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International Journal of Surgery... Dec 2017Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably...
BACKGROUND
Pelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.
MATERIALS AND METHODS
This was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fisher's exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.
RESULTS
Since 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).
CONCLUSION
The long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.
Topics: Adult; Aged; Aged, 80 and over; Chemotherapy, Adjuvant; Chi-Square Distribution; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Male; Margins of Excision; Middle Aged; Neoplasm Staging; Pelvic Exenteration; Postoperative Complications; Prospective Studies; Rectal Neoplasms; Rectum; Retrospective Studies; Statistics, Nonparametric; Treatment Outcome
PubMed: 28987560
DOI: 10.1016/j.ijsu.2017.09.069 -
Journal of Minimally Invasive Surgery Dec 2022Despite the public awareness of colorectal cancer screening with more and more early premalignant or malignant lesions detected, surgeons still face the challenges of...
Despite the public awareness of colorectal cancer screening with more and more early premalignant or malignant lesions detected, surgeons still face the challenges of operating for a patient suffering from locally advanced rectal carcinoma which required pelvic exenterations, and surgical outcomes mostly influenced by margin status, adjuvant chemotherapy, positive lymph nodes and liver metastasis, etc. Open pelvic exenteration has been the adopted approach in the past and laparoscopic surgery is another option in expert centers. A study in this issue of the demonstrated promising results of minimally invasive approaches for pelvic exenteration in patients with locally advanced rectal carcinoma, with overall complication rate of 28.2% with a 7.3% circumferential resection margin positivity and with no distal margin involvement, with local recurrence rate of 8.1% and overall survival of 85.2% by 2-year follow-up. We are expecting more results in the future to support the routine implementation of minimally invasive pelvic exenterations.
PubMed: 36601489
DOI: 10.7602/jmis.2022.25.4.127 -
Urology Journal Sep 2018To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or...
PURPOSE
To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or double-barrelled wet colostomy (DBWC).
MATERIALS AND METHODS
The medical records of all patients who had undergone pelvic exenteration and urinary diversion between 2006 and 2017 at our hospital were reviewed retrospectively.
RESULTS
In total, 15 patients with a mean age of 56 ± 13 years were included in the study. Simultaneous urinary and fecal diversions were carried out as PWC (n = 8), or DBWC (n = 7). No significant differences were found between PWC and DBWC groups in terms of operation time (373.7 ± 66.5 versus 394.2 ± 133.2 min, P = .955), estimated blood loss (862.8 ± 462.4 versus 726.2 ± 489.4 mL, P = .613), length of hospital stay (13.2 ± 9.1 versus 14.1 ±6.9 days), early complications (25% versus 28.6%, P = 1.0) and late term complications (37.5% versus 42.9%, P = 1.0). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically significant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618).
CONCLUSION
PWC and DBWC are valid options for creating simultaneous urinary and fecal diversion after extensive pelvic surgery in patients with short life expectancy. DBWC might be superior to PWC in terms of decreased risk of recurrent pyelonephritis.
