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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 -
Journal of Medicine and Life 2015Pelvic exenteration remains one of the most destructive surgical procedures in gynecologic oncology, performed in patients with locally advanced malignancies who were... (Review)
Review
Pelvic exenteration remains one of the most destructive surgical procedures in gynecologic oncology, performed in patients with locally advanced malignancies who were considered for a long time as unresectable. However, for these patients, an aggressive surgical approach seems to be the only potential curative solution. This is a literature review of the most important studies, which analyzes the benefits and the secondary risks of this demanding procedure.
Topics: Female; Genital Neoplasms, Female; Humans; Pelvic Exenteration; Pelvis
PubMed: 25866569
DOI: No ID Found -
Bailliere's Clinical Obstetrics and... Jun 1987Exenteration, or complete excision of the pelvic viscera, is an ultra-radical surgical procedure intended for curative treatment of the patient with advanced pelvic... (Review)
Review
Exenteration, or complete excision of the pelvic viscera, is an ultra-radical surgical procedure intended for curative treatment of the patient with advanced pelvic malignancy--primary or recurrent. At the time of introduction of this procedure, enthusiasm for its use was marred by the high incidence of serious surgical morbidity and mortality, which approached the five-year survival rate. With more careful physiological and psychological selection of patients, concentration of this kind of procedure in centres familiar with its use, improved urinary conduit techniques and careful attention to covering the pelvic floor with omentum and/or synthetic materials, the morbidity and mortality rate has been significantly reduced thus making exenteration a more acceptable treatment option to a wider spectrum of patients. More sophisticated haemodynamic monitoring, both intra- and postoperatively, intravenous hyperalimentation, prophylactic antibiotics and low-dose heparin are undoubtedly important adjuncts to the improvements in surgical technique and judgment. Psychosexual 'rehabilitation' in the broadest sense must be an integral part of patient care for those undergoing exenteration and in most instances necessitates involvement of the patient's partner. Exenteration has only a very limited role in palliation and all attempts should be made to avoid this procedure when cure is clearly not a possibility.
Topics: Female; Humans; Intestinal Obstruction; Pelvic Exenteration; Surgery, Plastic; Urinary Diversion; Vagina
PubMed: 3319341
DOI: 10.1016/s0950-3552(87)80061-5 -
International Journal of Gynecological... Jan 2021Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few... (Review)
Review
Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.
Topics: Female; Genital Neoplasms, Female; Humans; Medical Oncology; Pelvic Exenteration; Urinary Diversion
PubMed: 33229410
DOI: 10.1136/ijgc-2020-002015 -
Current Treatment Options in Oncology Apr 2023Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more... (Review)
Review
Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more conservative therapies. Mortality and morbidity outcomes have improved over time, but there are still significant peri-operative risks. Considerations before pursing pelvic exenteration must include the likelihood of oncologic cure and patients' fitness to undergo such a procedure, particularly given the high rate of surgical morbidity. Pelvic sidewall tumors have been a traditional contraindication for pelvic exenteration due to the difficulty in obtaining negative margins, but the use of laterally extended endopelvic resection and intra-operative radiation therapy allows for more radical resection of recurrent disease. We believe that these procedures to achieve R0 resection can expand the use of curative-intent surgery in recurrent gynecologic cancer, but require the surgical expertise of colleagues in orthopedic and vascular surgery and collaboration with plastic surgery for complex reconstruction and optimization of post-operative healing. Surgery of recurrent gynecologic cancer including pelvic exenteration, requires careful patient selection, pre-operative medical optimization and prehabilitation, and thorough counseling to optimize outcomes, both oncologic and peri-operative. We believe the creation of a well-developed team, including surgical teams and supportive care services, can lead to the best patient outcomes and improved professional satisfaction amongst providers.
Topics: Pelvic Exenteration; Humans; Female; Genital Neoplasms, Female; Neoplasm Recurrence, Local
PubMed: 36847987
DOI: 10.1007/s11864-023-01055-6 -
American Journal of Surgery Feb 1996Since it was first reported in 1948, pelvic exenteration has been used in the treatment of advanced pelvic cancers. The original procedure has been modified in an... (Review)
Review
Since it was first reported in 1948, pelvic exenteration has been used in the treatment of advanced pelvic cancers. The original procedure has been modified in an attempt to preserve urinary or fecal continence. A literature review was performed on selected series of total pelvic exenterations and modified pelvic exenterations in order to assess and discuss the different types of pelvic exenterations and the indications, contraindications, morbidity, mortality, and results of these procedures. According to the series reviewed, morbidity after pelvic exenteration ranges between 32% and 84%, postoperative mortality ranges from 0% to 14%, and and 5-year survival varies from 23% to 68% These numbers indicate that total pelvic exenteration and its modifications are a complex group of surgical procedures with significant early and late postoperative morbidity and mortality. While the authors do feel that these findings indicate that pelvic exenteration should only be undertaken by experienced surgeons at specialized centers, the authors caution that, about all, their findings indicate that the potential curability of a patient with adjacent organ involvement should not be compromised by doing less than an en bloc resection.
Topics: Contraindications; Humans; Morbidity; Pelvic Exenteration; Pelvic Neoplasms; Survival Rate
PubMed: 8619471
DOI: 10.1016/s0002-9610(97)89572-4 -
Journal of Surgical Oncology Dec 1985Sixty-eight patients at the University of Illinois, Cook County, and the West Side Veterans Administration hospitals underwent pelvic exenteration for advanced pelvic...
