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BJS Open Aug 2019Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is technically challenging but increasingly performed in...
BACKGROUND
Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is technically challenging but increasingly performed in specialist centres. The aim of this study was to compare outcomes of exenteration over time.
METHODS
This was a multicentre retrospective study of patients who underwent exenteration for LARC and LRRC between 2004 and 2015. Surgical outcomes, including rate of bone resection, flap reconstruction, margin status and transfusion rates, were examined. Outcomes between higher- and lower-volume centres were also evaluated.
RESULTS
Some 2472 patients underwent pelvic exenteration for LARC and LRRC across 26 institutions. For LARC, rates of bone resection or flap reconstruction increased from 2004 to 2015, from 3·5 to 12·8 per cent, and from 12·0 to 29·4 per cent respectively. Fewer units of intraoperative blood were transfused over this interval (median 4 to 2 units; = 0·040). Subgroup analysis showed that bone resection and flap reconstruction rates increased in lower- and higher-volume centres. R0 resection rates significantly increased in low-volume centres but not in high-volume centres over time (low-volume: from 62·5 to 80·0 per cent, = 0·001; high-volume: from 83·5 to 88·4 per cent, = 0·660). For LRRC, no significant trends over time were observed for bone resection or flap reconstruction rates. The median number of units of intraoperative blood transfused decreased from 5 to 2·5 units ( < 0·001). R0 resection rates did not increase in either low-volume (from 51·7 to 60·4 per cent; = 0·610) or higher-volume (from 48·6 to 65·5 per cent; = 0·100) centres. No significant differences in length of hospital stay, 30-day complication, reintervention or mortality rates were observed over time.
CONCLUSION
Radical resection, bone resection and flap reconstruction rates were performed more frequently over time, while transfusion requirements decreased.
Topics: Aged; Blood Transfusion; Female; Humans; Length of Stay; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Rectal Neoplasms; Rectum; Retrospective Studies; Surgical Flaps; Treatment Outcome
PubMed: 31388644
DOI: 10.1002/bjs5.50153 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Mar 2023In recent years, with advances in pelvic oncology and surgical techniques, surgeons have redefined the boundaries of pelvic surgery. Combined pelvic exenteration is now...
In recent years, with advances in pelvic oncology and surgical techniques, surgeons have redefined the boundaries of pelvic surgery. Combined pelvic exenteration is now considered the treatment of choice for some patients with locally advanced and locally recurrent rectal cancer, but it is only performed in a few hospitals in China due to the complexity of the procedure and the large extent of resection, complications, and high perioperative mortality. Although there have been great advances in oncologic drugs and surgical techniques and equipment in recent years, there are still many controversies and challenges in the preoperative assessment of combined pelvic organ resection, neoadjuvant treatment selection and perioperative treatment strategies. Adequate understanding of the anatomical features of the pelvic organs, close collaboration of the clinical multidisciplinary team, objective assessment and standardized preoperative combination therapy creates the conditions for radical surgical resection of recurrent and complex locally advanced rectal cancer, while the need for rational and standardized R0 resection still has the potential to bring new hope to patients with locally advanced and recurrent rectal cancer.
Topics: Humans; Pelvic Exenteration; Neoplasm Recurrence, Local; Rectum; Rectal Neoplasms; Pelvis; Treatment Outcome; Retrospective Studies
PubMed: 36925120
DOI: 10.3760/cma.j.cn441530-20221123-00488 -
Annals of Surgical Treatment and... Aug 2021Pelvic exenteration (PE) is a highly invasive procedure with high morbidity and mortality rates. Promising options to reduce this invasiveness have included laparoscopic...
PURPOSE
Pelvic exenteration (PE) is a highly invasive procedure with high morbidity and mortality rates. Promising options to reduce this invasiveness have included laparoscopic and transperineal approaches. The aim of this study was to identify the safety of combined transabdominal and transperineal endoscopic PE for colorectal malignancies.
METHODS
Fourteen patients who underwent combined transabdominal and transperineal PE (T group: 2-team approach, n = 7; O group: 1-team approach, n = 7) for colorectal malignancies between April 2016 and March 2020 in our institutions were included in this study. Clinicopathological features and perioperative outcomes were compared between groups.
RESULTS
All patients successfully underwent R0 resection. Operation time tended to be shorter in the T group (463 minutes) than in the O group (636 minutes, P = 0.080). Time to specimen removal was significantly shorter (258 minutes 423 minutes, P = 0.006), blood loss was lower (343 mL 867 mL, P = 0.042), and volume of blood transfusion was less (0 mL 560 mL, P = 0.063) in the T group, respectively. Postoperative complications were similar between groups.
CONCLUSION
Combined transabdominal and transperineal PE under a synchronous 2-team approach was feasible and safe, with the potential to reduce operation time, blood loss, and surgeon stress.
PubMed: 34386459
DOI: 10.4174/astr.2021.101.2.102 -
European Journal of Surgical Oncology :... Jan 2023Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and...
