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Journal of Minimally Invasive Gynecology Jan 2020To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically.
STUDY OBJECTIVE
To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically.
DESIGN
Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration.
SETTING
Tertiary care academic center.
PATIENTS
A patient undergoing pelvic exenteration for uterine leiomyosarcoma.
INTERVENTIONS
Robotic total supralevator pelvic exenteration.
MEASUREMENTS AND MAIN RESULTS
In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL.
CONCLUSION
Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.
Topics: Dissection; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Leiomyosarcoma; Pelvic Exenteration; Plastic Surgery Procedures; Robotic Surgical Procedures; Uterine Neoplasms; Viscera
PubMed: 31146031
DOI: 10.1016/j.jmig.2019.05.012 -
Langenbeck's Archives of Surgery Sep 2021Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional... (Review)
Review
Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.
Topics: Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Quality of Life; Rectal Neoplasms; Rectum
PubMed: 34341869
DOI: 10.1007/s00423-021-02285-8 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Mar 2023Pelvic radiation injury can potentially involve multiple pelvic organs, and due to its progressive and irreversible nature, its late stage can be complicated by...
Pelvic radiation injury can potentially involve multiple pelvic organs, and due to its progressive and irreversible nature, its late stage can be complicated by fistulas, perforations, obstructions and other complications involved multiple pelvic organs, which seriously affect the long-term survival and the quality of life of patients. As a multidisciplinary surgical approach, pelvic exenteration has potential application in the treatment of late complications of pelvic radiation injury by completely removing the irradiated lesion, relieving symptoms and avoiding recurrence of symptoms. In clinical practice, we should advocate the concept of "pelvic radiation injury", emphasize multidisciplinary collaboration, fully evaluate the overall status of patients, primary tumor and pelvic radiation injury. We should follow the principles of "damage-control" and "extended resection", and follow the principle of enhanced recovery after surgery to achieve the goal of ensuring the surgical safety, relieving patients' symptoms and improving patients' quality of life and long-term survival.
Topics: Humans; Pelvic Exenteration; Postoperative Complications; Quality of Life; Radiation Injuries; Neoplasm Recurrence, Local; Retrospective Studies
PubMed: 36925123
DOI: 10.3760/cma.j.cn441530-20221206-00510 -
Annals of Surgical Oncology Jul 2020Pelvic exenteration has increasingly been shown to improve disease-free and overall survival for patients with locally advanced pelvic malignancies. Squamous cell...
BACKGROUND
Pelvic exenteration has increasingly been shown to improve disease-free and overall survival for patients with locally advanced pelvic malignancies. Squamous cell carcinoma (SCC) is the second most common pelvic malignancy requiring exenteration.
OBJECTIVE
The aim of this study was to report the clinical and oncological outcomes from patients treated with pelvic exenteration for anal and urogenital SCC from a single, high-volume unit.
METHODS
A review of a prospectively maintained database from 1991 to 2018 at a high-volume specialised institution was performed. Primary endpoints included R0 resection rates, local recurrence and overall survival (OS) rates.
RESULTS
From January 1999 to July 2018, 361 patients underwent pelvic exenteration of which 31 patients were identified with SCC (15 anal SCC, 16 urogenital SCC). The majority of patients were females (n = 24, 77.4%). Median age was 59 (range 35-81). Twenty-seven patients underwent resection with curative intent with an R0 resection rate of 81.5%. Four patients underwent a palliative procedure [R1 = 3 (8%), R2 = 1 (3.3%)]. Mean hospital length of stay was 32 days (range 8-122 days). Disease-free survival was significantly increased in anal SCC with no significant difference in OS compared to urogenital SCC (p = 0.03, p = 0.447 respectively). Advanced pathological T stage was associated with decreased OS (p = 0.023). In the curative intent group the disease-free survival and OS rate was 59.3% and 70% at 24 months, respectively.
CONCLUSION
Complete R0 resection is achievable in a high proportion of patients. Urogenital SCC is associated with significantly worse disease-free survival, and advanced T-stage was a significant prognostic factor for OS.
