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PubMed2000

Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity.

PURPOSE: The purpose of this study was to analyze our experience with the influence of reconstructive techniques at the time of pelvic exenteration on morbidity. MATERIALS AND METHODS: Between June 1986 and December 1998, 60 pelvic exenterations for gynecologic malignancies were performed in our hospital. Forty-five were selected for this study because they met two criteria: they were performed by the same team (gynecologic oncologist), and they had similar primary tumors. There were 38 cervical, 2 vaginal, and 5 uterine malignancies. Sixteen patients underwent reconstructive surgery: 11 (68.8%) with placement of a myocutaneous flap with left rectus abdominis, 3 (18.8%) with gracilis muscle, and 2 (12.5%) with the Singapore fasciocutaneous flap. Twenty-nine patients had no reconstruction. Records were reviewed and statistical analysis was performed. RESULTS: Attachment of the grafts was complete in 14 of 16 (87.5%), with a partial vulvovaginal dehiscence in 2 cases. Morbidities included secondary infection in 3 (18.8%), partial necrosis in 3 (18.8%), and partial stenosis in 5 (31.6%); the last was significantly associated with a gracilis flap (P = 0.015). There were no statistical differences between neovagina and nonneovagina groups with respect to the rate of fever, small bowel fistula, bowel obstruction, wound infection or dehiscence, hernia, colorectal leak, colostomy or urostomy prolapse, deep vein thrombosis, pulmonary embolism, intraoperative blood transfusions, or hospital stay. There were no pelvic abscesses in the neovagina group compared with 27% (6/29) in the other group (P = 0.050). Surgery was significantly longer (P = 0.019) for the reconstructive surgery group, with no statistical difference between different kinds of flaps. There were no deaths in either group. CONCLUSIONS: Reconstruction of the vagina and pelvic floor at the time of pelvic exenteration can be done safely. Although this increases surgical time, morbidity is not significantly increased. The rectus abdominis flap seems to be the preferable option for primary vaginal and pelvic floor reconstruction.

Adult↗

PubMedDate not supplied

Total pelvic exenteration: results from a multispecialty team approach to complex cancer surgery.

Total pelvic exenteration is often the only curative option for recurrent or locally advanced pelvic cancers, but it carries a high risk of mortality and morbidity. A dedicated multispecialty team operative approach may provide the expertise to perform this uncommon procedure with favorable outcomes. Data were analyzed from a prospectively collected computerized database. There were 14 patients (2 men; mean age, 54.6 +/- 3.6 years) with mainly cervical cancers, of which 71.4% were recurrent. Anesthetic time was 5 +/- 0.9 hours, intraoperative blood loss was 2.1 +/- 0.5 liters, and postoperative hospitalization was 22 +/- 9.9 days. An ileal conduit was performed in all patients, but intestinal continuity was restorable with colonic J-pouch in 71.4% of the patients. There was no mortality at 30 days or during hospitalization. Complication rates were 35.7%, accounting for reoperations in 28.6%. Recurrences were detected in 50% patients at a mean follow-up of 53.1 +/- 9.2 months. The mean time for cancer recurrence was 13.3 +/- 3.3 months. Fifty percent of those patients had otherwise survived to date. We conclude that a dedicated multispecialty team may perform total pelvic exenteration with minimum mortality and acceptable morbidity.

Adult↗

PubMed1997

Pelvic exenteration for locally advanced rectal carcinoma: factors predicting improved survival.

