Isolated ileal segment as urine conduit after exenteration for pelvic cancer. Further experiences with improved technic.
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Humans↗
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[Value of surgery in the treatment of advanced cervical cancers].
Surgical resection of advanced nonmetastatic forms of cervical cancers is controversial, but improve local control. The local and regional staging assessment, comprising an examination under general anaesthesia, endocavitary ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) allows staging, evaluation of the main prognostic factors and selection of the therapeutic strategy. Pelvic and lumboaortic lymph nodes can be investigated by CT, MRI or laparoscopic lymphadenectomy. Surgical resections consist of colpohysterectomy possibly combined with radical lymphadenectomy or pelvic exenteration, followed by pelvic reconstruction using various procedures: low colorectal anastomosis, continent urinary diversion, and vaginal reconstruction with pelvic filling. The mortality and morbidity of pelvic exenteration remain high. It is therefore important to prevent the most frequent complications as effectively as possible. The local control, overall survival and recurrence-free survival can be improved by combining concomitant radiotherapy-chemotherapy and large surgical resection. Some unfavourable local situations can justify palliative pelvic exenteration in highly selected indications designed to improve local control and comfort of survival.
Combined Modality Therapy↗
Pelvic resection of recurrent rectal cancer.
OBJECTIVE: The authors describe their experience with pelvic resection of recurrent rectal cancer with emphasis on patient selection for curative intent based on known tumor risk factors. SUMMARY BACKGROUND DATA: Pelvic recurrence is a formidable problem in 30% of patients who have undergone a curative resection of primary rectal cancer. Although radiation can reduce the development of local recurrence and can provide palliation to many patients with localized disease, it is not curative. The authors and others have used the technique of abdominal sacral resection (ABSR) with or without pelvic exenteration to resect pelvic recurrence and its musculoskeletal extensions in selected patients with satisfactory long-term survival. METHODS: The technique of ABSR with or without pelvic exenteration or resection of pelvic viscera, which the authors have described previously, was used in 53 patients with recurrent rectal cancer--47 patients for curative intent and 6 for palliation. Previous surgeries were abdominal perineal resections (APRs) in 26 patients, anterior resections in 19 patients, and other procedures in 2 patients; original primary Dukes' stage was B in 52% and C in 48%. Almost all patients had been irradiated previously, generally in the 4000 to 5900 cGy range. Preoperative carcinoembryonic antigen (CEA) levels (before ABSR) were elevated (> 5 ng/mL) in 54%. RESULTS: Postoperative morbidity was encountered in most patients. Mortality was 8.5% in the curative group. Long-term survival for 4 years was achieved in 14 of 43 patients (33%), and 10 patients were alive with an acceptable quality of life after 5 years. Patients who had previous anterior resections or whose preoperative CEA levels were less than 10 ng/mL had a survival rate of approximately 45%, whereas patients with previous APRs and preoperative CEA levels greater than 10 ng/mL had a survival rate of only 15% to 18%. Patients with bone marrow invasion, positive margins, or pelvic node metastases had a median survival of only 10 months. CONCLUSIONS: Pelvic recurrence of rectal cancer can be resected safely with expectation of long-term survival of 33%. Patient selection based on known risk factors can identify patients most likely to benefit from resection and eliminate those who should be treated for palliation only.
Carcinoembryonic Antigen↗
[Exenteration of pelvic organs and its modifications].
A classification of modalities of exenteration of pelvic organs is discussed and standards for optimal procedures of surgical rehabilitation are suggested. Different modifications of pelvic organ exenteration involving removal of the urinary bladder were performed in 29 patients with localized and recurrent malignant tumors. Reconstructive procedures matched the exenteration modifications used. Surgical rehabilitation measures included; reinforcing the fundus of the pelvis, formation of an abdominal pouch for urine collection, a low coloanal anastomosis and vaginal reconstruction.
Anal Canal↗
[Surgery for extraperitoneal pelvic neoplasms].
