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PubMed2005

Mesorectal lymph node involvement and prognostic implications at total pelvic exenteration for gynecologic malignancies.

OBJECTIVES: To determine the incidence and prognostic implications of positive mesorectal lymph nodes in patients undergoing total pelvic exenteration for recurrent gynecologic malignancies. METHODS: We performed a retrospective chart review of all patients who had undergone total pelvic exenteration for a gynecologic malignancy between July 1992 and December 2003. Patient charts were reviewed for information regarding demographics, site of cancer, histology, pathology report, and time to recurrence. RESULTS: Fifty-eight women had undergone total pelvic exenteration for recurrent gynecologic malignancies during the study period and 57 were available for analysis. Primary cancer site was as follows: cervix, 37 (65%); vagina, 8 (14%); vulva, 5 (9%); and uterine corpus, 7 (12%). In 30 patients (53%), the mesorectal lymph node status was pathologically evaluated. Of these 30 patients, 3 (10%) had positive mesorectal lymph nodes at the time of total pelvic exenteration. All 3 patients had rectal wall involvement (rectal submucosa, 2; rectal mucosa, 1), and all 3 patients recurred within 4 months of pelvic exenteration. The median time to recurrence after surgery was 2.4 months in those patients with positive mesorectal lymph nodes compared with 7.3 months in those with negative mesorectal lymph nodes (P = 0.005). When individually adjusted for other prognostic variables, such as margin status, tumor grade, lymphovascular space involvement, primary cancer site, and histologic type, a finding of positive mesorectal lymph nodes was associated with a shorter time to recurrence of disease (all P < 0.05). CONCLUSIONS: Mesorectal lymph node involvement is a common finding at total pelvic exenteration, particularly in patients with rectal wall involvement. Patients with positive mesorectal lymph nodes appear to have a worse outcome with a shorter time to recurrence of disease.

Adolescent↗

PubMed1989

Reconstruction of sigmoid vagina and conduit in total pelvic exenteration for recurrent cervical carcinoma.

Although total pelvic exenteration is performed for central recurrent or persistent uterine cervical carcinoma, the patient is damaged both physiologically and psychologically by its massive surgical procedure and complications as well as the loss of the vagina. Vaginal reconstruction at the time of surgery brings much advantageous satisfaction to the patient's future life and a strong bond with her husband. Furthermore, a new reconstructed vagina occuping the pelvic cavity prevents intestinal herniation and is available for bimanual examination in the follow-up to surgery. A case of recurrent cervical carcinoma is presented, with reconstruction of the vagina and conduit using the sigmoid colon in total pelvic exenteration.

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Development and evolution of pelvic exenteration: historical notes.

Fifty years after the development of pelvic exenteration, the operation remains a gold standard in the surgical management of advanced pelvic malignancy. The operation has evolved through several predictable phases including technical improvements, lowered morbidity and mortality, and improved patient selection. Despite progress in supportive peri-operative care, pelvic exenteration is a major undertaking that should be performed in centers with proven interest and expertise in the field. We trace the early developments of the operation, the period of maturation, and the current place of this procedure in the armamentarium of the oncologic surgeon.

Female↗

PubMed1989

Clinical and histopathologic factors predicting recurrence and survival after pelvic exenteration for cancer of the cervix.

Between September 1969 and January 1, 1986, 143 pelvic exenterations for recurrent cervical cancer were performed by the gynecologic oncologists at the University of Alabama at Birmingham. Of this group, 78 patients underwent total pelvic exenteration, 63 patients had anterior exenteration, and two had posterior exenteration. The overall operative mortality rate was 6.3%, mostly associated with total pelvic exenteration. The 5-year survival rates were 50% overall, 63% with anterior exenteration and 42% with total exenteration. Univariate and multivariate analyses were performed to identify clinical and histopathologic factors predictive of prolonged survival. Using three clinical factors (duration from initial radiation therapy to exenteration, size of the central mass, and presence of preoperative sidewall fixation), low-, intermediate-, and high-risk groups were constructed; the 5-year survival rates for these groups were 82, 46, and 0%, respectively. Inclusion of one histopathologic factor (margin status of the surgical specimen) added to the ability to predict 2- and 5-year survival rates. The best candidates for cure by pelvic exenteration were those with recurrent small (less than 3 cm), mobile central masses who were a year or longer from the time of their previous radiation therapy. Attempts to resect bulky pelvic recurrences that impinge on the pelvic sidewall, especially in the case of persistent or early recurrent disease (within 6 months), or continuation of exenterative procedures in women known to have nodal metastases or extrapelvic spread, are generally futile. For those women falling between the two extremes, sound clinical and operative judgment is imperative in regard to selecting the treatment offering the best quality of life.

