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Gynecology and Minimally Invasive... 2024Vulvar intestinal adenocarcinoma is a rare malignancy. The most significant predictor of advanced vulvar cancer is achieving complete resection, although determining the...
Vulvar intestinal adenocarcinoma is a rare malignancy. The most significant predictor of advanced vulvar cancer is achieving complete resection, although determining the optimal treatment for this rare histologic type remains uncertain. We report the case of a 63-year-old woman with a primary vulvar tumor suspected of having rectal invasion and inguinal lymph node metastases based on preoperative magnetic resonance imaging and computed tomography scans. To achieve complete resection of stage IIIC intestinal-type vulvar adenocarcinoma, we performed a laparoscopic posterior pelvic exenteration (PPE) and radical vulvectomy, along with bilateral inguinal lymph node dissection. This case report highlights the use of a novel hybrid procedure that combines laparoscopic PPE with radical vulvectomy and bilateral inguinal lymph node dissection for vulvar adenocarcinoma of the intestinal type. Laparoscopic PPE can be considered a minimally invasive approach for vulvar tumor when complete resection is achievable with an appropriate safety margin.
PubMed: 38911313
DOI: 10.4103/gmit.gmit_103_23 -
International Journal of Surgery Case... Jul 2024Perineal hernias are protrusions of intra-abdominal contents resulting from weakness of the pelvic floor muscles. They are an uncommon complication after ultraradical...
INTRODUCTION AND IMPORTANCE
Perineal hernias are protrusions of intra-abdominal contents resulting from weakness of the pelvic floor muscles. They are an uncommon complication after ultraradical pelvic surgeries, with no established gold standard for surgical treatment. This case describes a rare anterior perineal hernia that developed after radical surgery for bladder carcinoma.
CASE PRESENTATION
A 77-year-old Caucasian woman presented with a painful 10 cm bulge in the perineal region. The hernial sac involved the entire left labia majora and developed 4 years after radical surgery for bladder carcinoma. She had been misdiagnosed twice in the past with vaginal prolapse, leading to two unsuccessful vaginoplasty procedures due to recurrence. She underwent hernia repair with perineal approach and polypropylene mesh placement. The postoperative period was uncomplicated, and the patient was discharged after five days, with histology showing no malignancy.
CLINICAL DISCUSSION
Perineal hernias are protrusions of intra- or extraperitoneal contents into the perineum due to a defect in the pelvic musculature. Various surgical modalities exist for perineal hernia repair, which adhere to the fundamental principles of hernia surgery: sac mobilization, precise incision, sac debridement and excision, and defect repair. Here, we successfully applied the perineal approach in a complicated case of a misdiagnosed perineal hernia after radical surgery.
CONCLUSION
The perineal approach for hernia repair, involving an implantation of a polypropylene mesh and tissue flap was successfully applied, confirming its main place in the surgical treatment of perineal hernias. During the two-year follow-up no postoperative complications or recurrence hernia were registered.
PubMed: 38875825
DOI: 10.1016/j.ijscr.2024.109859 -
International Journal of Colorectal... May 2024Empty Pelvis Syndrome, subsequent to the removal of pelvic organs, results in the descent of the small bowel into an inflamed pelvic cavity, leading to the formation of...
BACKGROUND
Empty Pelvis Syndrome, subsequent to the removal of pelvic organs, results in the descent of the small bowel into an inflamed pelvic cavity, leading to the formation of adhesions and subsequent small bowel obstruction. However, no effective measures have been previously described.
OBJECTIVE
Describe a simple and autologous solution to prevent "Empty Pelvis Syndrome," small bowel obstruction, and adhesions by utilizing the cecum to occlude the pelvis.
DESIGN
Mobilization of the right colon to lower the cecum into the pelvic cavity to occlude the superior pelvic ring to some degree and changing the direction of the terminal ileum.
SETTINGS
Hospital Universitario Fundación Jiménez Díaz, Department of General Surgery, Colorectal Service.
PATIENTS
Eight anonymized patients were included in this study, each with varying colorectal pathologies. Patients were above 18 years old.
MAIN OUTCOME MEASURES
Percent of blockage of the superior pelvic ring produced by the descended cecum recorded in percentage; the amount of small intestine descended past the superior pelvic ring recorded in cm.
RESULTS
The mobilization of the cecum achieved partial occlusion of the superior pelvic ring. The descent of the small bowel beyond this landmark ranged from 0 to 4.9 cm.
LIMITATIONS
Given the small number of patients included in this study, these results cannot be generalized to the whole of the population. A bladder emptying protocol prior to CT scans was not implemented, resulting in variations in measurements among patients.
