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Cancers Feb 2024Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some... (Review)
Review
Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some cases of advanced tumors, it is associated with several perioperative complications. We believe that careful patient selection is related to better oncologic outcomes and lower complication rates. The objectives of this review are to identify the most current indications for this intervention, suggest criteria for case selection, evaluate recommendations for perioperative care, and review oncologic outcomes and potential associated complications. To this end, an analysis of English language articles in PubMed was performed, searching for topics such as the indication for pelvic exenteration for recurrent gynecologic neoplasms selection of oncologic cases, the impact of tumor size and extent on oncologic outcomes, preoperative and postoperative surgical management, surgical complications, and outcomes of overall survival and recurrence-free survival.
PubMed: 38398208
DOI: 10.3390/cancers16040817 -
International Journal of Surgery... Dec 2017Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably...
BACKGROUND
Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.
MATERIALS AND METHODS
This was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fisher's exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.
RESULTS
Since 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).
CONCLUSION
The long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.
Topics: Adult; Aged; Aged, 80 and over; Chemotherapy, Adjuvant; Chi-Square Distribution; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Male; Margins of Excision; Middle Aged; Neoplasm Staging; Pelvic Exenteration; Postoperative Complications; Prospective Studies; Rectal Neoplasms; Rectum; Retrospective Studies; Statistics, Nonparametric; Treatment Outcome
PubMed: 28987560
DOI: 10.1016/j.ijsu.2017.09.069 -
Indian Journal of Surgical Oncology Dec 2018Pelvic exenteration (PE) is one of the most drastic operations in surgical oncology, associated with severe morbidity and mortality. The objective of our study was to...
Pelvic exenteration (PE) is one of the most drastic operations in surgical oncology, associated with severe morbidity and mortality. The objective of our study was to review our experience of PE in terms of surgical characteristics, complications, and overall survival. All patients who had PE surgery between January 1999 and December 2015 were identified. Patients with verified distant metastatic disease were excluded. Patients with advanced pelvic tumors experiencing incapacitating postradiation severe damages were included. The following parameters were recorded: age, sex, indication for surgery, tumor histology, type of exenteration, urinary tract and colon reconstruction methods, operative time, blood transfusion, intensive care unit admissions, length of hospital stay and readmissions, and characteristics of perioperative morbidity and mortality. A total of 25 patients were submitted to PE by our surgical team. Most of the patients suffered from cervical cancer followed by bowel cancer. There was no perioperative mortality. Early postoperative complications ensued in 56% of the patients. Most complications involved the urinary system. Five years survival was estimated at 38%. Most patients ( = 9, 36%) died due to their primary disease, 5 (20%) died because of complications following operation, and 2 (8%) died because they denied oral feeding, which was associated with depression. Patients with a variety of malignancies can benefit from PE. Meticulous surgical technique, perioperative care, counseling, and nutritional support play an important role.
PubMed: 30538387
DOI: 10.1007/s13193-018-0792-0 -
Indian Journal of Surgical Oncology Jun 2017Cervical cancer usually presents in advanced stages and is treated with chemoradiation. About 15-20 % patients present with local recurrence after chemoradiation....
Cervical cancer usually presents in advanced stages and is treated with chemoradiation. About 15-20 % patients present with local recurrence after chemoradiation. Radical surgical resection is the only treatment modality offering long term survival benefit in recurrent cervical cancer. The most common surgical option for these patients is pelvic exenteration. Radical hysterectomy may be done for patients with a small centrally located recurrence in the cervix with no infiltration of adjacent structures. The aim of this study was to evaluate the morbidity and survival outcome following radical hysterectomy and pelvic exenteration for recurrent cancer cervix. We retrospectively reviewed the medical records of our patients who underwent surgery for cancer cervix recurrence from January 2010 to December 2014. The postoperative morbidity was considered early if it happened in the initial 30 days of surgery and late if it occurred after 30 days. All patients were followed up till February 2015. Survival analysis was done using Kaplan- Meir method. Between January 2010 and December 2014, 20 patients with recurrent cervical cancer underwent radical surgical resection. The median age of the study group was 43 years (range 28-63 years). Seventeen patients had squamous cell carcinoma and 3 had adenocarcinoma. 13 underwent pelvic exenteration and 7 patients underwent radical type 2 hysterectomy with bilateral pelvic lymphnode dissection. In the exenteration group, 8 patients had anterior exenteration, 4 had total exenteration and one had posterior exenteration. Urinary diversion was done by ileal conduit in 8 patients, double barrel colostomy in two and wet colostomy in two patients. There were no immediate postoperative deaths. Operating time, blood transfusions needed and hospital stay was more in the exenteration group compared to radical hysterectomy patients. After pelvic exenteration post-operative complications were seen in 76.9 % of which the most common was of the urinary tract including 3 patients with pyelonephritis, 5 had renal insufficiency and 2 patients developed urinary fistulae. Post-operative morbidity was lower in radical hysterectomy patients. There were two patients in the hysterectomy group who developed vault recurrence while none in the exenteration group had local recurrence. The median follow up time was 19 months (range 9-53 months).Three year overall survival for the entire cohort was 43 %. Median survival time for the exenteration group was 28 months which was significantly higher than 14 months for the radical hysterectomy group. This study shows that radical surgical resection is feasible with good survival outcome and acceptable morbidity in recurrent cancer cervix patients. Radical hysterectomy can be done in selected patients but pelvic exenteration has better long-term survival but with the potential for both short- & long-term complications.