OBJECTIVE: To evaluate the methods of surgery for extraperitoneal pelvic neoplasms. METHODS: Clinical data related to surgery of 84 cases of extraperitoneal pelvic neoplasms were extracted and retrospectively analyzed. RESULTS: All 84 patients underwent operations, including one of them who received 4 operations within 6 months for resection of a single tumor. 58 abdominal, 16 buttock and 10 combined incisions were made in the series. Pelvic organs and structures were co-resected in 35 cases, including total pelvic exenteration in 2 cases and anterior pelvic exenteration in 2 cases. Common and/or external iliac vessels were resected and transplantations of artificial vessel were carried in 5 cases. Internal iliac arteries were ligated in 10 cases. The mean blood lose was 2 385 ml in our series and the largest was 15 000 ml. The complete resection rate of tumor was 81% for 84 operations and the largest resected tumor was 30 cm x 30 cm x 25 cm. There was no hospitalized death, and postoperative complication rate was 7% (6/84) in our series. Only 1 death were seen during the mean period of postoperative follow-up of 54 months, 22 operations were carried for 21 cases of recurrence, including 7 operations for 7 recurrences in a case within 12 years. CONCLUSIONS: Making adequate abdominal or/and buttock incisions, exenterations of involved pelvic organs and structures, total pelvic exenteration if necessary, appropriate management of iliac vessels, planned re-operation for one tumor, and re-operation for recurrences are important methods for the treatment of extraperitoneal pelvic neoplasms.
Adolescent↗
[Usage of the CUSA (cavitron ultrasonic surgical aspirator) in radical surgery of cervical carcinoma of the uterus].
Not infrequently, great difficulty is encountered in the operation for advanced cervical carcinoma of the uterus in dissecting cancerous tissues and controlling incidental bleeding. The CUSA is a major achievement of modern ultrasonic technology, and has been used by us to overcome such difficulties in 6 cases of total pelvic exenteration, 4 of anterior pelvic exenteration, 1 of posterior pelvic exenteration, 2 of cardinal ligament extirpation and 21 of radical hysterectomy. The handpiece of the CUSA contains a hollow titanium tip which vibrates longitudinally along its axis, driven by a magnetostrictive transducer. The vibration occurs with a frequency of 23 kHz and with an adjustable stroke of 0-300 microns. The tip of the device, placed in contact with the target tissues, destroys and emulsifies the cell membranes, which are irrigated and removed through a built-in suction tube. Since vessels larger than 0.5mm in diameter, nerves and fibrous tissue capsules contain much collagen, they rebound with the ultrasonic vibration waves emitted by the CUSA, and consequently they are left unimpaired by the procedure. It was noted in our operations that the larger the degree of tip excursion of the CUSA, the greater was the power added to fragment the target tissues. The effectiveness also depended upon the amount of water contained in the tissues. A very accurate sensation of the consistency of tissues was obtainable through the tip of the device in contact with them. This tactile feedback was quite helpful in enabling us to differentiate between target tissues. A clear visualization of detailed structures of vasculature and nerves in the pelvic cavity was attained as a result of sweeping dissection using the CUSA, and thereby extensive elimination of the cancerous tissues and lymph nodes was facilitated.
Female↗
Modified pelvic anterior exenteration.
During a 20-year time period, 117 patients with various histologic types of cancer underwent pelvic exentereation. Six of the 107 patients who needed anterior exenteration with urinary diversion received partial excision of the urinary bladder and modification surgery, of which three had uretero-cystostomy, two had mobilization of bladder and uretero-cystostomy and one had uretero-uterostomy. These six patients, except for two, died of disease in 1 year. Two patients are alive and happy, with quality of life because they can urinate normally. We suggest that anterior exenteration should be modified whenever possible to preserve the bladder and not to do an urinary diversion.
Female↗
Surgical pelvic packing as a means of controlling massive intraoperative bleeding during pelvic posterior exenteration--a case report and review of the literature.
This is a report of a case of gynecological hemorrhage after a posterior pelvic exenteration in patients with vulvar cancer treated by temporary pelvic packing at the Department of Gynecology of the Medical University in Gdańsk. The packing was successful and the sponges were removed after 24 h. Twenty-eight days after the operation, the patient was transferred to the Department of Radiotherapy for supplementary treatment. In patients with severe intraoperative hemorrhage, intra-abdominal packing has been successful as a mode of treatment.
Female↗
[Exenteration procedures in the pelvis].
Exenteration pelvic procedures are surgical options for treatment of locally advanced pelvic tumors. Due to the procedure's success rates, it has become a standard therapeutic procedure, when indicated. From the medical point of view, the following factors characterize the level of seriousness of these procedures: the fact that the procedure is extensive, its complicated reconstruction phase and high postoperative morbidity rates. From the patient's point of view, it is characterized by a principal change in the quality of life. In this case review the authors present their experience with a multidisciplinary approach to these procedures.
Adult↗
[Leiomyosarcoma of the prostate: a case report].