BACKGROUND
Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care.
METHOD
Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team.
RESULTS
This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities.
CONCLUSION
Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.
Topics: Humans; Pelvic Exenteration; Colorectal Neoplasms; Morbidity; Postoperative Complications; Neoplasm Recurrence, Local; Delivery of Health Care; Rectal Neoplasms
PubMed: 36030135
DOI: 10.1016/j.ejso.2022.08.011 -
International Braz J Urol : Official... 2020Total pelvic exenteration with permanent fecal and urinary diversion is a rare, extensive and morbid surgical procedure reserved for locally advanced soft tissue tumors...
INTRODUCTION
Total pelvic exenteration with permanent fecal and urinary diversion is a rare, extensive and morbid surgical procedure reserved for locally advanced soft tissue tumors arising in the pelvis. A robot assisted approach with intracorporeal diversion has the potential advantage of decreasing the morbidity of this procedure, but has not been well described in literature.
MATERIALS AND METHODS
Using a da Vinci Xi® system, robot assisted total pelvic exenteration with intracorporeal diversion was performed in a 49 year old gentleman with a 13.1 x 9.6cm soft tissue sarcoma in pelvis. The salient steps involved sigmoid colon transection after high ligation of inferior mesenteric artery, control of posterolateral pedicles, opening of endopelvic fascia, apical dissection of urethra and completion of posterior dissection over presacral fascia to extract the specimen through a simultaneous perineal approach, extended pelvic lymphadenectomy and intracorporeal ileal conduit creation.
RESULTS
Console time, blood loss and length of stay were 410 minutes, 400cc and 9 days respectively. He had a minor complication in the form of lymphorrhea from perineal wound which resolved on Foley drain placement per urethra. Histopathology revealed epithelioid leiomyosarcoma with muscle invasion in bladder and rectum, resected with negative margins (pT2N0R0). All 32 lymph nodes were negative for metastases.
CONCLUSION
Robotic approach to total pelvic exenteration is safe, feasible and replicates the principles of open oncological surgery while carrying the potential of decreasing the morbidity of this otherwise extensive surgery. This procedure is greatly facilitated by a thorough preoperative treatment planning by a multidisciplinary team.
PubMed: 32822147
DOI: 10.1590/S1677-5538.IBJU.2019.0302 -
Diseases of the Colon and Rectum Sep 2023Total pelvic exenteration, a surgical procedure for patients with highly advanced primary and recurrent rectal cancer, is technically demanding.
BACKGROUND
Total pelvic exenteration, a surgical procedure for patients with highly advanced primary and recurrent rectal cancer, is technically demanding.
IMPACT OF INNOVATION
We report the utility of a transanal minimally invasive surgical approach to total pelvic exenteration.
TECHNOLOGY MATERIALS AND METHODS
A 2-team approach with a laparoscopic transabdominal approach and transanal minimally invasive surgery was adopted. During the transabdominal approach in the pelvis, dissection was performed to remove the pelvic organs and visceral branches of the internal iliac vessels. The dissection goal via the transabdominal approach is the levator ani. During the transperineal approach, dissection is performed along the levator ani, and the tendinous arch of the levator ani is penetrated at the lateral side to achieve rendezvous between the 2 approaches. The levator ani is then dissected circumferentially, with identification of the internal pudendal vessels passing through the levator ani at the 4 o'clock and 8 o'clock positions, known as Alcock's canal. The anterior wall of Alcock's canal is formed by the coccygeus muscle and sacrospinous ligament, which are dissected by the transperineal approach to open Alcock's canal, thus obtaining a clear view of the internal pudendal vessels. On the anterior side, the urethra is divided with a laparoscopic linear stapler via the transperineal approach.
PRELIMINARY RESULTS
Eight patients with rectal cancer underwent this procedure. The median (range) blood loss was 200 (120-1520) mL and operating time was 467 (321-833) minutes. Reoperation was performed in 1 internal hernia case; however, there were no mortalities, and there were no cases with severe complications or conversion to open surgery.
CONCLUSIONS AND FUTURE DIRECTIONS
When performing total pelvic exenteration, transanal minimally invasive surgery offers direct visualization behind the tumor from the anal side and shows the deep pelvic structures, including the retroperitoneal space of the pelvic sidewall.
