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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 -
Colorectal Disease : the Official... Apr 2023Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for... (Review)
Review
AIM
Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for example the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short-term outcomes.
METHOD
Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS-1.
RESULTS
The search found 21 studies that reported pain following pelvic exenteration [n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%-100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection.
CONCLUSION
Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.
Topics: Adult; Humans; Middle Aged; Pelvic Exenteration; Pain Management; Colorectal Neoplasms; Pain, Postoperative; Retrospective Studies; Neoplasm Recurrence, Local
PubMed: 36572393
DOI: 10.1111/codi.16462 -
Asian Pacific Journal of Cancer... Apr 2022Total Pelvic Exenteration (TPE) is a radical operation for malignancies in which all of the organs inside the pelvic cavity, including the female reproductive organs,...
BACKGROUNDS
Total Pelvic Exenteration (TPE) is a radical operation for malignancies in which all of the organs inside the pelvic cavity, including the female reproductive organs, the lower urinary tract, and a part of the rectosigmoid are removed. In this study, we aimed to conduct a systematic review to assess the overall survival (OS) and disease-free survival (DFS) following TPE.
METHODS
This systematic review is composed of a comprehensive review of PubMed and Scopus databases with various related keywords to synthesis the overall survival and disease-free survival following TPE. The Synthesis Without Meta-analysis guideline was used to summarize the results.
RESULTS
We included the results of 39 primary studies and the results revealed that one-year OS of gynecological cancer in patients who have undergone TPE ranged from 50.0% to 72.0% and the 5-years OS ranged from 6.0% to 64.6%. The one-year survival rate of colorectal cancer patients was reported to be over 80% in almost all studies. The 3-year survival rate of patients varied from 25% to 75% and the lowest 5-year survival rate was 8% and the highest survival rate was 92%. To synthesis the disease-free survival rate in colorectal cancer, ten studies were included and one-year recurrence rate was 9.1% and the one-year DFS was reported as 61.0%. Three-year recurrence rate study was 20.4% and 3 and 5-year DFS ranged from 22.0% to 78.0%.
CONCLUSIONS
The results suggested that DFS in primary advanced cancers is higher than locally recurrence tumors. This review showed that patient overall survival and disease-free survival rates have increased over time, especially at high volume centers that are more experienced and possibly better equipped. Therefore, it can be suggested that the attitude towards PE as a palliative surgery can be turned into curative surgery.
Topics: Colorectal Neoplasms; Disease-Free Survival; Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Retrospective Studies
PubMed: 35485668
DOI: 10.31557/APJCP.2022.23.4.1137 -
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 -
Cancers Feb 2021Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative... (Review)
Review
BACKGROUND
Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers).
METHODS
We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE.
RESULTS
Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43-0.71; < 0.01/Group B: OR 0.54, CI 0.17-1.68; = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35-0.68; < 0.001/Group B: OR 0.38, 95% CI 0.12-1.17; < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39-4.35; < 0.01) and major (OR 1.67, 95% CI 0.90-3.08; = 0.1) perineal complications in Group C.
CONCLUSION
Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
PubMed: 33578769
DOI: 10.3390/cancers13040721 -
BMC Cancer May 2024Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including female reproductive organs, lower urological organs and involved parts of the digestive system. The aim of this meta-analysis is to estimate the intra-operative mortality, in-hospital mortality, 30- and 90-day mortality rate and overall mortality rate (MR) following TPE in colorectal, gynecological, urological, and miscellaneous cancers.
METHODS
This is a systematic review and meta-analysis in which three international databases including Medline through PubMed, Scopus and Web of Science on November 2023 were searched. To screen and select relevant studies, retrieved articles were entered into Endnote software. The required information was extracted from the full text of the retrieved articles by the authors. Effect measures in this study was the intra-operative, in-hospital, and 90-day and overall MR following TPE. All analyzes are performed using Stata software version 16 (Stata Corp, College Station, TX).
RESULTS
In this systematic review, 1751 primary studies retrieved, of which 98 articles (5343 cases) entered into this systematic review. The overall mortality rate was 30.57% in colorectal cancers, 25.5% in gynecological cancers and 12.42% in Miscellaneous. The highest rate of mortality is related to the overall mortality rate of colorectal cancers. The MR in open surgeries was higher than in minimally invasive surgeries, and also in primary advanced cancers, it was higher than in recurrent cancers.