Topics: Adult; Aged; Colostomy; Female; Humans; Length of Stay; Life Expectancy; Male; Middle Aged; Operative Time; Pelvic Exenteration; Postoperative Complications; Pyelonephritis; Retrospective Studies; Turkey; Urinary Diversion
PubMed: 29705982
DOI: 10.22037/uj.v0i0.4461 -
Medicina (Kaunas, Lithuania) Jan 2023The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease... (Review)
Review
The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease after six months from RTCT is about 20-30%. It is directly related to relapse risk and poor survival, such as in patients with recurrent cervical cancer. This systematic review aims to describe studies investigating salvage surgery's role in persistent/recurrent disease in LACC patients who underwent definitive RTCT. Studies were eligible for inclusion when patients had LACC with radiologically suspected or histologically confirmed residual disease after definitive RTCT, diagnosed with post-treatment radiological workup or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. The methodological quality of the articles was independently assessed by two researchers with the Newcastle-Ottawa scale. Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in May 2022. We applied no language or geographical restrictions but considered only English studies. We included studies containing data about postoperative complications and survival outcomes. Eleven studies fulfilled the inclusion criteria and all were retrospective observational studies. A total of 601 patients were analyzed concerning the salvage surgery in LACC patients for persistent/recurrent disease after RTCT treatment. Overall, 369 (61.4%) and 232 (38.6%) patients underwent a salvage hysterectomy (extrafascial or radical) and pelvic exenteration (anterior, posterior, or total), respectively. Four hundred and thirty-nine (73%) patients had histologically confirmed the residual disease in the salvage surgical specimen, and 109 patients had positive margins (overall range 0-43% of the patients). The risk of severe (grade ≥ 3) postoperative complications after salvage surgery is 29.8% (range 5-57.5%). After a median follow-up of 38 months, the overall RR was about 32% with an overall death rate of 40% after hysterectomy or pelvic exenteration with or without lymphadenectomy. There is heterogeneity between the studies both in their design and results, therefore the effect of salvage surgery on survival and recurrence cannot be adequately estimated. Future homogeneous studies with an appropriately selected population are needed to analyze the safety and efficacy of salvage hysterectomy or pelvic exenteration in patients with residual tumors after definitive RTCT.
Topics: Female; Humans; Uterine Cervical Neoplasms; Retrospective Studies; Neoplasm Recurrence, Local; Hysterectomy; Chemoradiotherapy; Postoperative Complications
PubMed: 36837394
DOI: 10.3390/medicina59020192 -
International Braz J Urol : Official... 2021One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract...
Simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion: step-by-step video-illustrated technique.
INTRODUCTION:
One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract urothelial cancer (UTUC) is exceptional. Minimally invasive approach for these synchronous tumors was just occasionally reported (1-4). The aim of this video article is to describe step-by-step the technique for simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion (ICUD). Patients and methods: A 66-year-old female presented with synchronous BCG refractory non-muscle invasive bladder cancer and a right-side UTUC. She was a former smoker and had previously been submitted to multiple transurethral resections of bladder tumor, BCG and right distal ureterectomy with ureteral reimplant. We performed a simultaneous laparoscopic right nephroureterectomy and robot-assisted anterior pelvic exenteration with totally intracorporeal ICUD. Combination of robot-assisted and pure laparoscopic approaches was proposed focusing on optimization of total operative time (TOT).
RESULTS:
Surgery was uneventful. TOT was of 330 minutes. Operative time for nephroureterectomy, anterior pelvic exenteration and ICUD were 48, 135, 87 minutes, respectively. Estimated blood loss was 150mL. Postoperative course was unremarkable and patient was discharged after 7 days. Histopathological evaluation showed a pT1 high grade urothelial carcinoma plus carcinoma in situ both in proximal right ureter and bladder, with negative margins. Twelve lymph nodes were excised, all of them negative.
CONCLUSION:
In our preliminary experience, totally minimally invasive simultaneous nephroureterectomy and cystectomy with intracorporeal ICUD is feasible. Pure laparoscopic approach to upper urinary tract may be a useful tactic to reduce total operative time.
Topics: Cystectomy; Humans; Laparoscopy; Nephroureterectomy; Pelvic Exenteration; Robotics; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 34260187
DOI: 10.1590/S1677-5538.IBJU.2020.1006 -
BMC Surgery Aug 2022Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of...
BACKGROUND
Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration.
METHODS
A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months.
RESULTS
The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications.
CONCLUSIONS
A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
Topics: Humans; Necrosis; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Floor; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies
PubMed: 35933336
DOI: 10.1186/s12893-022-01755-0 -
Gynecologic Oncology Reports May 2021Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis. All...
Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis. All women treated with anterior (APE) or total (TPE) pelvic exenteration at our University hospital within a five-year period were identified and their data retrospectively analysed. Parameters such as demographic information, tumor type and stage, previous therapy as well as complication rate and overall survival were evaluated. 47 women were enrolled in this study. Most common indication for PE was cervical cancer (51.1%) followed by carcinoma of the vagina (17%), vulva (10.6%), endometrium (8.5%), ovaries (4.3%) and uterus (2.1%). Patients had received 1, 2 or 3 treatment modalities prior in 12.8%, 38.8% and 21.2% respectively. Predominant urinary diversion was ileum conduit (75.5%). Major complications (Clavien Dindo ≥ III) were observed in 40.4%, none in 19.2%. Early mortality was 4.3%. Median Overall Survival (mOS) was 14 months with 2- and 3-year survival rates of 38.8% and 21.2% respectively. After a median follow up of 47 months, 25.5% were still alive. Excluding patients with metastatic disease (n = 10), mOS was 20.6 months with 2- and 3-year survival rates of 46% and 35.2%. OS was significantly worse for patients with positive margins (p = 0.003). Receiving neoadjuvant treatment (25.5%) correlated with negative margins (p = 0.013) but not with overall survival. PE is feasible with acceptable complication and mortality rates. The long-time benefit is notable bearing in mind the extensive nature of the malignancies and the procedure undertaken.
PubMed: 33898694
DOI: 10.1016/j.gore.2021.100757 -
Cancers Feb 2021Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative... (Review)
Review
BACKGROUND
Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers).
METHODS
We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE.
RESULTS
Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43-0.71; < 0.01/Group B: OR 0.54, CI 0.17-1.68; = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35-0.68; < 0.001/Group B: OR 0.38, 95% CI 0.12-1.17; < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39-4.35; < 0.01) and major (OR 1.67, 95% CI 0.90-3.08; = 0.1) perineal complications in Group C.
CONCLUSION
Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
PubMed: 33578769
DOI: 10.3390/cancers13040721 -
Cancers Feb 2024Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some... (Review)
Review
Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some cases of advanced tumors, it is associated with several perioperative complications. We believe that careful patient selection is related to better oncologic outcomes and lower complication rates. The objectives of this review are to identify the most current indications for this intervention, suggest criteria for case selection, evaluate recommendations for perioperative care, and review oncologic outcomes and potential associated complications. To this end, an analysis of English language articles in PubMed was performed, searching for topics such as the indication for pelvic exenteration for recurrent gynecologic neoplasms selection of oncologic cases, the impact of tumor size and extent on oncologic outcomes, preoperative and postoperative surgical management, surgical complications, and outcomes of overall survival and recurrence-free survival.
PubMed: 38398208
DOI: 10.3390/cancers16040817 -
Annals of the Royal College of Surgeons... Mar 2022We describe a case report of a robotic total pelvic exenteration (TPE) performed for a locally advanced rectal cancer at our institution in August 2018. Technical...
We describe a case report of a robotic total pelvic exenteration (TPE) performed for a locally advanced rectal cancer at our institution in August 2018. Technical details and comparison with published literature are discussed. A 62-year-old patient with a locally advanced low rectal cancer T4N1cM0 with extramural vascular invasion (EMVI) underwent an elective robotic pelvic clearance performed by the urology and colorectal teams. He received neoadjuvant long-course chemo-radiotherapy to downstage the rectal cancer. The primary tumour was T4N1c with involvement of the bladder (trigone area) and prostate. After neoadjuvant therapy, MRI scan showed tumour regression grade 4 (TRG4). The patient underwent single docking totally robotic pelvic clearance. Patient's body mass index (BMI) was 32. The operative time was 400 minutes with the docking time of 15 minutes. There were no intraoperative complications, and the blood loss was 100ml. Histology was ypT4b, ypN1b, ypMx with 2/9 positive lymph nodes, and there was a complete resection by >1mm at all margins. The postoperative complications were ileus and urinary tract infection. Length of stay was 11 days complicated by prolonged ileus requiring total parenteral nutrition (TPN). The 30-day follow-up had no postoperative complications or readmission. The robotic approach is safe and feasible for multiorgan resections for locally advanced pelvic cancers, with curative intent. The literature supports it by highlighting the advantages of robotic pelvic surgery: better access, stable platform, quick inter-specialty change of operator by use of dual console and superior visualisation.
Topics: Humans; Male; Middle Aged; Pelvic Exenteration; Rectal Neoplasms; Robotic Surgical Procedures
PubMed: 34730433
DOI: 10.1308/rcsann.2021.0137