Topics: Humans; Pelvic Exenteration; Neoplasm Recurrence, Local; Minimally Invasive Surgical Procedures; Pelvic Floor; Conversion to Open Surgery
PubMed: 37260267
DOI: 10.1097/DCR.0000000000002764 -
Clinical Oncology (Royal College of... Sep 2021Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative,... (Review)
Review
Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative, however, when new techniques are adopted, in the context of treating oncology patients, that the oncological efficacy and safety are established rigorously rather than assumed based on first principles. Here we have attempted to provide a comprehensive review of all the contentious and topical themes surrounding the use of MIS in the treatment of endometrial and cervix cancer following a thorough review of the literature. On the topic of endometrial cancer, we cover the role of laparoscopy in both early and advanced disease, together with the role and unique benefits of robotic surgery. The surgical challenge of patients with a raised body mass index and the frail and elderly are discussed and finally the role of sentinel lymph node assessment. For cervical cancer, the role of MIS for staging and primary treatment is covered, together with the interesting and highly specialist topics of fertility-sparing treatment, ovarian transposition and the live birth rate associated with this. We end with a discussion on the evidence surrounding the role of adjuvant hysterectomy following radical chemoradiation and pelvic exenteration for recurrent cervical cancer. MIS is the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations, based on the available evidence, are that the open approach should be considered the gold standard for the surgical management of early cervical cancer and that MIS should only be adopted in the context of research. Careful counselling of patients on the current evidence, discussing in detail the risks and benefits to enable them to make an informed choice, remains paramount.
Topics: Aged; Endometrial Neoplasms; Female; Humans; Hysterectomy; Laparoscopy; Neoplasm Recurrence, Local; Neoplasm Staging; Retrospective Studies; Robotic Surgical Procedures; Uterine Cervical Neoplasms
PubMed: 34053834
DOI: 10.1016/j.clon.2021.05.001 -
Journal of Surgical Oncology Mar 2022In selected patients with advanced rectal cancers involving the prostate or seminal vesicles, the bladder can be preserved to avoid the complications associated with an...
AIM
In selected patients with advanced rectal cancers involving the prostate or seminal vesicles, the bladder can be preserved to avoid the complications associated with an ileal conduit. The study was aimed at reviewing the technique and short-term outcomes of patients that underwent bladder sparing robotic pelvic exenteration with suprapubic cystostomy (SPC).
METHODS
Case series of bladder preserving exenteration from a single tertiary care center. Technique for en-bloc prostatectomy with abdominoperineal resection is described.
RESULTS
Five patients underwent bladder sparing robotic pelvic exenteration with SPC, all had R0 resections. Four patients had prostatic invasion and one patient had prostatic adenocarcinoma. Postoperative complications were seen in three patients of which two were re-explored. At a median follow-up of 10 months, two patients developed systemic relapses. There were no local recurrences.
CONCLUSION
Robotic bladder sparing exenteration is technically feasible, provides acceptable short-term outcomes, and avoids complications of ileal conduit.
Topics: Adult; Aged; Cohort Studies; Cystostomy; Humans; Length of Stay; Male; Middle Aged; Pelvic Exenteration; Proctectomy; Prostatectomy; Rectal Neoplasms; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34661920
DOI: 10.1002/jso.26719 -
BJU International Sep 2020To evaluate retrospectively the surgical, symptomatic and oncological outcomes of pelvic exenteration surgery (PES) in men with significant intrapelvic complications of...
OBJECTIVES
To evaluate retrospectively the surgical, symptomatic and oncological outcomes of pelvic exenteration surgery (PES) in men with significant intrapelvic complications of locally advanced castration-sensitive (CSPC) and castration-resistant prostate cancer (CRPC).
PATIENTS AND METHODS
A total of 103 patients with locally advanced progressive and symptomatic CSPC or CRPC underwent PES (radical cystoprostatectomy, n = 71 [68.9%]; radical prostatectomy with continent vesicostomy, n = 9 [8.7%]; total exenteration, n = 23 [22.3%]). All patients underwent local staging via magnetic resonance imaging, cystoscopy and rectoscopy. Systemic staging was carried out with chest, abdominal and pelvic computed tomography scans and bone scans. Peri-operative complications were assessed according to Clavien-Dindo classification. Symptom-free and overall survival were evaluated using the Kaplan-Meier method. Statistical tests were two-tailed with a P value <0.05 taken to indicate statistical significance.
RESULTS
After a median (range) follow-up of 36.5 (3-123) months, the symptom-free survival rate at 1 and 3 years was 89.2% (n = 89) and 64.1% (n = 66), respectively. The median symptom-free survival was 27.9 months. A total of 78.6% of the patients were symptom-free during their remaining lifetime. The overall survival rate at 1 and 3 years was 92.2% and 43.7%, respectively, and the median overall survival was 33.6 months. Clavien-Dindo grades 2, 3 and 4 complications developed in 31 (30.6%), 12 (11.6%) and eight patients (8.1%), respectively.
CONCLUSION
Pelvic exenteration surgery is technically feasible in well-selected patients, resulting in symptom relief in >90% of patients, covering 80% of their remaining lifetime.
Topics: Adult; Aged; Aged, 80 and over; Humans; Male; Middle Aged; Neoplasm Staging; Pelvic Exenteration; Prostatectomy; Prostatic Neoplasms; Prostatic Neoplasms, Castration-Resistant; Retrospective Studies; Treatment Outcome
PubMed: 32320130
DOI: 10.1111/bju.15088 -
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