PubMed: 28546709
DOI: 10.1007/s13193-015-0472-2 -
BMC Surgery Aug 2022Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of...
BACKGROUND
Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration.
METHODS
A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months.
RESULTS
The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications.
CONCLUSIONS
A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
Topics: Humans; Necrosis; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Floor; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies
PubMed: 35933336
DOI: 10.1186/s12893-022-01755-0 -
Experimental and Therapeutic Medicine Oct 2021This study was designed with an aim to share our experience of primary pelvic exenterations. The study included 23 patients with different types of pelvic cancer...
This study was designed with an aim to share our experience of primary pelvic exenterations. The study included 23 patients with different types of pelvic cancer enrolled at a single institution between November 2011 and July 2020. The patient mean age was 55 years (range, 43-72 years) and the oncological indications included: Stage IVa cervical cancer (11 cases, 48.9%), stage IVa endometrial cancer (1 case, 4.3%), stage IVa vaginal cancer (6 cases, 26%), stage IIIb bladder cancer (3 cases, 13%), stage IIIc rectal cancer (1 case, 4.3%) and undifferentiated pelvic sarcoma (1 case, 4.3%). Total, anterior, and posterior pelvic exenterations were performed on 34.4, 56.5 and 13% of cases, respectively. Related to levator ani muscle, 13 (56.5%) pelvic exenterations were supralevatorian, 10 (43.5%) infralevatorian, and 5 (21.7%) were infralevatorian with vulvectomy. No major intraoperative complications occurred. Seven patients (30.5%) developed early complications, 4 of them (17.4%) required reoperation and 1 (4.3%) perioperative death caused by a pulmonary embolism was recorded. Only 1 patient experienced a late complication, a urostomy stenosis. Over a median follow-up period of 35 months, 8 (34.8%) patients died. The median overall survival (OS) was 33 months (range, 1-96 months). The 2-year and 5-year survival rates were 72 and 66%, respectively. Primary pelvic exenteration may be related with various postoperative complications, without high perioperative morality and with long-term survival.
PubMed: 34434274
DOI: 10.3892/etm.2021.10494 -
Urology Journal Sep 2018To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or...
PURPOSE
To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or double-barrelled wet colostomy (DBWC).
MATERIALS AND METHODS
The medical records of all patients who had undergone pelvic exenteration and urinary diversion between 2006 and 2017 at our hospital were reviewed retrospectively.
RESULTS
In total, 15 patients with a mean age of 56 ± 13 years were included in the study. Simultaneous urinary and fecal diversions were carried out as PWC (n = 8), or DBWC (n = 7). No significant differences were found between PWC and DBWC groups in terms of operation time (373.7 ± 66.5 versus 394.2 ± 133.2 min, P = .955), estimated blood loss (862.8 ± 462.4 versus 726.2 ± 489.4 mL, P = .613), length of hospital stay (13.2 ± 9.1 versus 14.1 ±6.9 days), early complications (25% versus 28.6%, P = 1.0) and late term complications (37.5% versus 42.9%, P = 1.0). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically significant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618).
CONCLUSION
PWC and DBWC are valid options for creating simultaneous urinary and fecal diversion after extensive pelvic surgery in patients with short life expectancy. DBWC might be superior to PWC in terms of decreased risk of recurrent pyelonephritis.
Topics: Adult; Aged; Colostomy; Female; Humans; Length of Stay; Life Expectancy; Male; Middle Aged; Operative Time; Pelvic Exenteration; Postoperative Complications; Pyelonephritis; Retrospective Studies; Turkey; Urinary Diversion
PubMed: 29705982
DOI: 10.22037/uj.v0i0.4461 -
Gynecologic Oncology Nov 2021To explore pre-operative factors and their impact on overall survival (OS) in a modern cohort of patients who underwent pelvic exenteration (PE) for gynecologic...
