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Journal of Medical Case Reports Apr 2024Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes...
The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report.
BACKGROUND
Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.
CASE PRESENTATION
A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.
CONCLUSION
Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.
Topics: Female; Humans; Middle Aged; Activities of Daily Living; Pelvic Exenteration; Quality of Life; Uterine Cervical Neoplasms; Lower Extremity; Physical Therapy Modalities; Pelvic Pain; Edema; Postoperative Complications; Thrombosis
PubMed: 38610054
DOI: 10.1186/s13256-024-04516-0 -
Journal of Clinical Medicine Mar 2024Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph... (Review)
Review
Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph nodes are the primary site of extra-uterine dissemination in endometrial cancer (EC), setting the 5-year survival to 44-52%. It is standard practice for radiation therapy (RT) and/or chemotherapy (CTX) to be given as adjuvant treatments to prevent the progression of micrometastases. Also, administration of EC patients with RT and/or CTX regimens before surgery may decrease micrometastases, hence the need for lymphadenectomy. The primary aim of the systematic review and meta-analysis is to assess whether adjuvant RT and/or CTX improve oncological outcomes through the management of micrometastases and nodal recurrence. We performed systematic research using the string "Endometrial Neoplasms" [Mesh] AND "Lymphatic Metastasis/therapy" [Mesh]. The methods for this study were specified a priori based on the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Outcomes were 5-year overall survival, progression-free survival, recurrence rate, and complications rate. We assessed the quality of studies using the Newcastle-Ottawa Scale (NOS). A total of 1682 patients with stage I-to-IV EC were included. Adjuvant treatment protocols involved external-beam RT, brachytherapy, and CTX either alone or in combination. The no-treatment group showed a non-statistically significant higher recurrence risk than any adjuvant treatment group (OR 1.39 [95% CI 0.68-2.85] = 0.36). The no-treatment group documented a non-statistically significant higher risk of death than those who underwent any adjuvant treatment (RR 1.47 [95% CI 0.44-4.89] = 0.53; I2 = 55% = 0.000001). Despite the fact that early-stage EC may show micrometastases, adjuvant treatment is not significantly associated with better survival outcomes, and the combination of EBRT and CTX is the most valid option in the early stages.
PubMed: 38592342
DOI: 10.3390/jcm13051496 -
Journal of Surgical Oncology Jun 2024The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches...
Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience.
BACKGROUND
The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety.
OBJECTIVE
To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy.
DESIGN, SETTING, AND PARTICIPANTS
After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up.
OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS
Descriptive analysis of positive and negative results per template region.
RESULTS AND LIMITATIONS
FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified.
CONCLUSION
The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.
Topics: Humans; Urinary Bladder Neoplasms; Lymph Node Excision; Cystectomy; Female; Male; Aged; Middle Aged; Indocyanine Green; Feasibility Studies; Fluorescence; Prognosis; Follow-Up Studies; Spectroscopy, Near-Infrared; Lymph Nodes; Aged, 80 and over; Coloring Agents
PubMed: 38583145
DOI: 10.1002/jso.27618 -
Archivos Espanoles de Urologia Mar 2024Evidence regarding the relationship between the laterality of lymph node invasion (LNI) and the prostatic lobe affected is limited. Our aim was to review our records of...
BACKGROUND
Evidence regarding the relationship between the laterality of lymph node invasion (LNI) and the prostatic lobe affected is limited. Our aim was to review our records of patients with exclusively unilateral localised prostate cancer (PCa) with metastatic LN involvement.
METHODS
Between 2006 and 2023, after radical prostatectomy and extended pelvic lymphadenectomy at our centre, thirty patients with intermediate-high risk unilateral PCa and pN1 disease were identified. To perform a retrospective study, data were obtained from a prospective collected database approved by the ethical committee at the Valencian Oncology Institute Foundation. Descriptive and comparative statistical analysis was made using software R. The Fisher's Exact test was employed to analyse the categorical variables. In terms of continuous variables, both tumour volume and number of nodes retrieved exhibited normality; Hence Student's -test was employed. Mann-Whitney U test was utilized for the number of positive nodes.
RESULTS
The median age and prostate specific antigen (PSA) at diagnosis were 66 years old (interquartile range (IQR): 63.3-70.9) and 14.6 ng/mL (IQR: 7.4-21.5), respectively. Median follow-up time was 67 months (IQR: 35.9-92.9). Nineteen patients (63%) had a Gleason score of 7, and the rest had a Gleason score of 8-10. Most patients (73%) had locally advanced disease. Baseline characteristics were comparable between groups (-value > 0.05). Twenty-two patients (73%) had concordance between the laterality of the PCa lesion and the LNI. All the patients with right prostatic cancer had exclusive ipsilateral LNI.
CONCLUSIONS
In our experience, the majority of patients with unilateral PCa had exclusively ipsilateral LNI. However, sparing contralateral LN dissection in unilateral PCa should not be an option. To date, extended pelvic LN dissection remains the gold standard for N-staging and cannot be replaced yet by unilateral pelvic LN dissection until high quality evidence supports this scenario.