Adenocarcinoma↗

PubMed2003

Genitourinary tract preservation versus pelvic exenteration for advanced colorectal tumors.

INTRODUCTION: Total pelvic exenteration (TPE) is the standard of care for locally advanced colorectal cancer. This is a morbid procedure often leaving the patient with two ostomy sites and an extended recovery. Bladder preservation with complete tumor resection is often possible in these cases and we set out to determine if limited resection of the GU tract was as effective in tumor control as TPE. MATERIALS AND METHODS: This is a retrospective review of all patients over a 7-year period with colorectal tumors invading the urinary system. These patients were divided into two groups based upon the surgical procedure they received: TPE or GU tract sparing surgery. Tumor stage, adjuvant cancer therapy, and complications were reviewed. Recurrence and survival rates were calculated. RESULTS: There were 19 patients with colorectal tumors invading the GU tract. Eight patients were treated with TPE and 11 patients received GU tract sparing procedures. Tumor stage and extent of disease were similar for both groups as were adjuvant/neoadjuvant therapy received. The average follow up from surgery for TPE and GU tract sparing procedures was 40 months (range 9 - 96) and 53 months (range 21.5 - 94), respectively. The limited resection and TPE groups experienced similar complication rates: 7/11 (63.6%) and 6/8 (75%) respectively. The 5-year survival rate was 37.5% and 61.4% for TPE and limited GU resections, respectively (p=0.07). CONCLUSION: The cancer recurrence and complication rates were similar in both groups offering no clear advantage to TPE. GU sparing surgery in the face of locally invasive colorectal tumors is a viable option allowing for treatment of the disease and reducing the morbidity of total pelvic exenteration.

Aged↗

PubMed1984

Vaginal reconstruction performed simultaneously with pelvic exenteration.

Twenty-eight patients underwent vaginal reconstruction simultaneously with pelvic exenteration performed for recurrent pelvic malignancy. A satisfactory neovagina was created in 24 (86%) patients. Successful bilateral grafting was accomplished in 18 of 21 (86%) patients using gracilis myocutaneous grafts. Seven patients had a split-thickness skin graft, most of which was combined with an omental pedicle graft; six of these patients had a satisfactory neovagina. None of the patients developed herniation of the bowel through the reconstructed pelvic floor, or fistulas in the absence of recurrent malignancy. The gracilis myocutaneous graft is most feasible in patients in whom total pelvic exenteration is performed, whereas a split-thickness graft is preferable in those patients who undergo anterior exenteration or who have rectosigmoid reconstruction using low colon reanastomosis.

Adult↗

PubMed2005

[Reconstruction procedures following pelvic exenterations].

OBJECTIVE: Review of reconstruction procedures following pelvic exenterations. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, Department of Urology, 1st Department of Surgery, Faculty Teaching Hospital and 1st Medical Faculty of the Charles University, Prague. METHODS: Review and critical assessment of published data. CONCLUSIONS: Reconstruction procedures are important part of pelvic exenterations. The procedures are crucial for following quality of life. Currently the most frequently used techniques for isolated pelvic floor support are omental flaps (carpets), for combined reconstruction of pelvic floor and vagina TRAM (transverse rectus abdominis musculocutaneus flap). Reconstructions prolong operation time; however they are accompanied with low morbidity and some techniques decrease total morbidity of exenterative procedure. Total and posterior exenterations require sigmoideostomy in vast majority of cases. Low rectal anastomosis might be used in cases of supralevator procedures. They cause high morbidity especially in patients following radiotherapy. In these patients temporary diverting colostomy is being recommended. A bowel segment is usually used for urinary diversion following total or anterior exenteration. Golden standard remain the incontinent ureteroenterostomies using ileum or colon transversum. Currently continent diversions are considered more often due to encouraging results and good quality of life. Heterotopic diversions, with continent conduit and cutaneous stoma, are frequently used. Risk of serious complications, especially fistulas and stoma stenosis, after all types of diversions is possible to reduce by using appropriate bowel segment not handicapped by previous radiotherapy.