BACKGROUND: The purpose of this retrospective review was to determine whether a number of clinicopathologic factors (age, gender, type of exenteration, tumor extent, adjuvant therapy, tumor DNA ploidy, and S-phase fraction) that could be determined before operation were useful in predicting survival in patients undergoing pelvic exenteration for rectal cancer. METHODS: Between 1983 and 1992, 40 patients (15 male and 25 female) at our institution underwent pelvic exenteration for rectal adenocarcinoma in which tumor-free pathologic margins were obtained. Twenty-nine patients presented with primary tumors; 11 had recurrent disease. A total exenteration was performed in 20 patients, posterior exenteration in 18 patients, and an anterior exenteration in 2 patients. RESULTS: By multivariate (Cox proportional hazards regression) analysis, age, preoperative chemoradiation therapy, and an S phase of 10% or greater were found to be significant predictors of survival. Age older than 55 years was associated with a relative risk for cancer-related death (RR) of 0.13 (p = 0.02), and chemoradiation had an RR of 0.05 (p = 0.01), indicating their beneficial effect. An S-phase fraction of 10% or greater had an RR of 16.97 (p = 0.03), indicating a poor survival. The clinicopathologic factors listed above were used to derive a prognostic index (PI). A PI of less than 1.37 was associated with a 5-year survival rate of 65% (low risk), whereas patients with a PI of 1.37 or greater had a 5-year survival rate of 20% (high risk) (p = 0.005). CONCLUSIONS: These results indicate that adjuvant chemoradiation may significantly improve survival in patients who require pelvic exenteration for resection of locally advanced rectal carcinoma. An S-phase fraction of 10% or greater is also predictive of a poor outcome. Use of these factors allowed the generation of a PI that identifies high- and low-risk patients. Consideration of the ability to deliver chemoradiation and the determinates of the tumor S-phase fraction in patients requiring pelvic exenteration for rectal cancer may be helpful in predicting outcome and planning therapy.

Adenocarcinoma↗

PubMed1997

Pelvic exenteration for cervix cancer: would additional intraoperative interstitial brachytherapy improve survival?

OBJECTIVE: Improved local control with the addition of brachytherapy to pelvic exenteration for recurrent cervical cancer has been reported to improve survival. We examined the sites of recurrence after pelvic exenteration to determine if these patients might have been salvaged by the improved local control promised by interstitial brachytherapy. We sought to identify risk factors available intraoperatively or perioperatively which might predict decreased local control. METHODS: A retrospective review of 26 patients with recurrent cervical cancer who underwent total pelvic exenteration since 1988 at our institution was performed. RESULTS: Overall, the mean follow-up was 29.5 months (range 6.1-81.6). Of the 26 patients, 14 had no evidence of disease (NED), 1 was alive with disease (AWD), 9 were dead of disease (DOD), and 2 died of unrelated causes (DOC). Seven of 26 patients (27%) had margins < or = 5 mm, of whom 2 were NED, 4 DOD, and 1 AWD. Seven of 26 (27%) patients had lymphovascular involvement (LVI) or perineural invasion (PNI) with clear margins. Three of the seven with LVI or PNI and clear margins were NED, and four DOD. Of the 10 failures, 9 (90%) had close margins, PNI, or LVI. CONCLUSION: Our data reveal that 9 of 14 (64%) patients with close margins, LVI, or PNI were DOD or AWD, and 6 of 9 of those patients suffered local regional failure alone. Brachytherapy has the potential to cure 6 of 14 (43%) patients with these risk factors. Further study of brachytherapy at the time of pelvic extenteration is warranted.

Adult↗

PubMed1987

[Pelvic exenteration in advanced and or recurrent rectal cancer].

Operative procedures of pelvic exenteration which were performed on a 54 yrs male patient with irradiated rectal cancer involving the prostatic gland, perineal skin and gluteal muscles were demonstrated by cinema. Perianal fistula formation and hard fibrotic adhesion between the distal rectum and the sacrum were also seen. As a result, combined resection of the perianal skin, gluteal muscles and distal sacral bone (fourth and fifth sacral and coccygeal vertebrae) was carried out. Fifty four total pelvic exenteration were performed at National Cancer Center Hospital from 1962 to 1985. The procedures were performed as a definitive treatment for the primary tumors in 35 cases (31 males and 4 females) which corresponds to 2.7% of operated primary rectal cancer at the same period and for the locally recurrent cancer in 19 cases (13 males and 6 females). By post operative histopathological examination 35 operations, 28 of 35 primary and 7 of 19 recurrent cases, were assessed as potentially curative. Hospital death rate was 13%; i.e. 7 cases (1 of 35 primary and 6 of 19 recurrent cases). Postoperative survival rates of the 54 patients were calculated by Kaplan-Meier's method. There were 17 survivors among 35 curatively operated patients and 5 yr survival rate was 34%. On the other hand, though 6 patients are surviving, there is no long term survivor (more than 35 months) among 21 patients who were treated by palliative resection.