CONCLUSION
The cecum-to-pelvis technique is a simple method that can serve as an autologous solution to EPS (enteropelvic fistula) and help reduce postoperative complications such as SBO (small bowel obstruction) and adhesions. It is not essential to completely occlude the superior pelvic ring to achieve successful outcomes.
Topics: Humans; Cecum; Pelvis; Postoperative Complications; Female; Male; Middle Aged; Tissue Adhesions; Adult; Intestinal Obstruction; Aged
PubMed: 38797803
DOI: 10.1007/s00384-024-04649-0 -
Explore (New York, N.Y.) May 2024Stage IV colorectal cancer is a highly challenging condition to treat, with 5-year survival rates of 13% in Australia, improving to 40% for those patients with locally...
INTRODUCTION
Stage IV colorectal cancer is a highly challenging condition to treat, with 5-year survival rates of 13% in Australia, improving to 40% for those patients with locally recurrent rectal cancer who are suitable for total neoadjuvant therapy and pelvic exenterative surgery. This study reports a unique case of a patient with Stage IV locally recurrent rectal cancer (LRRC), who designed and implemented a holistic integrative oncology intervention.
CASE PRESENTATION
The patient was 59-years-old when diagnosed with Stage IV locally recurrent rectal cancer, and referred to a highly specialised centre for colorectal cancer care at a tertiary teaching hospital in Sydney, Australia. Treatment included chemo/radiotherapy, liver resection and posterior pelvic exenteration surgery. The patient's background as a health researcher and clinician optimised her ability to design and implement an integrative oncology model of care, including yoga, mindfulness, Buddhist meditation and study, social connection, exercise, psychotherapeutic and nutritional support. This paper describes these mind-body practices and lifestyle modifications and outlines her experiences and outcomes at each stage of her extensive and radical treatment.
CONCLUSION
This case provides a unique perspective into how the integration of mind-body practices and lifestyle modifications with conventional treatment can support those living with colorectal cancer.
PubMed: 38777724
DOI: 10.1016/j.explore.2024.05.002 -
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 -
Tumori May 2024Locally recurrent rectal cancer is resected with clear margins in only 50% of cases, and these patients achieve a three-year survival rate of 50%. Outcomes and...
Locally recurrent rectal cancer is resected with clear margins in only 50% of cases, and these patients achieve a three-year survival rate of 50%. Outcomes and therapeutic strategies for nonresectable locally recurrent rectal cancer have been much less explored. The aim of the study was to assess the three-year progression-free survival and the three-year overall survival in locally recurrent rectal cancer patients treated by chemotherapy/chemoradiation only vs. chemotherapy/chemoradiation and R2 surgical debulking vs. palliative care. A total of 86 patients affected by nonresectable locally recurrent rectal cancer were included: three-year progression-free survival was 15.8% with chemotherapy/chemoradiation vs. 20.3% with R2 surgical debulking (Log-rank p=0.567), but both rates were higher than best palliative care (0.0%, Log-rank p=0.0004). Three-year overall survival rates were respectively 62.0%, 70.8% and 0.0% (Log-rank p<0.0001). Chemotherapy/chemoradiation (HR 0.33, p=0.028) and R2 surgical debulking with or without chemotherapy/chemoradiation (HR 0.23, p=0.005) were independent predictors of improved progression-free survival on multivariate analysis. In conclusion, both chemotherapy/chemoradiation alone and R2 surgery with or without chemotherapy/chemoradiation provide a survival benefit over palliative care in nonresectable locally recurrent rectal cancer. However, considering that pelvic debulking is burdened by a high rate of complications, and considering its negligible impact on progression-free survival and overall survival when associated to medical therapy, surgery should be avoided in this setting.
PubMed: 38726768
DOI: 10.1177/03008916241253130 -
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 -
Cureus Apr 2024Purple urine bag syndrome (PUBS) is a rare manifestation of urinary tract infection (UTI) characterized by bluish-purple discoloration of urine, typically seen in...
Purple urine bag syndrome (PUBS) is a rare manifestation of urinary tract infection (UTI) characterized by bluish-purple discoloration of urine, typically seen in patients with long-term urinary catheters. It occurs due to the bacterial metabolism of dietary tryptophan into indole, which is converted into indoxyl sulfate in the liver and then excreted in the urine, where it reacts with catheter materials under alkaline conditions. Risk factors include chronic constipation, advanced age, female gender, dehydration, and recurrent UTIs. is one of the bacteria commonly implicated. Although usually benign, PUBS can signal underlying UTIs, especially in asymptomatic patients. The case presented involves an 81-year-old woman with a history of urothelial carcinoma and a monoJ catheter since pelvic exenteration and ureterostomy. She presented with blue-colored urine in the collection bag; she was asymptomatic, but the urinalysis had leukocytes, nitrites and alkaline pH, and the uroculture was positive for . Antibiotic therapy resolved the symptoms initially, but recurrence prompted further treatment and optimization of constipation management. PUBS, although rare, poses risks, especially in vulnerable populations. Identification of risk factors and causative agents is crucial for effective treatment, typically involving catheter replacement, antimicrobial therapy, and constipation correction. Prevention focuses on minimizing catheter use, regular replacement, and hygiene optimization. Early recognition and management in primary care settings can prevent complications and reduce patient and caregiver distress. In conclusion, PUBS is a visually evident condition that may serve as an early indication of UTI, particularly in patients with chronic catheterization. Treatment and prevention strategies should be tailored to individual risk factors to prevent the recurrence or persistence of the syndrome. Awareness among healthcare professionals and patients is essential for timely diagnosis and management. The presented case demonstrates the importance of primary care in managing complex conditions and highlights the close patient-physician relationship in such settings.