Colostomy↗

PubMed1999

[Total pelvic exenteration and rectal cancer. Apropos of 20 cases].

STUDY AIM: The report of a series of 20 patients with the aim of trying to specify the implications of pelvic exenteration for rectal cancer. PATIENTS AND METHODS: From 1986 to 1996, 20 total pelvic exenterations were performed for rectal adenocarcinoma. This retrospective study included locally extended carcinomas (n = 10), and recurrences (n = 10) after anterior resection (n = 7), and after abdominoperineal resection (n = 3). The subjects included 13 men and seven women with a mean age of 54 years (34-74 years). Complaints were major and serious: pain (n = 20), rectal syndrome (n = 17), recto-vesical fistula (n = 5) recto-vaginal fistula (n = 5), urinary infection (n = 13), and hematuria (n = 6). Preoperative radiotherapy was performed in 11 patients and preoperative radio chemotherapy in six. The surgical procedure included a total pelvic exenteration with perinectomy in 12 patients, and a total pelvic exenteration with preservation of levator ani and perineum in eight, associated in two cases with a partial resection of the sacrum, and in two other cases with partial hepatectomy for a single liver metastasis. Urinary diversion was a trans ileal ureterostomy in 17 patients and a direct double ureterostomy in three. RESULTS: The mean duration of surgery was 6 h. The mean preoperative blood loss was 1,200 L. Nine patients received blood transfusion. There was no postoperative mortality but in contrast, the morbidity rate was high with mainly urinary and digestive complications, pelvic sepsis and thromboembolic complications. After pathological examination, tumoral resections were classified R0 in 19 cases, and R1 in one. All tumors were T4 with tumoral invasion of the bladder (n = 15), prostate (n = 6), seminal vesicles (n = 4), ureter (n = 3), vagina (n = 7), urethra (n = 1), and sacrum (n = 1). Lymph node involvement was present in four patients. The 3 and 5 year actuarial survival rate was respectively 47 and 18%. Thirteen patients died of their cancer, nine from metastases, and four from local recurrence with a mean survival of 29 and 32 months respectively. Seven patients were alive at the time of this study, six without actual recurrence. CONCLUSIONS: In spite of its aggressive aspect, total pelvic exenteration seems justified in rectal carcinoma when extended to the urinary tract, when it causes major functional disorders, when there are no detectable metastases, and when the tumor has no posterior or lateral fixation. Local tumoral evolution can usually be controlled by pelvic exenteration but prolongation of survival is not demonstrated.

Adenocarcinoma↗

PubMed2002

Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques.

OBJECTIVES: Vaginal reconstruction following pelvic exenteration is an important aspect of the physical and psychological rehabilitation of women after radical surgery for pelvic malignancies. The choice of techniques is vast, and proper patient and surgical selection is important for obtaining satisfactory functional and aesthetic results. The objective of this retrospective study is to review different techniques for vaginal reconstruction and report the complications and patient satisfaction associated with the different procedures. METHODS: Between January 1988 and April 2001, 104 pelvic exenterations were performed by the division of gynecologic oncology at the University of Miami, School of Medicine. Twenty-five (24%) patients underwent vulvo-vaginal reconstruction at the time of the exenteration. A retrospective chart review of the 25 patients was performed, and 9 patients were available and contacted for an interview. RESULTS: Twenty-four (96%) patients had received prior definitive radiation therapy. Overall, there were 9 complications (6 major and 3 minor) attributed to vaginal reconstruction, accounting for 36% perioperative morbidity. Seven of the nine (78%) patients interviewed reported successful vaginal intercourse at some point after their operation. All 5 surviving patients in the myocutaneous flap group were very satisfied with their sexual function and were sexually active at the time of their interview. CONCLUSIONS: Vaginal reconstruction at the time of pelvic exenteration is an important topic that should be discussed with the patient during the preoperative visit. Although the myocutaneous flaps are associated with longer operative times, they appear to be the preferred type due to decreased postoperative fistulae and better patient satisfaction.

