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Gynecologic Oncology Apr 2021To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy.
OBJECTIVE
To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy.
METHODS
This comparative effectiveness study is a retrospective population-based analysis of the National Inpatient Sample from 10/2008-9/2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were evaluated based on the use of laparoscopic or robotic-assisted surgery. Patient demographics and intraoperative/postoperative complications related to a minimally invasive surgical approach were assessed.
RESULTS
Among 1376 women who underwent pelvic exenteration, 49 (3.6%) had the procedure performed via a minimally invasive approach. The majority of minimally invasive cases were robotic-assisted (51.0%). Women in the minimally invasive group were more likely to be old, white, have cervical/uterine cancers, and receive urinary diversion, but less frequently received vaginal reconstruction or colostomy when compared to those in the open surgery group (P < 0.05). Overall perioperative complication rates were similar between the minimally invasive and open surgery groups (79.6% versus 77.7%, P = 0.862), but the minimally invasive group had a decreased risk of high-risk complications compared to the open surgery group (adjusted-odds ratio 0.19, 95% confidence interval 0.07-0.51). Specifically, a minimally invasive approach was associated with decreased incidence of sepsis and thromboembolism compared to an open approach (P < 0.05). The minimally invasive group had a shorter length of stay (median, 9 versus 14 days) and lower total charge (median, $127,875 versus $208,591) compared to the open surgery group (P < 0.05).
CONCLUSION
Laparotomy remains the main surgical approach for pelvic exenteration for gynecologic malignancy and minimally invasive surgery was infrequently utilized during the study period in the United States. Before widely adopting this surgical approach, the utility and role of minimally invasive pelvic exenteration requires further investigation.
Topics: Aged; Cohort Studies; Female; Genital Neoplasms, Female; Humans; Longevity; Lymph Node Excision; Middle Aged; Minimally Invasive Surgical Procedures; Pelvic Exenteration; Perioperative Period; Retrospective Studies; Treatment Outcome; United States
PubMed: 33402282
DOI: 10.1016/j.ygyno.2020.12.036 -
Radiographics : a Review Publication of... 2015Pelvic exenteration is a radical surgery that is used in an attempt to cure patients with locally advanced central pelvic malignancies. Exenteration is a salvage... (Review)
Review
Pelvic exenteration is a radical surgery that is used in an attempt to cure patients with locally advanced central pelvic malignancies. Exenteration is a salvage operation that is considered only after other therapies, such as chemoradiation, have been exhausted. The high morbidity from exenteration's multiorgan resection warrants careful patient selection. Preoperative imaging plays a major role in the selection process, allowing the exclusion of patients with unresectable pelvic disease or distant metastases. Imaging is also crucial to surgical planning, providing the surgeon with a map of the distribution and extent of the pelvic disease.
Topics: Female; Humans; Magnetic Resonance Imaging; Middle Aged; Pelvic Exenteration; Pelvic Neoplasms; Preoperative Care; Surgery, Computer-Assisted; Tomography, X-Ray Computed
PubMed: 26172363
DOI: 10.1148/rg.2015140127 -
European Journal of Surgical Oncology :... Oct 2018Total pelvic exenteration (TPE) is a radical approach for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) in case of tumour invasion...
BACKGROUND
Total pelvic exenteration (TPE) is a radical approach for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) in case of tumour invasion into the urogenitary tract. The aim of this study is to assess surgical and oncological outcomes of TPE for LARC and LRRC in elderly patients compared to younger patients.
METHODS
All patients who underwent TPE for LARC and LRRC between January 1990 and March 2017 were retrospectively analyzed. Patients aged <70 years were classified as younger and ≥70 years as elderly patients.
RESULTS
In total 126 patients underwent TPE, of whom 88 younger and 38 elderly patients. Elderly patients had a significantly higher number of ASA > II patients (p = 0.01). Indication for surgery LARC (n = 73) and LRRC (n = 53) did not differ significantly. The 30-day mortality rate was significantly higher (p = 0.01) in elderly (13%) compared to younger patients (3%). Elderly patients experienced more anastomotic leakage (p = 0.02). Median overall survival (OS) was 75 months [95%CI 37.1; 112.9] for elderly and 45 months [95%CI 22.4; 67.8] for younger patients (p = 0.77). The 5-year OS rate was 44% in both groups. Median disease specific survival (DSS) was 78 months [95%CI 69.1; 86.9] for elderly and 60 months [95%CI 36.6; 83.4] for younger patients (p = 0.34). The 5-year DSS rate was 57% and 49%, respectively.
CONCLUSION
TPE is an invasive treatment for rectal cancer with high 30-day mortality in elderly patients. Oncological outcomes are similar in elderly and younger patients. Therefore, TPE should not be withheld because of high age only, but careful patient selection is needed.