Female↗

PubMed2003

Outcome of total pelvic exenteration for primary rectal cancer.

PURPOSE: This retrospective study identifies the clinicopathologic factors (age, gender, size of tumor, location, tumor stage, lymph node metastasis, histologic differentiation, and adjuvant therapies) that are useful in predicting long-term survival in patients undergoing total pelvic exenteration for advanced primary rectal cancer. METHODS: We reviewed the medical records of 71 patients with stage T3 or T4 primary rectal cancer who underwent a curative total pelvic exenteration. The effects of various clinical variables on long-term survival were analyzed. RESULTS: The postoperative mortality, hospital death, and morbidity rates were 1.4, 4.2, and 66.2 percent, respectively. The overall five-year survival rate after total pelvic exenteration was 54.1 percent. The five-year survival rate was 65.7 percent for patients with T3 lesions and 39 percent for patients with T4 lesions. A univariate analysis showed that postoperative survival was affected by age, tumor stage, and lymph node metastasis, while a multivariate analysis showed that age and lymph node metastasis were independent prognostic factors. CONCLUSION: Total pelvic exenteration may enable long-term survival in younger patients with stage T3 or T4 primary rectal cancer and little or no lymph node metastasis.

Adenocarcinoma↗

PubMed2004

Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis.

PURPOSE: This study evaluates the effectiveness of total pelvic exenteration with distal sacrectomy for fixed recurrent tumor that developed from primary rectal cancer. METHODS: We investigated surgical indications, techniques to minimize blood loss and reduce complications, and oncological outcomes in 57 patients who underwent total pelvic exenteration with distal sacrectomy between 1983 and 2001. RESULTS: Forty-eight patients (84 percent) had negative margins. A comparison between two periods (1983-1992 and 1993-2001) showed that mean blood loss decreased from 4,229 to 2,500 ml (P = 0.002), indicating a favorable learning curve in minimizing blood loss. Two hospital deaths were observed in the earlier period and none in the later period. The most common sacral amputation level was the S3 superior margin, followed by the S4 inferior margin and the S2 inferior margin. The most frequent complication was sacral wound dehiscence in 51 percent, followed by pelvic sepsis in 39 percent. The incidence of pelvic sepsis in the later period was significantly decreased to 23 percent, compared with 72 percent in the earlier period (P = 0.046). Multivariate analysis showed that negative margins and negative carcinoembryonic antigen predicted improved survival. In 48 patients with negative margins, three-year and five-year disease-specific survival rates were 62 percent and 42 percent, respectively. CONCLUSION: Strict patient selection makes total pelvic exenteration with distal sacrectomy a feasible radical approach for fixed recurrent tumor. Careful performance of this surgical procedure along with the proper steps to decrease blood loss should achieve a favorable learning curve and low rate of surgical complications.

Adult↗

PubMed2001

[Pelvic exenteration in the treatment of locally advanced tumors of surgical, gynaecological and urological origin].

Pelvic exenteration is a radical extirpative procedure designed to treat pelvic malignancy that has invaded more than one of the hollow organs of the gastrointestinal or genitourinary tracts. The operation comprises several radical procedures: resection of the rectum, hysterectomy (with adnexectomy) with partial or complete vaginectomy, pelvic lymphadenectomy and total (or partial) cystectomy with diversion of the urinary tract. The retrospective analysis of our results in 27 patients treated in the years 1995 to 2000 by means of pelvic exenteration showed a 7.4 % hospital mortality and 59.3 % morbidity rate. The recurrence and survival rates were adequate. This surprisingly favourable outcome in our patients should encourage Czech surgeons to perform this difficult procedures more often.

Colorectal Neoplasms↗

PubMed1990

Pelvic exenteration with low rectal anastomosis: survival, complications, and prognostic factors.