Topics: Male; Humans; Aged; Retrospective Studies; Prospective Studies; Lymphatic Metastasis; Lymph Node Excision; Prostatic Neoplasms; Prostatectomy
PubMed: 38583004
DOI: 10.56434/j.arch.esp.urol.20247702.17 -
Updates in Surgery Jun 2024Locally recurrent rectal cancer (LRRC) involving the lateral pelvic sidewall requires a complex approach to maximize the likelihood of R0 resection, which is the only...
Locally recurrent rectal cancer (LRRC) involving the lateral pelvic sidewall requires a complex approach to maximize the likelihood of R0 resection, which is the only predictor of survival. The purpose of this report is to describe a novel technique to resect a localized lateral pelvic sidewall LRRC. A 63-year-old male patient was referred for a 15-mm LRRC near the right internal iliac vessels. Endoscopic ultrasound and magnetic resonance imaging excluded any involvement of the pelvic colon or residual rectum. A combined extraperitoneal antero-lateral approach and gluteal access were used to optimize vascular control on the internal iliac vessels, to promptly identify the ureter and to achieve a better posterior exposition of the sciatic notch. This technique allowed a controlled and tailored resection of pelvic sidewall without entering into the abdominal cavity. The postoperative course was uneventful. The pathologic report confirmed clear margins (R0), with one involving obturator lymph node. At 3 months, the patient is alive and free from local re-relapse. A right lung metastasis has occurred, and it was treated by stereotactic radiotherapy. The present report proposes a novel extraperitoneal pelvic sidewall excision to resect lateral LRRC with a colorectal-sparing approach, thus minimizing the risk of exenterative surgery-related complications. A proper selection of patients is mandatory, as the proposed technique could not be generalized as the standard of care in all lateral LRRCs.
Topics: Humans; Male; Middle Aged; Rectal Neoplasms; Neoplasm Recurrence, Local; Pelvis; Organ Sparing Treatments; Magnetic Resonance Imaging; Rectum
PubMed: 38582795
DOI: 10.1007/s13304-024-01834-2 -
Archives of Gynecology and Obstetrics Jun 2024The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and...
OBJECTIVES
The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer.
MATERIALS AND METHODS
Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6 kg/m. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised.
RESULTS
The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation.
CONCLUSION
vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.
Topics: Humans; Female; Endometrial Neoplasms; Middle Aged; Overweight; Lymph Node Excision; Obesity; Neoplasm Staging; Aged; Feasibility Studies; Sentinel Lymph Node Biopsy; Sentinel Lymph Node; Retroperitoneal Space
PubMed: 38578545
DOI: 10.1007/s00404-024-07466-6 -
Journal of Cancer Research and Clinical... Apr 2024Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal...
PURPOSE
Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal cancer (LARC). In this study, we aimed to identify the clinicopathological factors correlated with RLNM in LARC patients with ypT0-2 after neoadjuvant chemoradiotherapy (NCRT).
METHODS
We retrospectively analyzed 417 patients histologically diagnosed middle-low LARC after NCRT and total mesorectal excision (TME), whose pathological staging was ypT0-2. All patients received pelvic magnetic resonance imaging (MRI) before NCRT. The radiation doses were 50-50.6 Gy for the planning gross tumor volume and 41.8-45 Gy for the planning target volume, respectively. A nomogram for predicting RLNM was constructed using a binary logistic regression. Nomogram performance was assessed by receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC).
RESULTS
After surgery, 191 patients (45.8%) were ypT0, 43 patients (10.3%) were ypT1 and 183 patients (43.9%) were ypT2, and a total of 49 patients (11.8%) were found the presence of RLNM. Multivariable analyses identified MRI-defined mesorectal fascia (MRF)-positive, high-grade histopathology at biopsy, advanced ypT-category, and the presence of perineural invasion (PNI) as the predictive factors. The nomogram, incorporating all these predictors, showed good discrimination and calibration efficacy, with the areas under the ROC curve of 0.690 (95% CI: 0.610-0.771). Both DCA and CIC demonstrated that this nomogram has good clinical usefulness.
CONCLUSION
The nomogram model can predict RLNM in patients with ypT0-2 tumors. It can help select suitable patients for performing organ-preserving strategies after NCRT.
Topics: Humans; Neoadjuvant Therapy; Lymphatic Metastasis; Retrospective Studies; Neoplasm Staging; Rectal Neoplasms; Chemoradiotherapy; Chemoradiotherapy, Adjuvant; Neoplasms, Second Primary
PubMed: 38575793
DOI: 10.1007/s00432-024-05662-0 -
Urologic Oncology Jul 2024Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are...
BACKGROUND
Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are at high risk of disease persistence and progression. Contemporary management trends of pN+ CaP are not well described.
MATERIALS AND METHODS
Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with clinically localized prostate cancer who underwent radical prostatectomy between 2012 and 2023 with cN0/pN+ disease were identified. The primary outcome was to evaluate patient and practice-level factors associated with time to secondary post-RP treatment. Secondary outcomes included practice-level variation in management of pN+ CaP and rates of secondary treatment modality. To assess factors associated with secondary treatment, a Cox proportional hazards model of a 60-day landmark analysis was performed.