Topics: Age Factors; Aged; Anastomotic Leak; Chemoradiotherapy, Adjuvant; Humans; Middle Aged; Neoadjuvant Therapy; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Neoplasm, Residual; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Survival Rate
PubMed: 30075979
DOI: 10.1016/j.ejso.2018.06.033 -
Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review.Surgical Endoscopy Dec 2018Pelvic exenteration is potentially curative for locally advanced and recurrent pelvic cancers. Evolving technology has facilitated the use of minimally invasive surgical... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pelvic exenteration is potentially curative for locally advanced and recurrent pelvic cancers. Evolving technology has facilitated the use of minimally invasive surgical (MIS) techniques in selected cases. We aimed to compare outcomes between open and MIS pelvic exenteration.
METHODS
A review of comparative studies was performed. Firstly, we evaluated the differences in surgical techniques with respect to operative time, blood loss, and margin status. Secondly, we assessed differences in 30-day morbidity and mortality rates, and length of hospital stay.
RESULTS
Four studies that directly compared open and MIS exenteration were included. Analysis was performed on 170 patients; 78.1% (n = 133) had open pelvic exenteration, while 21.8% (n = 37) had a MIS exenteration. The median age for open exenteration was 57.7 years versus 63 years for MIS exenteration. Even though the operative time for MIS exenteration was 83 min longer (p < 0.001), it was associated with a median of 1,750mls less blood loss. The morbidity rate for MIS exenterative group was 56.7% (n = 21/37) versus 88.5% (n = 85/96) in the open exenteration group, with pooled analysis observing a 1.17 relative risk increase in 30-day morbidity (p = 0.172) in the open exenteration group. In addition, the MIS cohort had a 6-day shorter length of hospital stay (p = 0.04).
CONCLUSION
MIS exenteration can be performed in highly selective cases, where there is favourable patient anatomy and tumour characteristics. When feasible, it is associated with reduced intra-operative blood loss, shorter length of hospital stay, and reduced morbidity.
Topics: Humans; Minimally Invasive Surgical Procedures; Neoplasm Staging; Outcome and Process Assessment, Health Care; Patient Selection; Pelvic Exenteration; Pelvic Neoplasms
PubMed: 30019221
DOI: 10.1007/s00464-018-6299-5 -
Gynecologic Oncology Apr 2023The aim of this study was to analyze morbidity and survival after pelvic exenteration for gynecologic malignancies and evaluate prognostic factors influencing...
OBJECTIVES
The aim of this study was to analyze morbidity and survival after pelvic exenteration for gynecologic malignancies and evaluate prognostic factors influencing postoperative outcome.
METHODS
We retrospectively reviewed all patients who underwent a pelvic exenteration at the departments of gynecologic oncology of three tertiary care centers in the Netherlands, the Leiden University Medical Centre, the Amsterdam University Medical Centre, and the Netherlands Cancer Institute, during a 20-year period. We determined postoperative morbidity, 2- and 5-year overall survival (OS) and 2- and 5-year progression free survival (PFS), and investigated parameters influencing these outcomes.
RESULTS
A total of 90 patients were included. The most common primary tumor was cervical cancer (n = 39, 43.3%). We observed at least one complication in 83 patients (92%). Major complications were seen in 55 patients (61%). Irradiated patients had a higher risk of developing a major complication. Sixty-two (68.9%) required ≥1 readmission. Re-operation was required in 40 patients (44.4%). Median OS was 25 months and median PFS was 14 months. The 2-year OS rate was 51.1% and the 2-year PFS rate was 41.5%. Tumor size, resection margins and pelvic sidewall involvement had a negative impact on OS (HR = 2.159, HR = 2.376, and HR = 1.200, respectively). Positive resection margins and pelvic sidewall involvement resulted in decreased PFS (HR = 2.567 and HR = 3.969, respectively).
CONCLUSION
Postoperative complications after pelvic exenteration for gynecologic malignancies are common, especially in irradiated patients. In this study, a 2-year OS rate of 51.1% was observed. Positive resections margins, tumor size, and pelvic sidewall involvement were related to poor survival outcomes. Adequate selection of patients who will benefit from pelvic exenteration is important.
Topics: Humans; Female; Genital Neoplasms, Female; Pelvic Exenteration; Retrospective Studies; Margins of Excision; Uterine Cervical Neoplasms; Neoplasm Recurrence, Local
PubMed: 36870097
DOI: 10.1016/j.ygyno.2023.02.010 -
Surgical Endoscopy Jan 2016Generalization of laparoscopic pelvic surgery has brought about profound knowledge of the pelvic anatomy and has encouraged expansion of indications for laparoscopic... (Comparative Study)
Comparative Study
BACKGROUND
Generalization of laparoscopic pelvic surgery has brought about profound knowledge of the pelvic anatomy and has encouraged expansion of indications for laparoscopic surgery to extended pelvic surgery. Pelvic exenteration (PE) is still a demanding surgical procedure and remains an essential technique for pelvic surgery although minimally invasive and function-preserving surgery is in the mainstream of surgical treatment. However, the techniques of laparoscopic PE (LPE) have been rarely explained nor has its feasibility been fully evaluated. The aim of this study was to describe important technical points and to assess the feasibility of LPE for pelvic malignancies.
