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Nagoya Journal of Medical Science Nov 2023Ureteroenteric anastomotic strictures (UEAS) are typical complications after creating an ileal conduit for total pelvic exenteration (TPE) of rectal tumors. We report...
Ureteroenteric anastomotic strictures (UEAS) are typical complications after creating an ileal conduit for total pelvic exenteration (TPE) of rectal tumors. We report the ileal conduit for reconstruction in three patients, in the age-range of 47-73 years. Case 1 was when a left-sided UEAS had sufficient length of ureter for anastomosis, Case 2 was a right-sided UEAS with sufficient length of ureter for anastomosis, and Case 3 was a left-sided UEAS with insufficient length of ureter for anastomosis. There were no complications after operation and no recurrence of UEAS. It is important to learn the open surgical procedures for repair of a benign UEAS after TPE of rectal cancers. This has fewer complications and is safe in the long term.
Topics: Humans; Middle Aged; Aged; Ureter; Pelvic Exenteration; Constriction, Pathologic; Urinary Diversion; Rectal Neoplasms; Anastomosis, Surgical; Postoperative Complications
PubMed: 38155623
DOI: 10.18999/nagjms.85.4.836 -
Journal of Personalized Medicine Dec 2023Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial...
Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial diagnosis, surgery represents the mainstay of treatment, often implying wide, eventually multi-organ resections in order to achieve negative surgical margins. Perineal wound morbidity, particularly in extralevator abominoperineal excision, leads to complications and local infection rates of up to 40%. Strategies to reduce postoperative wound complications are being pursued to address this issue. The VRAM flap remains the gold standard for autologous reconstruction after pelvic oncological resection; it was initially designed for abdominal wall defects and later expanded for large pelvic tissue defects. The flap's application is based on its physical characteristics, including abundant tissue and a generous skin paddle, which effectively obliterates dead space after exenterations. The generous skin paddle offers good cosmetic and functional outcomes at the recipient site. This article describes the case of a patient histopathologically diagnosed with stage IIIA squamous cell carcinoma of the uterine cervix who received multimodal onco-surgical treatment. The surgical mainstay of this treatment is pelvic exenteration. Pelvic reconstruction after this major surgery was performed using a vertical flap with the rectus abdominis.
PubMed: 38138938
DOI: 10.3390/jpm13121711 -
European Journal of Surgical Oncology :... Feb 2024Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of... (Review)
Review
Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.
Topics: Humans; Female; Genital Neoplasms, Female; Pelvic Exenteration; Quality of Life; Pelvis; Perineum; Myocutaneous Flap; Rectus Abdominis; Retrospective Studies
PubMed: 38134482
DOI: 10.1016/j.ejso.2023.107278 -
Colorectal Disease : the Official... Feb 2024There is increasing research interest in pelvic exenteration for locally advanced and recurrent rectal cancer. Heterogeneity in outcome reporting can prevent meaningful... (Review)
Review
AIM
There is increasing research interest in pelvic exenteration for locally advanced and recurrent rectal cancer. Heterogeneity in outcome reporting can prevent meaningful interpretation and valid synthesis of pooled data and meta-analyses. The aim of this study was to assess homogeneity in outcome measures in the current pelvic exenteration literature.
METHOD
MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases were searched from 1990 to 25 April 2023 to identify studies reporting outcomes of pelvic exenteration for locally advanced or recurrent rectal cancer. All reported outcomes were extracted, merged with those of similar meaning and assigned a domain.
RESULTS
Of 4137 abstracts screened, 156 studies met the inclusion criteria. A total of 2765 outcomes were reported, of which 17% were accompanied by a definition. There were 1157 unique outcomes, merged into 84 standardized outcomes and assigned one of seven domains. The most reported domains were complications (147 studies, 94%), survival (127, 81%) and surgical outcomes (123, 79%). Resection margins were reported in 122 studies (78%): the definition of a clear resection margin was not provided in 45 studies (37%), it was unclear in 11 studies (9%) and not specified beyond microscopically 'clear' or 'negative' in 31 (28%). Measurements of 2, 1, 0.5 mm and any healthy tissue were all used to define R0 margins.