RESULTS
We identified 666 patients with pN+ disease. Overall, 66% underwent secondary treatment within 12 months post-RP. About 19% of patients with detectable post-RP PSA did not receive treatment. Of patients receiving secondary treatment after 60-days post-RP, 34% received androgen deprivation therapy (ADT) alone, 27% received radiation (RT) alone, 36% received combination, and 4% received other systemic therapies. In the multivariable model, pathologic grade group (GG)3 (HR 1.5; 95%CI: 1.05-2.14), GG4-5 (HR 1.65; 95%CI: 1.16-2.34), positive margins (HR 1.46; 95%CI: 1.13-1.88), and detectable postoperative PSA ≥0.1 ng/ml (HR 3.46; 95%CI: 2.61-4.59) were significantly associated with secondary post-RP treatment. There was wide variation in adjusted practice-level 12-month secondary treatment utilization (28%-79%).
CONCLUSIONS
The majority pN+ patients receive treatment within 12 months post-RP which was associated with high-risk pathological features and post-RP PSA. Variation in management of pN+ disease highlights the uncertainty regarding the optimal management. Understanding which patients will benefit from secondary treatment, and which type, will be critical to minimize variation in care.
Topics: Humans; Male; Prostatic Neoplasms; Prostatectomy; Middle Aged; Aged; Quality Improvement; Lymph Node Excision; Lymphatic Metastasis; Retrospective Studies; Lymph Nodes; Michigan
PubMed: 38570271
DOI: 10.1016/j.urolonc.2024.03.015 -
Colorectal Disease : the Official... May 2024Total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) is rapidly spreading. The robotic surgical techniques to approach lateral invasion, such as...
AIM
Total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) is rapidly spreading. The robotic surgical techniques to approach lateral invasion, such as that of the pelvic plexus, have not yet been established. In this technical note, we present a video illustrating a surgical technique for lateral invasion using our novel technique and discuss its pitfalls.
METHOD
We present the case of a 65-year-old man with LARC. Robotic surgery was performed after TNT using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical procedure was as follows: (1) D3 lymph node dissection around the inferior mesenteric artery using a medial-to-lateral approach; (2) rectal mobilization; (3) dissection of the ureterohypogastric fascia and ureter; and (4) combined resection of the hypogastric nerve and pelvic plexus. The key surgical point for sidewall invasion is the resection extent. Dividing the resection extent into three areas is important: zone A, which contains the pelvic plexus and is closest to the tumour; zone B, which contains the iliac vessels; and zone C, the most lateral zone, which contains the obturator nerves. This allows organ and function preservation by resecting only the smallest organ that truly requires R0 resection.
RESULTS
The operating time was 333 min, console time was 232 min, and blood loss was 0 mL. The circumferential resection margin was 10 mm, and an R0 resection was achieved.
CONCLUSION
We introduced a novel approach for robotic surgery after TNT for LARC with sidewall invasion. This technique can be performed safely and may help standardize 'beyond total mesorectal excision'.
Topics: Humans; Rectal Neoplasms; Male; Neoadjuvant Therapy; Aged; Robotic Surgical Procedures; Neoplasm Invasiveness; Rectum; Proctectomy; Lymph Node Excision; Hypogastric Plexus
PubMed: 38566354
DOI: 10.1111/codi.16969 -
Journal of Robotic Surgery Mar 2024The aim of this study is to evaluate the major postoperative complication rate after robot-assisted radical prostatectomy (RARP) and to identify related risk factors. A...
The aim of this study is to evaluate the major postoperative complication rate after robot-assisted radical prostatectomy (RARP) and to identify related risk factors. A consecutive series of patients who underwent RARP between September 2016 and May 2021, with or without extended pelvic lymph node dissection (ePLND) were analyzed for postoperative complications that occurred within 30 days following surgery. Potential risk factors related to complications were identified by means of a multivariate logistic analysis. Electronic medical records were retrospectively reviewed for the occurrence of major complications (Clavien-Dindo grade III or higher) on a per patient level. A multivariate logistic regression with risk factors was performed to identify contributors to complications. In total, 1280 patients were included, of whom 79 (6.2%) experienced at least 1 major complication. Concomitant ePLND was performed in 609 (48%) of patients. The majority of all complications were likely related to the surgical procedure, with anastomotic leakage and lymphoceles being the most common. Upon multivariate analysis, performing ePLND remained the only significant risk factor for the occurrence of major complications (OR 2.26, p = 0.001). In contrast to robot-assisted radical prostatectomy alone, the combination with extended pelvic lymph node dissection (ePLND) has a substantial risk of serious complications. Since the ePLND is performed mainly for staging purpose, the clinical contribution of the ePLND has to be reconsidered with the present use of the PSMA-PET/CT.
Topics: Male; Humans; Robotic Surgical Procedures; Robotics; Retrospective Studies; Positron Emission Tomography Computed Tomography; Pelvis; Lymph Node Excision; Prostatectomy; Risk Factors
PubMed: 38554195
DOI: 10.1007/s11701-024-01881-2