Topics: Adult; Aged; Aged, 80 and over; Anus Neoplasms; Carcinoma, Squamous Cell; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Retrospective Studies; Treatment Outcome; Urogenital Neoplasms
PubMed: 31993856
DOI: 10.1245/s10434-020-08229-8 -
Gynecologic Oncology Oct 2019Because of the anatomic proximity of the rectosigmoid to the female pelvic organs and its frequent involvement in ovarian cancer, an en bloc resection of ovarian tumors...
OBJECTIVE
Because of the anatomic proximity of the rectosigmoid to the female pelvic organs and its frequent involvement in ovarian cancer, an en bloc resection of ovarian tumors together with the uterus and rectosigmoid, also known as a modified posterior pelvic exenteration (MPPE), is frequently performed to achieve optimal cytoreduction [1]. Additionally, if the tumor has infiltrated the pelvic side-wall, a MPPE combined with pelvic side-wall resection can be selected [2]. We report the details of a technique for this surgery requiring intestinal and urinary reconstruction.
METHODS
A 55-year-old woman underwent an up-front cytoreductive surgery for FIGO stage IIIC (pT3c N1 M0) ovarian cancer. Preoperatively, a tumor infiltrating the left pelvic side-wall was suspected; however, hydronephrosis of the left kidney was not observed on an enhanced computed tomography examination. During a laparotomy, tumor involvement of the left ureter and internal iliac vessels was observed; a MPPE with pelvic side-wall resection including a partial ureterectomy was thus performed. After the resection of the pelvic and omental tumors, colorectal and vesicoureteral anastomoses were performed.
RESULTS
Histopathologically, a high-grade serous adenocarcinoma spreading into the muscular layer of the rectum, located close to the ureter and artery, and within 5 mm of the left pelvic side-wall was identified. Diet intake was started on postoperative day (POD) 3. The indwelling bladder catheter was removed on POD 10. Spontaneous voiding after surgery was sufficient and the volume of postvoid residual urine was noted to be <50 mL. The postoperative hospital stay was 12 days. No surgery-related complications occurred. Chemotherapy was initiated 3 weeks after the surgery. The ureteral stent was placed until 3 months after surgery.
DISCUSSION
A MPPE requiring intestinal and urinary reconstruction is both feasible and safe and can be considered for patients with ovarian cancer involving the pelvic side-wall. Postoperative bladder function was preserved in this patient. However, difficulty in spontaneous voiding after surgery occurs and self-intermittent catheterization is necessary in some patients undergoing a MPPE combined with pelvic side-wall resection. In the previous study, we evaluated the impact of MPPE with or without nerve preservation on bladder function of the patients with ovarian and endometrial cancer [2]. All patients with bilateral nerve-sparing surgery had sufficient micturition from the early postoperative period. Though 40% of the patients with unilateral nerve-sparing surgery had difficulty in spontaneous voiding and needed intermittent catheterization, voiding ability of them improved and no self-catheterization was required 3 months after surgery. The assessment of patient questionnaires suggested that bladder function was acceptable in both groups at 6 months. Patients with bilateral nerve-sacrificing surgery complained of neurogenic bladder requiring self-catheterization even 6 months after surgery. Careful follow-up is required to assess bladder function after MPPE to the extent of pelvic autonomic nerve preservation.
Topics: Cytoreduction Surgical Procedures; Female; Humans; Intestines; Middle Aged; Neoplasm Staging; Ovarian Neoplasms; Pelvic Exenteration; Plastic Surgery Procedures; Urinary Bladder
PubMed: 31351675
DOI: 10.1016/j.ygyno.2019.07.015 -
International Journal of Gynecological... Oct 2015To text the feasibility of a psychological intervention package administered to 49 pelvic exenteration candidates, aimed at evaluating the preoperative prevalence of...
OBJECTIVES
To text the feasibility of a psychological intervention package administered to 49 pelvic exenteration candidates, aimed at evaluating the preoperative prevalence of psychological distress and assessing the presence of any correlation between preoperative psychological distress and clinical variables such as pain and hospitalization length.
METHODS
Patients were referred to the psychology unit from the very beginning of their clinical pathway and were administered the Psychological Distress Inventory (PDI) and the Mini-Mental Adjustment to Cancer (Mini-MAC) questionnaire at prehospital admission. Patients presenting with a significant level of distress received nonstandardized psychological support. Statistical analyses were performed to detect the presence of any correlation between psychological variables at prehospital admission and clinical outcomes.
