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Colorectal Disease : the Official... May 2023Pelvic exenteration surgery is an umbrella term for a multitude of operative techniques for locally advanced and recurrent pelvic malignancy. Currently, there is...
AIM
Pelvic exenteration surgery is an umbrella term for a multitude of operative techniques for locally advanced and recurrent pelvic malignancy. Currently, there is heterogeneity in the operative description that limits the interpretation of patient outcome and collaboration between units through standardized data collection. Our study aims to develop a consensus lexicon to describe the operative components of extended and exenteration pelvic surgery.
METHOD
This study adopted a mixed-methods approach using semi-structured interviews, questionnaires, focus groups and validation exercises involving pelvic exenteration experts from centres in the UK. Qualitative data were collected, and descriptive statistics are presented.
RESULTS
We identified eight headings with 32 subheadings that encompass all components of the extent of the potential surgery. The lexicon was validated by 15 UK specialists. A 'high-complexity pelvic exenteration' was defined as encompassing 'conventional pelvic exenteration' with the extension of surgery to remove bony structures or the structures in the pelvic sidewall. Pelvic sidewall structures include major vessels, sciatic nerves and/or bone. Bony structures include the sacrum and/or pubic bones.
CONCLUSION
This pelvic exenteration lexicon will permit classification of the surgical approach used that will improve data synthesis, allow more accurate activity recording for audit and ultimately improved outcomes for patients.
Topics: Humans; Pelvic Neoplasms; Pelvic Exenteration; Pelvis; Carcinoma; Surveys and Questionnaires; Neoplasm Recurrence, Local; Retrospective Studies
PubMed: 36660781
DOI: 10.1111/codi.16476 -
Journal of Minimally Invasive Gynecology Jun 2024Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to...
STUDY OBJECTIVE
Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed.
DESIGN
The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM).
SETTING
Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling.
INTERVENTIONS
The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up.
CONCLUSION
Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.
PubMed: 38866099
DOI: 10.1016/j.jmig.2024.06.003 -
Journal of Minimally Invasive Gynecology 2019To assess the feasibility and efficacy of minimally invasive pelvic exenteration (MIPE) in a multi-institutional Italian case series of women with gynecologic cancer and... (Review)
Review
STUDY OBJECTIVE
To assess the feasibility and efficacy of minimally invasive pelvic exenteration (MIPE) in a multi-institutional Italian case series of women with gynecologic cancer and a review of the literature.
DESIGN
Retrospective cohort study (Canadian Task Force classification II-2).
SETTING
Three Italian university/teaching hospitals: "Agostino Gemelli" Foundation University Hospital in Rome, "ARNAS Civico Di Cristina Benfratelli" Hospital in Palermo, and "Maggiore della Carità" Hospital in Novara.
PATIENTS
We reviewed all consecutive cases with gynecologic malignancies in this multi-institutional setting recorded between March 2014 and June 2017. Women with primary or central recurrent/persistent gynecologic cancer considered suitable for exenterative surgery after multidisciplinary tumor board discussion were included. Clinicopathological, perioperative, and survival data were retrieved from the institutional electronic database (STAR center).
INTERVENTIONS
All patients underwent total or anterior MIPE with a laparoscopic or robotic approach.
MEASUREMENTS AND MAIN RESULTS
Twenty-three patients underwent MIPE during the study period, including 12 (52.1%) by a laparoscopic approach and 11 (47.9%) by a robotic approach. All but 1 woman underwent MIPE for recurrent disease. The overall median operative time was 540 minutes (range, 310-720 minutes) with laparoscopy, slightly longer than with the robotic approach (p = .04). Median estimated blood loss was 400 mL (range, 200-600 mL). R0 resection was achieved in 17 of 23 patients (73.9%). There were no perioperative deaths. Early major postoperative complications occurred in 2 patients (8.7%). The median duration of hospitalization was 10 days (range, 6-33 days). With a median follow-up of 15 months, 11 patients (47.8%) developed recurrence. The median disease-free survival was 11 months (range, 5-18 months). To date, 155 MIPEs for gynecologic cancers have been reported in the literature. Among these, 12.6% had major postoperative complications, and overall postoperative mortality was 0.6%.
CONCLUSION
MIPE is a feasible procedure with low rate of intraoperative and postoperative complications. Careful patient selection is crucial to balance perioperative risks and potential survival benefits and to achieve complete tumor resection.