PubMed: 38707090
DOI: 10.7759/cureus.57620 -
Journal of Clinical Medicine Apr 2024Abdominoperineal resection (APR) has been advocated for persistent or recurrent disease after failure of chemoradiation (CRT) for anal squamous cell cancer (SCC)....
Abdominoperineal resection (APR) has been advocated for persistent or recurrent disease after failure of chemoradiation (CRT) for anal squamous cell cancer (SCC). Treatment with salvage APR can potentially achieve a cure. This study aimed to analyze oncological outcomes for salvage APR in a recent time period at a comprehensive cancer center. A retrospective review of all patients who underwent APR for biopsy-proven persistent or recurrent anal SCC between 1 January 2007 and 31 December 2020 was performed. Patients with stage IV disease at the time of initial diagnosis and patients with missing data were excluded. Univariate analysis was used with a chi-square test for categorical variables, and non-parametric tests were used for continuous variables. Kaplan-Meier survival analysis was performed to evaluate disease-specific (DSS), post-APR local recurrence-free (RFS), and disease-free survival (DFS). A total of 96 patients were included in the analysis: 39 (41%) with persistent disease and 57 (59%) with recurrent SCC after chemoradiation had been completed. The median follow-up was 22 months (IQR 11-47). Forty-nine patients (51%) underwent extended APR and/or pelvic exenteration. Eight (8%) patients developed local recurrence, 30 (31%) developed local and distant recurrences, and 16 (17%) developed distant recurrences alone. The 3-year DSS, post-APR local recurrence-free survival, and disease-free survival were 53.8% (95% CI 43.5-66.5%), 54.5% (95% CI 44.4-66.8%), and 26.8% (95% CI 18.6-38.7%), respectively. In multivariate logistic regression analysis, positive microscopic margin (OR 10.0, 95% CI 2.16-46.12, = 0.003), positive nodes in the surgical specimen (OR 9.19, 95% CI 1.99-42.52, = 0.005), and lymphovascular invasion (OR 2.61 95% CI 1.05-6.51, = 0.04) were associated with recurrence of disease. Gender, indication for APR (recurrent vs. persistent disease), HIV status, extent of surgery, or type of reconstruction did not influence survival outcomes. Twenty patients had targeted tumor-sequencing data available. Nine patients had PIK3CA mutations, seven of whom experienced a recurrence. Salvage APR for anal SCC after failed CRT was associated with poor disease-specific survival and low recurrence-free survival. Anal SCC patients undergoing salvage APR should be counseled that microscopic positive margins, positive lymph nodes, or the presence of lymphovascular invasion in the APR specimen are prognosticators for disease relapse. Our results accentuate the necessity for additional treatment strategies for the ongoing treatment challenge of persistent or recurrent anal SCC after failed CRT.
PubMed: 38673429
DOI: 10.3390/jcm13082156 -
International Journal of Colorectal... Apr 2024Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be...
A novel classification of posterior pelvic exenteration to assess prognosis in female patients with locally advanced primary rectal cancer: a retrospective cohort study from China PelvEx collaborative.
PURPOSE
Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be addressed. Therefore, we investigated the short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification.
METHODS
We retrospectively analysed a prospective database from China PelvEx Collaborative across three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified based on four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed.
RESULTS
Differences were significant among the four groups regarding colorectal reconstruction (p < 0.001), perineal reconstruction (p < 0.001), in-hospital complications (p < 0.05), and urinary retention (p < 0.05). The R resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, the PPE-IV group demonstrated the lowest 5-year overall survival rate (p < 0.001) and 5-year disease-free survival rate (p < 0.001).
CONCLUSION
The Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.
Topics: Humans; Female; Pelvic Exenteration; Rectal Neoplasms; Retrospective Studies; Middle Aged; Prognosis; China; Aged; Neoplasm Staging; Treatment Outcome; Adult; Disease-Free Survival
PubMed: 38664256
DOI: 10.1007/s00384-024-04632-9