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Cancers Dec 2021The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient...
PURPOSE
The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view.
METHODS
This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used.
RESULTS
A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes).
CONCLUSION
Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.
PubMed: 34944783
DOI: 10.3390/cancers13246162 -
Obstetrics & Gynecology Science Sep 2021To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure.
OBJECTIVE
To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure.
METHODS
LEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic sidewall. Its initial indications were for lymph node positive Stage Ib (current International Federation of Gynecology and Obstetrics 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic sidewall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic sidewall.
RESULTS
During LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic sidewall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic sidewall veins.
CONCLUSION
LEP is a feasible technique for removing pelvic sidewall recurrences, aiming to obtain surgical free margins.
PubMed: 34030221
DOI: 10.5468/ogs.21103 -
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 -
Investigative and Clinical Urology Jan 2021To describe the surgical technique and examine the feasibility and outcomes following robotic pelvic exenteration and extended pelvic resection for rectal and/or...
PURPOSE
To describe the surgical technique and examine the feasibility and outcomes following robotic pelvic exenteration and extended pelvic resection for rectal and/or urological malignancy.
MATERIALS AND METHODS
We present a case series of seven patients with locally advanced or synchronous urological and/or rectal malignancy who underwent robotic total or posterior pelvic exenteration between 2012-2016.
RESULTS
In total, we included seven patients undergoing pelvic exenteration or extended pelvic resection. The mean operative time was 485±157 minutes and median length of stay was 9 days (6-34 days). There was only one Clavien-Dindo complication grade 3 which was a vesicourethral anastomotic leak requiring rigid cystoscopy and bilateral ureteric catheter insertion. Eighty-five percent of patients had clear colorectal margins with a median margin of 3.5 mm (0.7-8.0 mm) while all urological margins were clear. Six out of seven patients had complete (grade 3) total mesorectal excision. Three patients experienced recurrence at a median of 22 months (21-24 months) post-operatively. Of the three recurrences, one was systemic only whilst two were both local and systemic. One patient died from complications of dual rectal and prostate cancer 31 months after the surgery.
CONCLUSIONS
We report a large series examining robotic pelvic exenteration or extended pelvic resection and describe the surgical technique involved. The robotic approach to pelvic exenteration is highly feasible and demonstrates acceptable peri-operative and oncological outcomes. It has the potential to benefit patients undergoing this highly complex and morbid procedure.
Topics: Aged; Anastomosis, Surgical; Anastomotic Leak; Cystectomy; Feasibility Studies; Humans; Length of Stay; Male; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neoplasms, Multiple Primary; Operative Time; Pelvic Exenteration; Proctectomy; Prostatectomy; Prostatic Neoplasms; Rectal Neoplasms; Robotic Surgical Procedures; Treatment Outcome; Urethra; Urinary Bladder
PubMed: 33381928
DOI: 10.4111/icu.20200176 -
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 -
European Journal of Surgical Oncology :... Jun 2022Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers...
BACKGROUND
Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival.
METHODS
Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed.
RESULTS
The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients.
CONCLUSION
The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
Topics: Humans; Morbidity; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Retrospective Studies
PubMed: 34998633
DOI: 10.1016/j.ejso.2021.12.472 -
Journal of Gynecologic Oncology May 2022Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze...
OBJECTIVE
Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE.
METHODS
Ninety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021.
RESULTS
A 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51-74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery.
CONCLUSION
PPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate.
Topics: Aged; Carcinoma, Ovarian Epithelial; Cytoreduction Surgical Procedures; Female; Humans; Middle Aged; Ovarian Neoplasms; Pelvic Exenteration; Retrospective Studies
PubMed: 35320883
DOI: 10.3802/jgo.2022.33.e31 -
Journal of Endourology Sep 2021Radical cystectomy is the standard of care for patients with nonmetastatic high-risk bladder cancer. Robotic approach to radical cystectomy has been developed to reduce...
Radical cystectomy is the standard of care for patients with nonmetastatic high-risk bladder cancer. Robotic approach to radical cystectomy has been developed to reduce perioperative morbidities and enhance postoperative recovery while maintaining oncologic control. Classically, radical cystectomy in female patient entails anterior pelvic exenteration with removal of the bladder, uterus, fallopian tubes, ovaries, anterior vaginal wall, and urethra. Pelvic organ-sparing radical cystectomy has been adopted in carefully selected patients to optimize postoperative sexual and urinary function, especially in those undergoing orthotopic urinary diversion. In this article, we describe our techniques of both classical and organ-sparing robot-assisted laparoscopic radical cystectomy in female patients. We also review patient selection criteria, perioperative management, and alternative approaches to improve operative outcomes in female patients.
Topics: Cystectomy; Female; Humans; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 34499552
DOI: 10.1089/end.2020.1190 -
Journal of Gastrointestinal Oncology Dec 2019There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours... (Review)
Review
There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.
PubMed: 31949941
DOI: 10.21037/jgo.2019.01.21