Topics: Adult; Aged; Cytoreduction Surgical Procedures; Female; Genital Neoplasms, Female; Humans; Middle Aged; Minimally Invasive Surgical Procedures; Pelvic Exenteration; Retrospective Studies
PubMed: 30611973
DOI: 10.1016/j.jmig.2018.12.019 -
Frontiers in Surgery 2021Pelvic exenteration represents the last resort procedure for patients with advanced primary or recurrent gynecological malignancy. Pelvic exenteration can be divided...
Pelvic exenteration represents the last resort procedure for patients with advanced primary or recurrent gynecological malignancy. Pelvic exenteration can be divided into different subgroup based on anatomical extension of the procedures. The growing application of the minimally invasive surgical approach unlocked new perspectives for gynecologic oncology surgery. Minimally invasive surgery may offer significant advantages in terms of perioperative outcomes. Since 2009, several Robotic Assisted Laparoscopic Pelvic Exenteration experiences have been described in literature. The advent of robotic surgery resulted in a new spur to the worldwide spread of minimally invasive pelvic exenteration. We present a review of the literature on robotic-assisted pelvic exenteration. The search was conducted using electronic databases from inception of each database through June 2021. 13 articles including 53 patients were included in this review. Anterior exenteration was pursued in 42 patients (79.2%), 2 patients underwent posterior exenteration (3.8%), while 9 patients (17%) were subjected to total exenteration. The most common urinary reconstruction was non-continent urinary diversion (90.2%). Among the 11 women who underwent to total or posterior exenteration, 8 (72.7%) received a terminal colostomy. Conversion to laparotomy was required in two cases due to intraoperative vascular injury. Complications' report was available for 51 patients. Fifteen Dindo Grade 2 complications occurred in 11 patients (21.6%), and 14 grade 3 complications were registered in 13 patients (25.5%). Only grade 4 complications were reported (2%). In 88% of women, the resection margins were negative. Pelvic exenteration represents a salvage procedure in patients with recurrent or persistent gynecological cancers often after radiotherapy. A careful patient selection remains the milestone of such a mutilating surgery. The introduction of the minimally invasive approach has led to advantages in terms of perioperative outcomes compared to classic open surgery. This review shows the feasibility of robotic pelvic exenteration. An important step forward should be to investigate the potential equivalence between robotic approaches and the laparotomic one, in terms of long-term oncological outcomes.
PubMed: 34917648
DOI: 10.3389/fsurg.2021.790152 -
European Journal of Surgical Oncology :... Nov 2022The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of... (Review)
Review
The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.
Topics: Humans; Pelvic Exenteration; Neoplasm Recurrence, Local; Retrospective Studies; Rectal Neoplasms; Neoadjuvant Therapy; Margins of Excision; Neoplasms, Second Primary; Treatment Outcome
PubMed: 34922810
DOI: 10.1016/j.ejso.2021.11.007 -
European Urology Focus May 2021Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer.
BACKGROUND
Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer.
OBJECTIVE
To assess urological reconstructive outcomes and adverse events in this setting.
DESIGN, SETTING, AND PARTICIPANTS
A total of 104 patients underwent TPE from 2004 to 2016 in this single-centre, retrospective study. Electronic and paper records were evaluated for data extraction. Mean follow-up was 36.5 mo.
INTERVENTION
TPE.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Urological complications were analysed using two-tailed t and chi-square tests, binary logistic regression analysis.
RESULTS AND LIMITATIONS
Sixty-three (61%) patients received radiotherapy prior to TPE. Incontinent diversions included ileal conduit (n = 95), colonic conduits (n = 4), wet colostomy (n = 1), and cutaneous ureterostomy (n = 1). Three patients had a continent diversion. The overall urological complication rate was 54%. According to Clavien-Dindo classification, 30 patients, five patients, and one patient had grade III, IV, and V complications, respectively. The commonest complication was urinary tract infection (in 32 [31%] patients). Anastomotic leaks were seen in 14 (13%) cases, of which eight (8%) were urinary leaks. Fistulas were seen in three (3%) patients, involving the urinary system. A return to theatre was required in 12 (12%) patients. Ureteroenteric strictures were seen in seven (7%). No differences were seen in urological outcomes in patients with primary or recurrent rectal cancer (p = 0.69), or by radiation status (p = 0.24). The main limitation is the retrospective nature of the study.