CONCLUSION
There is significant heterogeneity in outcome measurement and reporting in the current pelvic exenteration literature, raising concerns about the validity of comparative or collaborative studies between centres and meta-analyses. Coordinated international collaboration is required to define core outcome sets and benchmarks.
Topics: Humans; Pelvic Exenteration; Treatment Outcome; Neoplasm Recurrence, Local; Rectal Neoplasms; Benchmarking; Margins of Excision; Retrospective Studies
PubMed: 38131647
DOI: 10.1111/codi.16844 -
Translational Andrology and Urology Nov 2023Total pelvic exenteration (TPE) in men is a surgical procedure to treat genitourinary and colorectal malignancies. Despite improvement in multimodal strategies and...
BACKGROUND
Total pelvic exenteration (TPE) in men is a surgical procedure to treat genitourinary and colorectal malignancies. Despite improvement in multimodal strategies and technology, mortality is still high and literature is limited about perioperative outcomes comparison to other radical procedures.
METHODS
We analyzed National Surgical Quality Improvement Program (NSQIP) baseline database of all male patients undergoing cystectomy, low anterior resection/abdominoperineal resection (LAR/APR) or TPE from January 1, 2005 to December 31, 2016. Postoperative complications within 30 days after surgery were measured including: Wound infection, septic complications, deep vein thrombosis, cardiovascular events, and return to the operating room or mortality, etc. Differences between groups were analyzed using analysis of variance (ANOVA) tests.
RESULTS
A total of 7,375 patients underwent radical cystectomy, 49,762 underwent LAR/APR and 792 underwent TPE. Cystectomy patients were on average older compared to TPE or LAR/APR patients (P<0.001). In univariable and multivariable analysis, patients undergoing TPE had greater infectious and septic complications compared to cystectomy (odds ratio =1.09; 95% confidence interval (CI): 1.06-1.12) and LAR/APR (odds ratio =1.08; 95% CI: 1.05-1.11). Moreover, TPE had a slightly higher mortality within the 30-day postoperatively than those who underwent LAR/APR (odds ratio =1.01; 95% CI: 1.00-1.02) and cystectomy (odds ratio =1.01; 95% CI: 1.00-1.01).
CONCLUSIONS
Men undergoing TPE had greater rates of infections and postoperative complications compared to those undergoing radical cystectomy and LAR/APR. From a clinical standpoint, TPE has high morbidity that could provide opportunity for quality improvement projects with the goal of mitigating high complication rates.
PubMed: 38106684
DOI: 10.21037/tau-23-266 -
Langenbeck's Archives of Surgery Dec 2023Exenteration surgery for multi-visceral pelvic malignancy is a complex life-changing operation with high perioperative morbidity and mortality. Traditional open surgery...
Feasibility of robotic platform to perform R0 resection for locally advanced multi-visceral pelvic malignancy: an institutional experience on outcomes of robotic pelvic exenteration.
BACKGROUND
Exenteration surgery for multi-visceral pelvic malignancy is a complex life-changing operation with high perioperative morbidity and mortality. Traditional open surgery has long been the standard approach for pelvic exenteration for achieving Ro resection which is the main aim of surgery. In the current era of minimally invasive surgery, robotic-assisted pelvic exenteration has provided a promising alternative, offering potential advantages in terms of improved oncological outcomes and enhanced postoperative recovery. This study aims to explore the feasibility of a robotic platform for locally advanced multi-visceral pelvic malignancy.
METHODS
A retrospective review from the prospectively maintained robotic colorectal surgery database at University Hospital Coventry and Warwickshire (UHCW) Trust was performed. Demographic details and clinical and surgical details were documented from the case records. Data was analysed using SPSS version 22.