Adult↗

PubMed1998

[Indications and follow-up of total pelvic exenteration].

From 1988 to 1996 we performed 18 total pelvic exenterations in patients with an average age of 59.8 years who could be followed up for a mean 29.8 months. In 10 cases a recurrent tumor of the pelvic viscera and 7 times a primary carcinoma of the rectum, bladder or prostate were treated. In 1 patient a radiogenic fistula led to this operation. Intestinal continuity could be reconstructed in 7 cases. Following cystectomy, urinary diversion was accomplished in half of the cases by an ileal conduit. Due to septic multiorgan failure 2 patients died postoperatively (hospital mortality rate 11%). In 82% a complete resection (R0) was possible. Subsequently 5 patients (29%) developed tumor recurrence. Distant metastases were observed in 3 patients, 8-9 months after surgery. So far 10 further patients have died. Their mean survival time was 28.9 months (range 5-99 months). The remaining 6 patients are still alive between 22 and 36 months postoperatively. Despite the extent of this kind of major surgery, which also requires multidisciplinary cooperation, and the psychosocial problems resulting from two permanent stomas, total pelvic exenteration should be regarded as an adequate alternative in the treatment plan in selected patients with locally advanced or recurrent pelvic disease.

Adult↗

PubMed1996

Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma.

BACKGROUND: Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy. METHODS: Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n = 7) and TPE (n = 2). RESULTS: Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only. CONCLUSION: Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.

Adenocarcinoma↗

PubMedDate not supplied

Improvements in pelvic exenteration: factors responsible for reducing morbidity and mortality.

BACKGROUND: Since pelvic exenteration for the treatment of recurrent gynecologic malignancy first was described, reported rates of morbidity and mortality have declined steadily. However, the factors responsible for this decline have never been clearly delineated. METHODS: We reviewed the charts of 154 patients who underwent pelvic exenteration for gynecologic malignancy between 1954 and 1994. Charts were abstracted for details of the surgical procedure, pathologic findings, postoperative management, short- and long-term complications, time to recurrence, and overall survival. RESULTS: Seventy-two patients (47%) experienced 95 identifiable postoperative complications, resulting in death in 22 patients (14%). The rate of infectious complications declined to a statistically significant degree between the first two decades and latter two decades of the study (odds ratio [OR] 0.28. 95% CI 0.11-0.69). The use of routine prophylactic antibiotics was associated with this decline in infectious complications (OR 0.25, 95% CI 0.07-0.83). The use of preoperative subcutaneous heparin was associated with a reduction in thrombotic complications from 5 of 100 patients to 0 of 54 patients (P = .11), as well as a significant reduction in overall risk of complications (OR 0.53, 95% CI 0.33-0.85) and risk of postoperative mortality (OR 0.19, 95% CI 0.05-0.80). There was a significant reduction in overall risk of postoperative complications with both intensive care unit monitoring postoperatively (OR 0.65, 95% CI 0.43-0.99) and routine postoperative monitoring with a pulmonary artery catheter (OR 0.61, 95% CI 0.38-0.98). CONCLUSIONS: Routine use of prophylactic antibiotics, prophylactic subcutaneous heparin, and intensive postoperative monitoring appear to have reduced morbidity from pelvic exenteration.

Adult↗

PubMed1990

Types of pelvic exenterations: a reappraisal.

Subgrouping of pelvic exenterations as supralevator (type I), infralevator (type II), with vulvectomy (type III), and, an added category, extended can be helpful to facilitate communication when referring to these patients. It also can facilitate a more detailed analysis of operative risk factors, complications, and results and can increase our knowledge of the indications and limitations of the different exenterative procedures.

Evaluation Studies as Topic↗

PubMed1998

[Pelvic exenteration from the surgical viewpoint].