CONCLUSIONS
TPE is complex with recognised high risk of morbidity. In this cohort, there was no significant difference in outcomes between primary and recurrent disease, and surgery after radiation.
PATIENT SUMMARY
In this study, we assessed urological complications following total pelvic exenteration. Urinary complications affected more than half of patients. Urinary tract infection is the commonest risk. Approximately one-third of patients required surgical, radiological, or endoscopic intervention ± intensive care admission. Radiation prior to the operation did not affect urinary complications.
Topics: Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Rectal Neoplasms; Retrospective Studies; Urinary Tract Infections
PubMed: 32622667
DOI: 10.1016/j.euf.2020.06.008 -
International Journal of Colorectal... May 2024Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly...
UNLABELLED
Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.
METHOD
A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.
RESULTS
A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.
CONCLUSION
This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.
Topics: Humans; Incidence; Female; Risk Factors; Pelvic Exenteration; Male; Middle Aged; Postoperative Complications; Aged; Hernia; Adult; Retrospective Studies
PubMed: 38717479
DOI: 10.1007/s00384-024-04638-3 -
Current Urology Jun 2020Pelvic exenterative surgery is both complex and challenging, especially in the setting of locally recurrent disease. In recent decades, improved surgical techniques have... (Review)
Review
Pelvic exenterative surgery is both complex and challenging, especially in the setting of locally recurrent disease. In recent decades, improved surgical techniques have facilitated more extensive resection of both locally advanced and recurrent pelvic malignancies, but its role in urological cancer surgery is highly selective. However, it remains an important part of the armamentarium for the management of bladder and prostate cancer cases where there is local invasion into adjacent organs or localized recurrence. Better diagnostics, reconstructive options and centralized care have reduced associated morbidity considerably, and it is still used rarely in palliative settings. Despite this, there is sparse prospective evidence reporting on long-term oncological or quality of life outcomes.
PubMed: 32774229
DOI: 10.1159/000499258 -
Cirugia Espanola Aug 2023Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity...
Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.
Topics: Male; Humans; Pelvic Exenteration; Robotic Surgical Procedures; Retrospective Studies; Rectum; Proctectomy
PubMed: 37487944
DOI: 10.1016/j.cireng.2023.03.012 -
Investigative and Clinical Urology Jan 2021To describe the surgical technique and examine the feasibility and outcomes following robotic pelvic exenteration and extended pelvic resection for rectal and/or...
PURPOSE
To describe the surgical technique and examine the feasibility and outcomes following robotic pelvic exenteration and extended pelvic resection for rectal and/or urological malignancy.
MATERIALS AND METHODS
We present a case series of seven patients with locally advanced or synchronous urological and/or rectal malignancy who underwent robotic total or posterior pelvic exenteration between 2012-2016.
RESULTS
In total, we included seven patients undergoing pelvic exenteration or extended pelvic resection. The mean operative time was 485±157 minutes and median length of stay was 9 days (6-34 days). There was only one Clavien-Dindo complication grade 3 which was a vesicourethral anastomotic leak requiring rigid cystoscopy and bilateral ureteric catheter insertion. Eighty-five percent of patients had clear colorectal margins with a median margin of 3.5 mm (0.7-8.0 mm) while all urological margins were clear. Six out of seven patients had complete (grade 3) total mesorectal excision. Three patients experienced recurrence at a median of 22 months (21-24 months) post-operatively. Of the three recurrences, one was systemic only whilst two were both local and systemic. One patient died from complications of dual rectal and prostate cancer 31 months after the surgery.
CONCLUSIONS
We report a large series examining robotic pelvic exenteration or extended pelvic resection and describe the surgical technique involved. The robotic approach to pelvic exenteration is highly feasible and demonstrates acceptable peri-operative and oncological outcomes. It has the potential to benefit patients undergoing this highly complex and morbid procedure.
Topics: Aged; Anastomosis, Surgical; Anastomotic Leak; Cystectomy; Feasibility Studies; Humans; Length of Stay; Male; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neoplasms, Multiple Primary; Operative Time; Pelvic Exenteration; Proctectomy; Prostatectomy; Prostatic Neoplasms; Rectal Neoplasms; Robotic Surgical Procedures; Treatment Outcome; Urethra; Urinary Bladder
PubMed: 33381928
DOI: 10.4111/icu.20200176