Sixty-eight patients at the University of Illinois, Cook County, and the West Side Veterans Administration hospitals underwent pelvic exenteration for advanced pelvic malignancies during the 15-year period from 1969 to 1984. Thirty-two had colorectal cancers, eleven cervical, seven bladder, and six vulvar; in twelve the cancers were in miscellaneous pelvic sites. Forty-five exenterations were done with intent to cure, and twenty-three for palliation of patients with bulky, necrotic tumors that had caused symptomatic fistulae, local sepsis, chronic bleeding, or severe localized pain. The total 30-day postoperative mortality was 4.4% (3/68). The 5-year survival rate of patients who underwent curative exenteration was 33% (median 27 months). Pelvic exenteration appears to be a feasible surgical procedure for a variety of advanced malignancies as well as for palliation of severely symptomatic patients.
Topics: Adult; Aged; Female; Humans; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Palliative Care; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Prognosis; Retrospective Studies
PubMed: 2417058
DOI: 10.1002/jso.2930300409 -
Anticancer Research Jun 2021In selected patients, pelvic exenteration (PE) is curative, but morbidity and mortality are feared. Unfortunately, prerequisites for indicating PE are not generally...
BACKGROUND/AIM
In selected patients, pelvic exenteration (PE) is curative, but morbidity and mortality are feared. Unfortunately, prerequisites for indicating PE are not generally defined. The aim of the study was to identify prognostic factors for survival after PE in advanced pelvic gynecological malignancies for finding possible prerequisites for the indication of PE.
PATIENTS AND METHODS
Between 2002 and 2016, 49 patients underwent pelvic exenteration for advanced pelvic malignancies apart from ovarian cancer. Progression-free survival (PFS) and overall survival (OS) were calculated based on the Kaplan-Meier method. Factors significantly affecting 5-year overall survival were identified using multivariate regression analysis. Survival distributions between the best and the worst group were compared by the log rank test.
RESULTS
Forty-nine patients with recurrent or primary pelvic gynecological malignancy (20 recurrent disease, 29 primary disease) were included. Seventeen patients had oligometastatic disease at surgical intervention. Resection margin, age, primary versus secondary exenteration and metastatic disease were independent prognostic factors in multivariate regression analysis. A significant difference was observed in 5-year overall survival regarding the best group (57.14%) and the worst group (10%) (p=0.009). Cervical cancer was the only identified risk factor for increased morbidity.
CONCLUSION
Pelvic exenteration is a valuable therapeutic option with most long-term survivors in the group of patients below 63 years, as primary treatment, with clear microscopic margins and no distant metastases. These four factors may serve as valuable prerequisites for the indication of pelvic exenteration as survival and morbidity in this group of patients compares favorably to alternative therapeutic options.
Topics: Adult; Aged; Aged, 80 and over; Female; Genital Neoplasms, Female; Humans; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Survival Analysis; Treatment Outcome
PubMed: 34083295
DOI: 10.21873/anticanres.15086 -
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 -
European Journal of Obstetrics,... Jul 2022For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary... (Review)
Review
For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary surgery, pelvic exenteration (PE) is considered the only curative option. Whilst initially considered a morbid procedure, improved surgical techniques, advancing technology, and nuanced reconstructive options have facilitated more radical resections and improved morbidity and mortality. Open PE remains the gold standard approach, however, minimally invasive techniques for PE may lessen morbidity whilst achieving the same oncological outcomes. The objective of this study was to assess the feasibility and safety of minimally invasive PE with a laparoscopic or robot-assisted approach. We also performed a review of the literature on robot-assisted PE which has not been widely reported for cases of recurrent gynaecological malignancy. Between 2015 and 2021six minimally invasive PE were performed. All patients underwent extensive multi-disciplinary assessment and counselling pre-operatively. Patient characteristics, treatment indication, perioperative data, short-term complications, and histological outcomes were recorded. There were two anterior exenterations, three posterior exenterations and one total exenteration performed. The primary cancer stage varied from stage 1a-3b. Five out of six patients had pre-operative chemo-radiotherapy. The average operative time (including surgical docking) was 600 min. Mean blood loss was 400 mL and the average length of stay was eight days. Enhanced recovery practices were used where possible. There were no intraoperative complications and one major post-operative complicationwhich was breakdown of an inferior gluteal artery perforator flap perineal reconstruction. All patients had negative margins at post-operative histopathology. All patients are alive and recurrence free at follow-up, but long-term outcome data is needed. This initial case series suggest that minimally invasive pelvic exenterationcan feasibly be performed in place of open pelvic exenteration. Furthermore, our findings suggest this may be a safe alternative as we report similar findings to the existing literature, however no firm conclusions can be drawn at such an early stage. Long term follow-up data and a larger cohort study will be needed to establish non-inferiority to open PE.
Topics: Cohort Studies; Female; Genital Neoplasms, Female; Humans; Neoplasm Recurrence, Local; Neoplasm Staging; Pelvic Exenteration; Retrospective Studies
PubMed: 35584578
DOI: 10.1016/j.ejogrb.2022.05.003