A 39-year-old man with the chief complaints of gross hematuria and dysuria was referred to our hospital on June 6th, 1985. Physical examination revealed a tumor in the left lobe of the prostate. Prostatic needle biopsy showed the histological evidence of leiomyosarcoma. Pelvic exenteration with pelvic lymph adenectomy was performed on June 18th, 1985. Histological findings of the tumor revealed leiomyosarcoma and no lymph nodes metastasis. Two courses of vincristine-adriamycin-cyclophosphamide chemotherapy were given postoperatively after a clonogenic assay was done. He considerably improved and was discharged 3 months after operation. He shows no recurrence of tumor 17 months after operation. Thirty-three cases of leiomyosarcoma reported in Japan are reviewed.
Adult↗
Exenteration as palliation for patients with advanced pelvic malignancy.
OBJECTIVE: To examine the place of pelvic exenteration in the palliation of advanced and recurrent pelvic tumours. PATIENTS AND METHODS: The notes of patients referred for palliative exenteration were reviewed retrospectively. Fourteen patients (three men, mean age 52 years, and 11 women, mean age 61 years) with a variety of pelvic tumours associated with severe symptoms, had a laparotomy with a view to pelvic exenteration and 10 underwent total or anterior exenteration. RESULTS: Eight patients achieved excellent or good palliation based on survival and quality of life assessment, and two received no benefit. Four of eight patients were alive and apparently free of tumour at a mean of 17 months after surgery. Four were alive, symptom-free but with evidence of malignancy at a mean of 19 months. Two patients who received no benefit died at 2 and 7 months after surgery. The planned exenteration was abandoned in four patients; three of these four patients were dead at a mean of 13 months and one was alive at 12 months. CONCLUSION: Our results confirm that with careful selection and appropriate multi-specialty care, aggressive pelvic surgery is of value in the palliation of some tumours.
Adenocarcinoma↗
Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft.
The earliest efforts at neovaginal reconstruction used split-thickness skin grafts when bladder and rectum remained in place. In patients undergoing total pelvic exenteration, the pelvic organs are not available to accept the skin graft. By modifying the omental flap normally used to close off the pelvic inlet after total pelvic exenteration with or without lower coloproctostomy, a cylinder can be created that provides anterior, posterior, and lateral walls for the neovagina. When this omental cylinder is lined with a split-thickness skin graft and secured in the postoperative period using a soft vaginal form, a satisfactory neovagina can be created. This article presents the authors' experience with 20 patients who underwent radical pelvic exenteration for gynecological malignancy and neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft. In this series, all flaps and skin grafts have remained soft and completely viable with no pelvic infections, perineal fistulae, or hernias, and they offer the potential for sexual function in approximately 80 percent of patients. Average reconstruction operating time is less than 2 hours. In the properly selected patient, this method provides distinct advantages over reconstruction with myocutaneous flaps, which may be too bulky, too difficult to pass into the pelvis, and require additional donor-site incision with prolonged operative time. Myocutaneous flaps may have greater potential for partial or complete tissue loss. Neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft compares favorably with previously described methods by providing support for the pelvic floor with primary healing while restoring the potential for sexual function with minimal overall morbidity.
Adult↗
Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies.
OBJECTIVE: The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies. METHODS: We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. RESULTS: Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catheterization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients). CONCLUSIONS: Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.
Adult↗
[Initial experience in exenteration interventions in the pelvis].
OBJECTIVE: Discussion of experiences with pelvic exenterations. DESIGN: Case-report. SETTING: Department of Obstetrics and Gynecology, Department of Urology, Department of Surgery, Department of Pathology, Department of Clinical Oncology, General Teaching Hospital and Ist Medical Faculty of the Charles University, Prague, Czech Republic. METHODS: Presentation of 4 cases of pelvic exenterations. Discussion with published data. RESULTS: Altogether four cases of pelvic exenterations are presented, one case of supralevator total exenteration for recurrent cervical cancer, one case of infralevator total exenteration for recurrent vaginal cancer, one case of supralevator anterior exenteration in the treatment of locally advanced cancer of urinary bladder, and one case of supralevator posterior exenteration for recurrent vaginal cancer.
Adult↗
Pelvic exenterative procedures for locally advanced or recurrent colorectal carcinoma in a community hospital.
