Step by step Indiana pouch construction in a previously irradiated patient with a cervical cancer relapse

Abstract

Introduction: Radiation therapy and radical pelvic surgery, either radical cystectomy or pelvic exenteration, is the golden standard treatment for infiltrating bladder carcinoma, as well as advanced or recurrent cervical, vulvar, vaginal and endometrial cancer. However, due to the poor radiation sensitivity of the cervix and vagina, a high-radiation dose is required, leading to early and/or late onset urogenital complications in approximately 50% of the patients.

Case presentation: The following case report describes a 64-year-old native Russian woman presenting a relapse of a vaginal cuff squamous cell carcinoma, who underwent a laterally extended endopelvic resection (LEER) followed by a neobladder reconstruction based on the Indiana pouch (IP) technique. The process is described here step by step.

Discussion: Indiana pouch urinary diversion was based on thorough research, the reproducibility of the technique, our urologist's experience with the Indiana Pouch, as well the lower rate of complications published in various separate series.

Conclusion: Indiana pouch is a successful continence urinary reservoir with a reproductible technique, however long-term observation is needed.

Keywords: Cervical cancer; Indiana Pouch (IP); LEER; Previously irradiated pelvis; Step by step.

Fig. 1

Identification of the bowel segment used for the Indiana Pouch.

Fig. 2

Resection of the ascending colon to the right of the middle colic artery, and the terminal ileum approximately 15–20 cm away from the ileocecal valve.

Fig. 3

Sectioning of terminal ileum, approximately 15–20 cm away from the ileocecal valve.

Fig. 4

The right colon segment is detubularized along the taenia coli using an electric scalpel.

Fig. 5

A 12 French Nelaton catheter is introduced inside the ileal segment, which is then tapered over using a GIA stapler, forming a “pseudo-appendix”. Imbricating sutures (arrow) are placed at the ileocecal valve in order to ensure the smooth catheterization of the channel.

Fig. 6

The left ureter is crossed over to the right, passing under the mesosigma, and spatulated. A direct mucosae to mucosae anastomosis is performed (ureteroenteric anastomosis) using 5-0 monofilament simple sutures. The same is done with the contralateral ureter.

Fig. 7

The ureteroenteric anastomosis are then stented using 8 French catheters, and led out of the pouch and through the abdominal wall (in the right flank), lateral to the medial laparotomy incision.

Fig. 8

A Malecot or Pezzer 20 French catheter is inserted through the right abdominal flank, and into the pouch, securing it with a purse-string suture, and will serve as a cystostomy drain.

Fig. 9

The rest of the pouch is then sutured in a spherical reservoir using the 3-0 monofilament continuous suture.

Fig. 10

In the right pelvic region, the previously catheterized and tapered ileum is exteriorized.

Fig. 11

The exteriorized ileum is fixed to the skin using simple vycril 3-0 sutures.