METHODS
Data on 67 patients with pelvic malignancies, who underwent PE between June 2006 and August 2014, were analyzed retrospectively. LPE has been indicated since 2013. Patients were divided into the LPE group (n = 9) and the conventional open PE (OPE) group (n = 58).
RESULTS
Operative time in the LPE and OPE groups was similar (935 vs. 883 min, p = 0.398). Intraoperative blood loss in the LPE group was significantly less than that in the OPE group (830 vs. 2769 ml, p = 0.003). Pathological R0 resection rate was similar in both groups (77.8 vs. 75.9%). Overall incidence of any complication and major complications were much lower in the LPE group (66.7 and 0%) compared to the OPE group (89.7 and 32.8%), although not statistically significant (p = 0.094 and 0.053, respectively). Postoperative hospital stay was significantly shorter in the LPE group than in the OPE group (27 vs. 43 days, p = 0.003).
CONCLUSIONS
We confirmed that LPE for pelvic malignancies resulted in less blood loss, a lower complication rate, and shorter postoperative hospital stay compared to OPE. LPE performed by an experienced pelvic surgeon was safe and efficient, and might be a promising option for carefully selected patients.
Topics: Adult; Aged; Blood Loss, Surgical; Female; Humans; Laparoscopy; Length of Stay; Male; Middle Aged; Operative Time; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Retrospective Studies; Young Adult
PubMed: 25795381
DOI: 10.1007/s00464-015-4172-3 -
The British Journal of Surgery Dec 2015Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the...
BACKGROUND
Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment.
METHODS
Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review.
RESULTS
Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage.
CONCLUSION
The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Colorectal Neoplasms; Female; Follow-Up Studies; Humans; Male; Middle Aged; New South Wales; Pelvic Exenteration; Retrospective Studies; Survival Rate; Treatment Outcome; Young Adult
PubMed: 26694992
DOI: 10.1002/bjs.9915 -
Colorectal Disease : the Official... Jan 2021The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal...
Pelvic exenteration combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for advanced primary or recurrent colorectal cancer with peritoneal metastases.
AIM
The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure.
METHODS
Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases.
RESULTS
Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases.
CONCLUSION
Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.
Topics: Antineoplastic Combined Chemotherapy Protocols; Colorectal Neoplasms; Combined Modality Therapy; Cytoreduction Surgical Procedures; Humans; Hyperthermia, Induced; Hyperthermic Intraperitoneal Chemotherapy; Neoplasm Recurrence, Local; Pelvic Exenteration; Peritoneal Neoplasms; Quality of Life; Retrospective Studies; Survival Rate
PubMed: 32978813
DOI: 10.1111/codi.15378 -
Techniques in Coloproctology Nov 2023Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to...
Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative.
PURPOSE
Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients.
METHOD
From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared.
RESULTS
A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295 min, p = 0.009), blood loss (100 vs. 300 ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13 days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR 1.02, p = 0.002), poor tumor differentiation (HR 3.05, p = 0.004), and (y)pT4b stage (HR 2.35, p = 0.035) were independent risk factors for disease-free survival.
CONCLUSION
LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.
Topics: Humans; Female; Pelvic Exenteration; Retrospective Studies; Rectal Neoplasms; Laparoscopy; Rectum; Treatment Outcome; Neoplasm Recurrence, Local
PubMed: 37243857
DOI: 10.1007/s10151-023-02824-z -
Surgery Today Dec 2016Pelvic infection is a significant clinical problem after pelvic exenteration. The clinical benefit of an omental flap in reducing the incidence of such infections is...
Pelvic infection is a significant clinical problem after pelvic exenteration. The clinical benefit of an omental flap in reducing the incidence of such infections is unknown. The aim of this study was to evaluate whether an omental flap after pelvic exenteration reduces the incidence of pelvic infection and the length of postoperative hospital stay. In this study, we demonstrate a safe, effective, simple method for reducing the incidence of pelvic infection using an omental flap. We performed pelvic exenteration for tumors that were suspected to have extensive invasion to the bladder, prostate, or uterus. The omentum was dissected from the transverse colon and greater curvature of the stomach. The flap was based on the right gastroepiploic vessels and tunneled in the retrocolic plane, through the mesentery of the transverse colon and ileocecum, to the defect. Twenty-seven patients were analyzed retrospectively. Ten patients received omental flaps, and 17 patients underwent pelvic exenteration without an omental flap. The incidence of pelvic infection was significantly reduced in the patients with omental flaps.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Omentum; Pelvic Exenteration; Pelvic Infection; Pelvic Neoplasms; Postoperative Complications; Retrospective Studies; Surgical Flaps; Treatment Outcome
PubMed: 27226018
DOI: 10.1007/s00595-016-1348-y