RESULTS
Thirteen female patients diagnosed with primary or recurrent pelvic malignancy who underwent robotic pelvic exenteration at UHCW between February 2019 and April 2023 at UHCW were included. The mean age of our patients was 60.4 (± 10.1) years. Complete Ro resection was achieved in all 13 (100%) cases on final histopathology. The median length of hospital stay was 15 days after this extensive surgery. Grade 3 morbidity on Clavien-Dindo classification was observed in four (30.7%) patients, while zero percent 30-day mortality was experienced in this study. At a median follow-up of 21 (3-53) months, we observed tumor recurrence in three (23.7%) patients, while death in four (30.7%) patients. Only few studies have highlighted outcomes of robotic pelvic exenteration, and our results were quite comparable to them.
CONCLUSION
Robotic-assisted pelvic exenteration for primary or recurrent pelvic malignancy is feasible with improved oncological and acceptable postoperative outcomes.
Topics: Humans; Female; Middle Aged; Aged; Pelvic Exenteration; Pelvic Neoplasms; Robotic Surgical Procedures; Feasibility Studies; Neoplasm Recurrence, Local; Retrospective Studies; Rectal Neoplasms; Treatment Outcome
PubMed: 38102305
DOI: 10.1007/s00423-023-03206-7 -
Surgical Oncology Feb 2024Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship...
BACKGROUND
Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship of patients undergoing exenterative surgery remain. This is especially important in the context of vulvovaginal resection, where patients are often younger and surgery can have a profoundly negative impact on quality of life, body image and overall wellbeing. Reconstructive procedures are an important means of mitigating these adverse effects but outcomes are poorly described.
AIM
To define the outcomes associated with gynaecological reconstructive procedures following pelvic exenterative surgery and to compare them with the outcomes of those patients who did not undergo reconstruction.
METHODS
An international, multicentre retrospective investigation comparing the outcomes of reconstruction with no reconstruction. The protocol was prospectively registered (NCT05074069).
RESULTS
334 patients were included. 77 patients had a neovagina reconstructed, 139 patients underwent flap reconstruction and 118 were not reconstructed. Patients who underwent reconstruction had a longer operative time and hospital stay with an increased risk of minor perineal complications. Reconstruction did not confer an increased risk of surgical reintervention, and overall complication rates were equivalent. Procedure-specific major morbidity was 5.2 % and 11.5 % for neovaginal and flap reconstruction, respectively. 66 % of patients undergoing neovaginal reconstruction experienced no long term morbidity. 7 % developed neovaginal stenosis and 12 % suffered disease recurrence.
CONCLUSION
Neovaginal reconstruction is safe in carefully selected patients and offers specific advantages over alternative techniques, with few patients requiring reoperation. Primary closure does not increase perineal morbidity.
Topics: Humans; Pelvic Exenteration; Plastic Surgery Procedures; Postoperative Complications; Quality of Life; Retrospective Studies; Treatment Outcome
PubMed: 38096764
DOI: 10.1016/j.suronc.2023.101996 -
Colorectal Disease : the Official... Jan 2024Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The...
AIM
Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously.
METHOD
This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS.
RESULTS
A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years.
CONCLUSIONS
In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.
Topics: Humans; Pelvic Exenteration; Retrospective Studies; Prognosis; Neoplasm Staging; Neoplasm Recurrence, Local; Rectal Neoplasms; Treatment Outcome
PubMed: 38071402
DOI: 10.1111/codi.16817 -
The British Journal of Surgery Jan 2024
Topics: Humans; Pelvic Exenteration; Rectal Neoplasms
PubMed: 38064685
DOI: 10.1093/bjs/znad407 -
Colorectal Disease : the Official... Jan 2024
Topics: Humans; Pelvic Exenteration; Rectal Neoplasms; Fascia
PubMed: 38057694
DOI: 10.1111/codi.16829