Pelvic exenteration (PE) is associated with specific problems in the indication of excision and reconstructive surgery. Indication are colorectal cancer or cervical cancer recurrence. In each case intensive and early cooperation of gynecologist, surgeon and urologist is warranted. Thus, PE is indicated in some T3 N1 and T4 rectal carcinoma patients without distant metastases and may be superior to chemotherapy. In cervix carcinoma recurrence, PE with or without intestinal reconstruction is of specific importance. While intestinal reconstruction may improve the quality of life in R0 resected patients we reluctantly perform this in noncurative treated patients, since their expected survival time is limited and reconstructive surgery in these pretreated patients (radiation and surgery) increases the risk of morbidity.

Adult↗

PubMed1982

Pelvic exenteration for locally advanced colorectal carcinoma.

Pelvic exenteration provided worthwhile palliation and achieved a cumulative five-year survival rate of 38.8% in 49 patients who had carcinoma of the lower colon or rectum infiltrating adjoining pelvic viscera. Survival and the disease-free period were not significantly different after total or posterior exenteration. The stage of disease was the major determinant of outcome: five-year survival rates averaged 51.8% and 28.8% for Stages II and III, respectively. Hospital mortality (26.9%) after total exenteration was chiefly due to technical mishaps, and the inclusion of many high-risk but symptomatic elderly patients. Complete clearance of locally advanced colorectal cancer by pelvic exenteration is indicated in fit patients, especially those with Stage II disease.

Adenocarcinoma↗

PubMed2000

Total pelvic exenteration for locally advanced rectal cancer.

BACKGROUND: Since its first description in 1948, total pelvic exenteration has been a surgical option for the treatment of locally advanced rectal cancer in selected patients. During these 50 years, it has remained a formidable procedure with high mortality and substantial morbidity. This report describes the results of total pelvic exenteration for rectal cancer in terms of post-operative mortality, morbidity, and longterm survival in patients with locally advanced primary and recurrent rectal cancer. STUDY DESIGN: A study of the patient records revealed that 24 patients underwent total pelvic exenteration as the treatment for locally advanced primary or recurrent cancer of the rectum from 1983 to 1998. The charts of the patients were reviewed, and morbidity and mortality were documented. The survival of the patients was also analyzed. RESULTS: Fifteen patients had primary tumor and 9 had locally recurrent cancer. The mean age was 62 years old. There were no postoperative deaths, and the complication rate was 54%. In the treatment of primary tumor, bowel continuity was possible in 60% of the patients. Previous radiation or operation for recurrent disease was not associated with increased morbidity. The overall 5-year survival was 44%. The 5-year survival of patients with primary cancer was 64% and was significantly better than the rate for those with recurrent disease. Only one patient with recurrent disease survived more than 24 months. CONCLUSIONS: Total pelvic exenteration now can be performed with low mortality rates, but the morbidity remains high. In the treatment of primary rectal cancer, good survival (64%) can be achieved, but results are dismal for the treatment of recurrent disease. We suggest better selection of patients for this procedure, especially as a treatment for recurrent rectal cancer.

Adenocarcinoma↗

PubMed2004

Composite pelvic exenteration: is it worthwhile?

BACKGROUND: In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis. METHODS: Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3. RESULTS: Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively. CONCLUSIONS: Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.

Anus Neoplasms↗

PubMed1994

Pelvic exenteration in gynecologic oncology. Review.

Pelvic exenteration is still indicated in the treatment of gynecological cancer, in patients with pelvic resectable disease, after the failure of standard treatment. The reported survival ranges from 20 to 60% and has been increasing in the last 15 years; the prognostic factors more frequently described are margin status, time from diagnosis or radiotherapy, lesion size, preoperative side-wall fixation. The role of palliative exenteration in patients with non-resectable disease and/or nodal metastases is discussed. Survival and morbidity in elderly patients are comparable to the younger group and age cannot be considered as an exclusion criteria. Gastrointestinal, urinary and infectious complications are still considerable, but morbidity and mortality have been reduced by surgical and intensive care developments. New surgical techniques, i.e. vaginal reconstruction and continent urinary diversions, have improved quality of life, especially in younger patients, with longer expected survival.

Aged↗