CONCLUSION
In conclusion, it can be said that performing TPE in a specialized surgical center with careful patient eligibility evaluation is a viable option for advanced malignancies of the pelvic organs.
Topics: Humans; Pelvic Exenteration; Female; Hospital Mortality; Neoplasms; Genital Neoplasms, Female; Male
PubMed: 38750417
DOI: 10.1186/s12885-024-12377-5 -
Colorectal Disease : the Official... Apr 2022Pelvic exenteration (PE) carries high morbidity. Our aim was to analyse the use of patient-reported outcome measures (PROMs) in PE patients. (Review)
Review
AIM
Pelvic exenteration (PE) carries high morbidity. Our aim was to analyse the use of patient-reported outcome measures (PROMs) in PE patients.
METHOD
Search strategies were protocolized and registered in PROSPERO. PubMed, Embase, Cochrane Library, Google Scholar, Web of Science and ClinicalTrials.gov were searched with the terms 'patient reported outcomes', 'pelvic exenteration' and 'colorectal cancer'. Studies published after 1980 reporting on PROMs for at least 10 PE patients were considered. Study selection, data extraction, rating of certainty of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers.
RESULTS
Nineteen of 173 studies were included (13 retrospective, six prospective). All studies were low to very low quality, with an overall moderate/serious risk of bias. Studies included data on 878 patients with locally advanced rectal cancer (n = 344), recurrent rectal cancer (n = 411) or cancer of unknown type (n = 123). Thirteen studies used validated questionnaires, four used non-validated measures and two used both. Questionnaires included the Functional Assessment of Cancer Therapy-Colorectal questionnaire (n = 6), Short Form Health Survey (n = 6), European Organization for Research and Treatment for Cancer (EORTC) Quality of Life Questionnaire C30 (n = 6), EORTC-CR38 (n = 4), EORTC-BLM30 (n = 1), Brief Pain Inventory (n = 2), Short Form 12 (n = 1), Assessment of Quality of Life (n = 1), Short Form Six-Dimension (n = 1), the Memorial Sloan Kettering Cancer Center Sphincter Function Scale (n = 1), the Cleveland Global Quality of Life (n = 1) or other (n = 4). Timing varied between studies.
CONCLUSIONS
Whilst the use of validated questionnaires increased over time, this study shows that there is a need for uniform use and timing of PROMs to enable multicentre studies.
Topics: Humans; Neoplasm Recurrence, Local; Patient Reported Outcome Measures; Pelvic Exenteration; Prospective Studies; Quality of Life; Rectal Neoplasms; Retrospective Studies
PubMed: 34941002
DOI: 10.1111/codi.16028 -
Diseases of the Colon and Rectum Apr 2013Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer. (Review)
Review
BACKGROUND
Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer.
OBJECTIVE
This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration.
DATA SOURCES
A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified.
STUDY SELECTION
Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination.
MAIN OUTCOME MEASURES
Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates.
RESULTS
A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer.
LIMITATIONS
Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported.
CONCLUSIONS
Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.
Topics: Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Rectal Neoplasms
PubMed: 23478621
DOI: 10.1097/DCR.0b013e31827a7868 -
International Journal of Surgery... Aug 2022Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent... (Review)
Review
BACKGROUND
Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery.
METHODS
A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool.
RESULTS
Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report.
CONCLUSION
Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.
Topics: Humans; Margins of Excision; Neoplasm Recurrence, Local; Pelvic Exenteration; Rectal Neoplasms; Rectum; Retrospective Studies; Treatment Outcome
PubMed: 35781038
DOI: 10.1016/j.ijsu.2022.106738 -
European Journal of Surgical Oncology :... Aug 2023Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical... (Meta-Analysis)
Meta-Analysis Review
Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis.
INTRODUCTION
Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial.
METHODS
A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted.
RESULTS
11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality.
CONCLUSION
MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.
Topics: Humans; Pelvic Neoplasms; Pelvic Exenteration; Pelvis; Minimally Invasive Surgical Procedures; Blood Loss, Surgical
PubMed: 37087374
DOI: 10.1016/j.ejso.2023.04.003