OBJECTIVES
To explore pre-operative factors and their impact on overall survival (OS) in a modern cohort of patients who underwent pelvic exenteration (PE) for gynecologic malignancies.
METHODS
A retrospective review was performed for all patients who underwent a PE from 1/1/2010 through 12/31/2018 at our institution. Inclusion criteria were exenteration due to recurrent or progressive carcinoma of the uterus, cervix, vagina or vulva, with histologically confirmed complete surgical resection of the malignancy. Exclusion criteria included PE for palliation of symptoms without recurrence, and for ovarian or rare histologic malignancies. Univariable and multivariable analysis were performed to identify factors predicting prolonged survival.
RESULTS
Overall, 71 patients met the inclusion criteria. Median age at time of exenteration was 62 years (range, 28-86 years). Vulvar cancer was the most common primary diagnosis (32%); 30% had cervical cancer; 23%, uterine cancer; 15%, vaginal cancer. Median OS was 55.1 months (95% confidence interval (CI): 36-not estimable) with a median follow-up time of 40.8 months (95% CI: 1-116.1). On univariable analysis, age > 62 years (hazard ratio (HR) 2.71, 95% CI 1.27-5.79), American Society of Anesthesia (ASA) 3-4 (HR: 3.41 (95% CI 1.03-11.29), and vulvar cancer (HR 4.19 (95% CI 1.17-14.96) predicted worse OS. Tumor size and prior progression-free interval (PFI) did not meet statistical significance in OS analyses. On multivariable analysis, there were no significant factors associated with worse OS.
CONCLUSIONS
PE performed with curative intent may be considered a treatment option in well-counseled, carefully selected patients, irrespective of tumor size and PFI before exenteration.
Topics: Adult; Aged; Aged, 80 and over; Female; Follow-Up Studies; Genital Neoplasms, Female; Humans; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Patient Selection; Pelvic Exenteration; Progression-Free Survival; Retrospective Studies; Risk Factors; Time Factors; Tumor Burden
PubMed: 34518053
DOI: 10.1016/j.ygyno.2021.08.033 -
Frontiers in Oncology 2015Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an... (Review)
Review
Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region per se has many different functions for urination, bowel evacuation, sexuality, and reproduction. Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome. Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of postresectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory. In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted. For intra-abdominally and/or pelvic tumors of the rectum, the anus, or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous vertical rectus abdominis myocutaneous (VRAM) flap reconstruction is recommendable. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques, especially VRAM flap and pedicled flaps like antero-lateral thigh flap or free flaps. Finally, this review outlines some considerations concerning timing of the different operative steps.
PubMed: 26500887
DOI: 10.3389/fonc.2015.00212 -
International Braz J Urol : Official... 2021One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract...
Simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion: step-by-step video-illustrated technique.
INTRODUCTION:
One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract urothelial cancer (UTUC) is exceptional. Minimally invasive approach for these synchronous tumors was just occasionally reported (1-4). The aim of this video article is to describe step-by-step the technique for simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion (ICUD). Patients and methods: A 66-year-old female presented with synchronous BCG refractory non-muscle invasive bladder cancer and a right-side UTUC. She was a former smoker and had previously been submitted to multiple transurethral resections of bladder tumor, BCG and right distal ureterectomy with ureteral reimplant. We performed a simultaneous laparoscopic right nephroureterectomy and robot-assisted anterior pelvic exenteration with totally intracorporeal ICUD. Combination of robot-assisted and pure laparoscopic approaches was proposed focusing on optimization of total operative time (TOT).
RESULTS:
Surgery was uneventful. TOT was of 330 minutes. Operative time for nephroureterectomy, anterior pelvic exenteration and ICUD were 48, 135, 87 minutes, respectively. Estimated blood loss was 150mL. Postoperative course was unremarkable and patient was discharged after 7 days. Histopathological evaluation showed a pT1 high grade urothelial carcinoma plus carcinoma in situ both in proximal right ureter and bladder, with negative margins. Twelve lymph nodes were excised, all of them negative.
CONCLUSION:
In our preliminary experience, totally minimally invasive simultaneous nephroureterectomy and cystectomy with intracorporeal ICUD is feasible. Pure laparoscopic approach to upper urinary tract may be a useful tactic to reduce total operative time.
Topics: Cystectomy; Humans; Laparoscopy; Nephroureterectomy; Pelvic Exenteration; Robotics; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 34260187
DOI: 10.1590/S1677-5538.IBJU.2020.1006