder was not classified as a complication, and a bowel resection to address a fistula or anastomotic leak was not considered an operative injury. Statistical Analyses All statistical analyses were conducted using MedCalc statistical software for biomedical research (version 9.5.1 for Windows). The initial data analysis was conducted by employing a descriptive statistical approach, which underwent further examination via multinomial logistic regression and the Pearson’s χ2 test to discern any prognostic relationship amongst the various clinicopathologic variables.
Results
Following a review of chart data, 1,618 subjects who met the inclusion criteria were identified. The patients had cancer of the uterus (n = 709/43.8%), ovary (672/41.5%), cervix (n = 183/11.3%) and vagina (n = 54/3.4%). The subjects’ median age was 60 years (range 30–89) and BMI was 27.21 (range 15.27–55.08). The most common surgical procedure was hysterectomy and lymphadenectomy (n = 423/26.1%). The remaining subjects were treated via hysterectomy alone (n = 352/21.8%), a cytoreductive procedure (n = 325/20.1%), radical hysterectomy (n = 128/7.9%) or a noncytoreductive surgical procedure (n = 390 or 24.1%); of the aforementioned operations, 1,212 (74.9%) were performed via an open procedure and 406 (25.1%) were conducted endoscopically. Management for disease recurrence occurred in 189 (11.7%) of the surgeries performed. Sixty-five (4.0%) gastrointestinal or genitourinary complications were encountered, 4 of which were identified postoperatively. In the study group, 47 (2.9%) patients had an injury to the colon (n = 18) or small intestine (n = 29). There were 18 (1.1%) genitourinary complicaRettenmaier et al.
Downloaded by: UCONN Storrs 198.143.38.1 - 1/26/2016 1:13:04 PM
0.79–8.3% of gynecologic operations and primarily involve the bladder [9–11]. The incidence and severity of genitourinary and gastrointestinal operative injuries vary in accordance with the complexity of surgery. Therefore, one would surmise that gynecologic oncology complication rates are higher than in general gynecology [12, 13]. In particular, when treating gynecologic cancer, the pelvic anatomy may be distorted or obstructed, complicating surgical access and manipulation [14]. There are also issues related to previous radiotherapy and chemotherapy which further predispose a patient to an operative injury [15]. An appreciation of the conditions inherent in iatrogenic gynecologic oncology-related gastrointestinal and genitourinary injuries could decrease the corresponding surgical complication rates [5]. Consequently, the purpose of this retrospective study was to discern the potential determining factors and frequency of these specific complications encountered at a single medical institution by the same group of gynecologic oncologists. Prior to initiating the review, we speculated that undergoing an open procedure, surgical management for recurrent disease and cytoreductive surgery would significantly contribute to the risk for developing a gastrointestinal or genitourinary injury.
Operative Injuries in Gynecologic Oncology
Table 1. The number of GI and GU operative injuries in accordan-
ce with surgical approach and specific clinical risk factors in 1,618 patients Open procedures (total = 1,212) Cancerous involvement of the GI tract Yes 549 (45.3) No 663 (54.7) Cancerous involvement of the GU tract Yes 222 (18.3) No 990 (81.7) Recurrent disease Yes 157 (12.9) No 1,055 (87.1) History of pelvic surgery Yes 768 (63.4) No 444 (36.6) GI Hysterectomy Hysterectomy with LND Radical hysterectomy Cytoreductive procedure Noncytoreductive procedurea
Endoscopic (total = 406) 51 (12.6) 355 (87.4) 17 (4.2) 389 (95.8) 28 (6.9) 378 (93.1) 171 (42.1) 235 (57.9)
GU
GI
GU
8 (3.6) 3 (1.3) 1 (0.9)
3 (1.3) 3 (1.3) 4 (3.6)
0 (0) 2 (1.0) 1 (5.6)
0 (0) 1 (0.5) 1 (5.6)
17 (5.4)
3 (0.9)
1 (0.8)
0 (0)
14 (4.2)
3 (0.9)
0 (0)
0 (0)
Figures represent the number (%) of injuries. GI = Gastrointestinal; GU = genitourinary. a Including cystoscopy, pelvic-floor restoration and herniorrhaphy.
Table 2. Significant prognostic indicators for the manifestation of a gastrointestinal or genitourinary operative injury in 1,618 patients
Variable
p value
Disease recurrence Surgery type Undergoing a laparotomy Having gastrointestinal or genitourinary surgery History of pelvic surgery Age