BACKGROUND: We describe our experience with exenterative pelvic surgery for colorectal cancer in a small community hospital. METHODS: We retrospectively evaluated 26 consecutive patients (14 women) with locally advanced (n=16) or recurrent (n=10) colorectal adenocarcinomas who underwent pelvic exenterations between August 1990 and December 2001 in our service. RESULTS: Seventeen patients had posterior pelvic exenteration (PPE), eight had total pelvic exenteration (TPE) and one had TPE with internal hemipelvectomy. Major morbidity occurred in 12 patients (46%), causing 3 deaths (11%) in the immediate postoperative period. Fourteen of 23 patients who survived the immediate postoperative period have relapsed (61%). At a median follow-up of 42 months, the 5-year survival is 38%. CONCLUSION: Pelvic exenterative procedures can be offered to patients with bulky or recurrent colorectal carcinomas with adequate results and satisfactory palliation, even in a community setting.
Adenocarcinoma↗
[The role of radical surgery in the treatment of epidermoid carcinoma of the anal canal].
In order to define the role of radical surgery in the actual treatment of epidermoid carcinoma of the anal canal (ECAC), we retrospectively reviewed the charts of patients with primary ECAC, treated with radical surgery in the Hospital de Oncología, National Medical Center IMSS. We analyzed the recurrence pattern, its treatment and the contemporary literature was reviewed. From 1975 to 1990, we treated 16 patients; 13 females, 3 males, mean age was 64 years. The presurgical stage was T2, 6; T3 7; T4, 3. An abdominoperineal resection was performed in 12 patients; a posterior pelvic exenteration in 3; a total pelvic exenteration in 1. Ten patients developed surgical complications, 4 of them were major, 2 required surgical reintervention. There was no operative mortality. We obtained local tumor control in 5/16 patients (32%); the local recurrence by stage were T2, 3/6 (50%); T3, 5/7 (71%); T4, 3/3 (100%) p = 0.04. Ten of them were located at the pelvis brim and 1 was located to the central pelvis (vagina, perineum), 9 were treated with radiation therapy (RT) a mean dose of 45 Gy, only the patient with central local recurrence obtained local tumor control. Regional recurrences were as follows: T2 patients, 1/6 (16%); T3, 2/7 (28%); T4, 2/3 (66%). The 2 patients with metachronous inguinal lymph node metastases were treated with a radical groin dissection, with tumor control. In conclusion, the radical surgical treatment is associated with a low loco-regional tumor control; the pelvic tumor relapses were located at the pelvis brim and with no response to RT. With the results herein obtained and the results with other treatment modalities such as RT and its associations with chemotherapy (C) in regard to local tumor control, the actual role of the radical surgical treatment in the salvage of central pelvic relapses to primary treatment with RT or C-RT.
Adult↗
Local recurrence of rectal adenocarcinoma following preoperative radiation therapy and surgery.
An important therapeutic endpoint of the surgical treatment of rectal adenocarcinoma is to obtain local control. In an attempt to enhance this goal, we started a regimen of treatment consisting of preoperative radiation therapy (PRT), 45 Gy in 5 weeks, followed by surgery 4-6 weeks after termination of the PRT. Depending on the local characteristics of the tumor, either an abdominoperineal resection (APR), a posterior pelvic exenteration (PPE), and a total pelvic exenteration (TPE) were performed. All patients found with distant metastasis were excluded from this study. There were 66 patients: 40 males and 26 females. Fifty six underwent an APR, six a PPE, and four a TPE. Their median age was 56 years. Major complications were intraoperative bleeding (15%); perineal wound infection (21%); abdominal wound infection (9%). Five patients (7.5%) died within 30 days of surgery; two after APR, two after PPE and one after TPE. Median follow-up is 60 months. The overall local recurrence rate is 9.8%. Recurrences related to the Astler-Coller modification of Dukes' stage were 0/21 in A or B1, but 6/40 (15%) when the stages were B2, B3, C1, C2 and C3. In conclusion, we found this treatment approach effective in obtaining local control of the rectal adenocarcinoma and comparable to the results of other series. However, it was associated with significant morbidity and mortality.
Actuarial Analysis↗
Malignant peripheral nerve sheath tumor of the vulva: a multimodal treatment approach.
BACKGROUND: Malignant peripheral nerve sheath tumors (MPNSTs) are rare in the gynecological population and have a high risk for local and distant failures. Multimodal management of a patient with MPNST of the vulva and review of the literature are outlined. CASE: A 34-year-old woman presented with a complaint of a rapidly increasing pelvic mass, pain, and difficulty ambulating. A disfiguring 20 x 20-cm vulvar mass was identified and a recurrent MPNST diagnosed. Therapy included external-beam radiation, anterior pelvic exenteration with pelvic reconstruction, and adjuvant chemotherapy without complication. CONCLUSION: It is recommended that for malignant peripheral nerve sheath tumors of the vulva, complete surgical resection be performed with adjuvant radiation and chemotherapy in selected cases.
Adult↗