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Obstetrics & Gynecology Science Sep 2021To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure.
OBJECTIVE
To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure.
METHODS
LEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic sidewall. Its initial indications were for lymph node positive Stage Ib (current International Federation of Gynecology and Obstetrics 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic sidewall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic sidewall.
RESULTS
During LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic sidewall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic sidewall veins.
CONCLUSION
LEP is a feasible technique for removing pelvic sidewall recurrences, aiming to obtain surgical free margins.
PubMed: 34030221
DOI: 10.5468/ogs.21103 -
Surgical Oncology Jun 2021This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone... (Review)
Review
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
Topics: Humans; Patient Selection; Pelvic Exenteration; Perioperative Care; Rectal Neoplasms
PubMed: 33799076
DOI: 10.1016/j.suronc.2021.101546 -
Chirurgia (Bucharest, Romania : 1990) Apr 2024Bearing in mind that the open procedure is already validated by multiple studies, the article aims to prove that pelvic exenteration performed in a minimally invasive...
Bearing in mind that the open procedure is already validated by multiple studies, the article aims to prove that pelvic exenteration performed in a minimally invasive fashion might offer better survival and to potentially identify prognostic factors for the outcome of these patients. Material and Data regarding past and present classifications and surgical indications are presented. Patient data were collected retrospectively. The most frequent diseases treated with pelvic exenteration, in terms of the hystological type, were gynecological malignancy and squamous cell carcinoma. Recurrent pelvic disease was found in 68.2% of patients. R0 resection was achieved in 72.7% of patients in the MI group, and in 73.7% of patients in the OP group. Peri-operative morbidity was reported to be 56.6% for open surgery, and 18.1% for minimally invasive. Average DFS was 20.15 months, ranging from 1.5 to 70.3 months, while the OS was calculated to be 38.1 months (0.33 1508) up until November 2023. Conclusion: Pelvic exenteration is a continuously improving surgical procedure, open approach being favored to minimally invasive one. On the other hand, hospitalization and morbidity are reduced when choosing the latter. R0 and lymph node status are important predictors for overall survival, as well as major early postoperative complications. All in all, pelvic exenteration is still a promising surgical procedure to extend cancer patients lives.
Topics: Humans; Pelvic Exenteration; Female; Retrospective Studies; Treatment Outcome; Male; Carcinoma, Squamous Cell; Middle Aged; Aged; Prognosis; Adult; Neoplasm Recurrence, Local; Romania; Genital Neoplasms, Female; Disease-Free Survival; Minimally Invasive Surgical Procedures
PubMed: 38743833
DOI: 10.21614/chirurgia.2024.v.119.i.2.p.201 -
Cancers Dec 2021The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient...
PURPOSE
The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view.
METHODS
This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used.
RESULTS
A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes).
CONCLUSION
Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.
PubMed: 34944783
DOI: 10.3390/cancers13246162 -
European Journal of Surgical Oncology :... Nov 2022
Topics: Humans; Pelvic Exenteration; Postoperative Complications; Retrospective Studies
PubMed: 36243647
DOI: 10.1016/j.ejso.2022.08.002 -
International Journal of Radiation... Nov 2019
Topics: Adenocarcinoma, Clear Cell; Antineoplastic Agents; Brachytherapy; Chemoradiotherapy; Cisplatin; Female; Humans; Lymphatic Irradiation; Magnetic Resonance Imaging; Middle Aged; Neoplasm Invasiveness; Pelvic Exenteration; Radiotherapy, Intensity-Modulated; Urethral Neoplasms; Urinary Bladder Neoplasms; Vaginal Neoplasms
PubMed: 31655652
DOI: 10.1016/j.ijrobp.2018.02.167 -
European Journal of Surgical Oncology :... Jun 2022Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers...
BACKGROUND
Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival.
METHODS
Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed.
RESULTS
The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients.
CONCLUSION
The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
Topics: Humans; Morbidity; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Retrospective Studies
PubMed: 34998633
DOI: 10.1016/j.ejso.2021.12.472 -
ANZ Journal of Surgery Nov 2022Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now... (Review)
Review
Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.
Topics: Humans; Pelvic Exenteration; Quality of Life; Rectal Neoplasms; Neoplasm Recurrence, Local; Pelvic Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 35490337
DOI: 10.1111/ans.17734 -
The Pan African Medical Journal 2023in patients with advanced primary or recurrent gynecologic, urologic, or rectal cancers without metastatic disease, extensive aggressive surgery such as pelvic...
INTRODUCTION
in patients with advanced primary or recurrent gynecologic, urologic, or rectal cancers without metastatic disease, extensive aggressive surgery such as pelvic exenteration may be necessary for curative intent treatment. This study aims to present the initial experience and clinical outcome of curative pelvic exenteration procedures for advanced or recurrent pelvic cancer in our center.
METHODS
a retrospective cross-sectional study was conducted at the colorectal unit at King Hussein Medical Center in Amman, Jordan, between March 2014 and December 2021. All patients who underwent pelvic exenteration procedures were included in this study. Demographic characteristics, type of procedure, completeness of excision, postoperative complications, morbidity, and mortality were analyzed.
RESULTS
a total of 30 patients underwent thirty-one operations. There were 22 females and eight males with a median age of 55 (range 25-86) years. Twenty-six surgeries were for advanced primary and 5 for recurrent malignancies. Twenty-nine operations were performed for colorectal and 2 for gynecological tumors. There were 19 posterior pelvic exenterations, 2 posterior pelvic exenterations with sacrectomy, and ten total pelvic exenterations. Completeness of tumor excision R0 was observed in 21 specimens, incomplete (R1/R2) in 6 specimens. The overall complication rate was 67.7% and 30-day mortality was 16.7%. Ten (33.3%) patients are disease free at a median follow-up of 22 months.
CONCLUSION
in our study, pelvic exenteration provides above 40% overall survival at a median follow-up of two years. Gaining experience in this type of procedure, a multidisciplinary approach, careful patients' selection, and preoperative counseling will reduce postoperative morbidity and mortality.
Topics: Male; Humans; Female; Adult; Middle Aged; Aged; Aged, 80 and over; Pelvic Exenteration; Retrospective Studies; Cross-Sectional Studies; Neoplasm Recurrence, Local; Rectal Neoplasms; Postoperative Complications; Treatment Outcome
PubMed: 37455871
DOI: 10.11604/pamj.2023.44.170.37182