RESULTS
The 40% of patients had significant levels of distress at prehospital admission (PDI ≥ 30). As regards Mini-MAC, the mean value of fighting spirit attitude and fatalism was higher in our sample than in the normative sample of the Mini-MAC validation study in the Italian cancer population. Their anxious preoccupation attitude was lower. There were no correlations between clinical and psychological variables: level of postsurgery pain was higher (3.7) in the subgroup of patients with presurgery PDI < 30 compared with those with PDI ≥ 30 (3.5). However, this difference was not statistically significant (P = 1.00). Considering hospitalization length, the above described trend was similar.
CONCLUSIONS
Although highly distressed, pelvic exenteration candidates show an adaptive range of coping mechanisms. This calls for a greater effort in studying the complexity of their psychoemotional status to provide them with the best multidisciplinary care. Extensive study of the real effectiveness of psychological intervention is warranted: randomized clinical trials could help in detecting the presence of any correlation between clinical and psychological variables in a multidisciplinary approach.
Topics: Adaptation, Psychological; Adult; Aged; Endometrial Neoplasms; Female; Follow-Up Studies; Humans; Middle Aged; Neoplasm Staging; Pelvic Exenteration; Prognosis; Prospective Studies; Psychometrics; Quality of Life; Stress, Psychological; Surveys and Questionnaires; Uterine Cervical Neoplasms
PubMed: 26244759
DOI: 10.1097/IGC.0000000000000523 -
Colorectal Disease : the Official... Mar 2019Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these...
AIM
Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these multi-visceral resections leads to fluid accumulation and translocation of bowel within the pelvic cavity, which may increase the risk of pelvic abscess, perineal fluid discharge with perineal wound dehiscence and prolonged ileus. This study describes a novel technique using degradable synthetic mesh with overlying omentum to preclude small bowel and fill the empty space after total pelvic exenteration, and aimed to investigate the rate of pelvic abscess and perineal wound-related complications in this group.
METHOD
Ten patients who underwent total pelvic exenteration followed by implantation of degradable synthetic mesh at a quaternary referral centre were identified and included. The mesh was moulded to the contours of the bony pelvis at the level of the pubic symphysis anteriorly and inferior to the sacral promontory posteriorly. The data on the number of postoperative perineal wound-related complications including pelvic abscesses were collected.
RESULTS
There was no perioperative mortality. Five patients (50%) developed postoperative complications. One patient developed an abscess inferior to the mesh that required surgical drainage and another had a pre-sacral collection that was successfully managed conservatively. Two patients developed intra-abdominal collections requiring percutaneous drainage. Median length of stay was 20 days (range 16-35). No perineal hernia or entero-perineal fistula was detected in any patient either clinically or radiologically at a median follow-up of 7 months.
CONCLUSION
Degradable synthetic mesh reconstruction following exenterative surgery may reduce postoperative complications related to the perineal wound.
Topics: Abscess; Adult; Aged; Female; Humans; Incidence; Male; Middle Aged; Omentum; Pelvic Exenteration; Pelvis; Perineum; Postoperative Complications; Prospective Studies; Plastic Surgery Procedures; Sacrum; Surgical Mesh; Surgical Wound Dehiscence; Syndrome; Treatment Outcome
PubMed: 30548166
DOI: 10.1111/codi.14523 -
In Vivo (Athens, Greece) 2019Although pelvic exenteration is an aggressive surgical procedure, it remains almost the only curative solution for patients diagnosed with large pelvic malignancies. (Meta-Analysis)
Meta-Analysis
BACKGROUND/AIM
Although pelvic exenteration is an aggressive surgical procedure, it remains almost the only curative solution for patients diagnosed with large pelvic malignancies.
PATIENTS AND METHODS
We present a series of 100 patients submitted to pelvic exenteration with curative intent.
RESULTS
The origin of the primary tumor was most commonly represented by cervical cancer, followed by, endometrial cancer, rectal cancer, ovarian cancer and vulvo-vaginal cancer. An R0 resection was confirmed in 68 cases, while the remaining 32 cases presented lateral positive resection margins or perineal positive margins. The postoperative morbidity rate was 37% while the mortality rate was 3%. As for the-long term outcomes, the median overall survival time was 38.7 months, being most significantly influenced by the origin of the primary tumor.
CONCLUSION
Although pelvic exenteration is still associated with an increased morbidity, an important improvement in the long-term survival can be achieved, especially if radical resection is feasible.
Topics: Adult; Aged; Disease Management; Female; Humans; Male; Middle Aged; Neoplasm Grading; Neoplasm Recurrence, Local; Neoplasm Staging; Pelvic Exenteration; Pelvic Neoplasms; Prognosis; Treatment Outcome; Tumor Burden
PubMed: 31662557
DOI: 10.21873/invivo.11723 -
Colorectal Disease : the Official... Oct 2021Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this...
AIM
Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this study was to determine the short-term functional outcomes following pelvic exenteration surgery using objective measures of physical function.
METHOD
Patients undergoing pelvic exenteration surgery between January 2017 and May 2020 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary measures were the 6-min walk test (6MWT) and the five times sit to stand (5STS) test. Data were collected at baseline (preoperatively), 10 days postoperatively and at discharge from hospital, and were analysed according to tumour type, extent of exenteration, sacrectomy, length of hospital stay, major nerve resection and postoperative complications.
RESULTS
The cohort of patients that participated in functional assessments consisted of 135 patients, with a median age of 61 years. Pelvic exenteration patients had a reduced 6MWT distance preoperatively compared to the general population (P < 0.001). Following surgery, we observed a further decrease in 6MWT distance (P < 0.001) and an increase in time to complete 5STS (P < 0.001) at postoperative day 10 compared to baseline, with a slight improvement at discharge. There were no differences in 6MWT and 5STS outcomes between patients based on comparisons of surgical and oncological factors.
CONCLUSION
Pelvic exenteration patients are functionally impaired in the preoperative period compared to the general population. Surgery causes a further reduction in physical function in the short term; however, functional outcomes are not impacted by tumour type, extent of exenteration, sacrectomy or nerve resection.
Topics: Humans; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Prospective Studies; Retrospective Studies
PubMed: 34346149
DOI: 10.1111/codi.15834 -
International Journal of Gynecological... Mar 2024Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the... (Review)
Review
Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the surrounding bony pelvis and pelvic musculature. As opposed to advanced ovarian cancer, where cytoreduction is the goal, in these scenarios, an oncologic approach to achieve negative margins is critical for benefit. Surgeries aimed at achieving a R0 resection in gynecologic oncology can have a significant impact on pelvic anatomy, and require reconstruction. Overall, it appears that these types of radical surgery are less frequently performed; however, when required, multidisciplinary teams at high-volume centers can potentially improve short-term morbidity. There are few data to examine the long-term, quality-of-life outcomes after reconstruction following oncologic resection in advanced and recurrent gynecologic cancers. In this review we outline considerations and approaches for reconstruction after surgery for gynecologic cancers. We also discuss areas of innovation, including minimally invasive surgery and the use of 3D surgical anatomy models for improved surgical planning.In the era of 'less is more', pelvic exenteration in gynecologic oncology is still indicated when there are no other curative-intent alternatives in persistent or recurrent gynecological malignancies confined to the pelvis or with otherwise unmanageable symptoms from fistula or radiation necrosis. Pelvic exenteration is one of the most destructive procedures performed on an elective basis, which inevitably carries a significant psychologic, sexual, physical, and emotional burden for the patient and caregivers. Such complex ultraradical surgery, which requires removal of the vagina, vulva, urinary tract, and/or gastrointestinal tract, subsequently needs creative and complex reconstructive procedures. The additional removal of sidewall or perineal structures, like pelvic floor muscles/vulva, or portions of the musculoskeletal pelvis, and the inclusion of intra-operative radiation further complicates reconstruction. This review paper will focus on the reconstruction aspects following pelvic exenteration, including options for urinary tract restoration, reconstruction of the vulva and vagina, as well as how to fill large empty spaces in the pelvis. While the predominant gastrointestinal outcome after exenteration in gynecologic oncology is an end colostomy, we also present some novel new options for gastrointestinal tract reconstruction at the end.
Topics: Female; Humans; Genital Neoplasms, Female; Surgery, Plastic; Neoplasm Recurrence, Local; Pelvic Exenteration; Ovarian Neoplasms
PubMed: 38438169
DOI: 10.1136/ijgc-2023-004620