Between July 1979 and January 1989 there were 31 patients who underwent pelvic exenteration with low rectal anastomosis (PE and LRA) at the University of Alabama at Birmingham (UAB). There were no operative deaths; however, 32% of the patients experienced significant postoperative morbidity. Survival (Kaplan-Meier) at 1 year is 86%. Overall survival is 68% with follow-up ranging from 10 months to greater than 9 years. For those patients with disease confined to the cervix and/or vagina (n = 18) the survival is 89% while it is 38% for patients with spread to the bladder, rectum, or parametrium (n = 13). Survival was not influenced by tumor differentiation, time from irradiation to exenteration, or initial stage. Complete healing of the LRA was achieved in 16 patients (52%). However, in the subset of patients with an omental wrap (n = 13) the complete healing rate is 85%. Protective colostomies were utilized in 12 patients; however, this was not shown to improve the healing rate of the LRA. This group of patients is compared to similar patients who had anterior pelvic exenteration at UAB for morbidity and survival. LRA at the time of pelvic exenteration for recurrent cervical cancer is associated with acceptable morbidity and survival and should be attempted in those patients who are appropriate candidates.

Adult↗

PubMed1985

Pelvic exenteration for advanced primary and recurrent adenocarcinoma.

The authors report on 45 patients who have undergone pelvic exenteration for adenocarcinoma since 1979. Three patients underwent exenteration as the initial treatment for their disease but all others had had previous surgery, radiotherapy or chemotherapy. Operating time and blood loss were lower in previously irradiated patients. There were seven in hospital deaths (15.5%). The number of complications and length of postoperative hospital stay have decreased significantly as experience with pelvic exenteration has been acquired. Symptoms have been controlled in a high proportion of patients. Exenterative surgery is an effective method of treatment in selected patients with pelvic adenocarcinoma but should be undertaken only by experienced surgeons who have access to a wide range of supportive facilities for optimal perioperative management.

Adenocarcinoma↗

PubMed2006

Pelvic exenteration for recurrent or persistent cervical cancer: experience of five years at the National Cancer Institute in Mexico.

Cervical cancer constitutes a major health problem in Mexico and other developing countries. The purpose of our study was to assess the experience of a comprehensive national oncological reference center on pelvic exenteration for post-radiotherapy recurrent or persistent cervical cancer, describing the prognostic value of time to recurrence, procedure complications, and survival. Medical records from 42 patients with post-radiotherapy recurrent or persistent cervical cancer who underwent a pelvic exenteration with curative purposes from 1984 to 1989 were retrospectively reviewed. Histological diagnoses were squamous cell carcinoma (32 patients), adenosquamous carcinoma (9 patients), and adenocarcinoma (1 patient). Average follow up was of 56.3 mo after the procedure and global survival at 5 yr was 65.8%. Survival for patients with early recurrence was 56.9% vs 78% for patients with late recurrence (p = 0.05). Complications were observed in 65.3% of the cases with a surgical mortality of 4.8%. Pelvic exenteration is a surgical procedure with high morbidity in spite of the recent medical advances. Pelvic exenteration should not be indicated with palliative purposes owing to the high rate of complications. Patients with tumor persistence or early recurrence have a worse prognosis. In well-selected cases, exenteration may provide a survival benefit.

Adenocarcinoma↗

PubMed1982

Urinary diversion in patients undergoing pelvic exenteration.

Between October, 1969, and April, 1981, gynecologic oncologists at the University of Alabama Medical Center in Birmingham have performed 119 pelvic exenterations. One hundred fifteen of these patients had a concurrent supravesical urinary diversion. Fifty-six patients (48.7%) had an anterior exenteration and 59 patients (51.3%) had a total exenteration. An ileal segment was used as a conduit in 97 patients while the segment of transverse colon was used in 16 patients. Two patients had sigmoid conduits. Eighty-five patients (73.9%) had the intestinal anastomosis and conduit constructed with gastrointestinal staplers. Stapler use shortened the mean operating time for the exenterative procedure by approximately 30%. No increase in postoperative gastrointestinal complications was noted. Urinary diversion preformed as part of a pelvic exenteration has been associated with short- and long-term complications. The use of ureteral stents and the gastrointestinal staplers shortens the procedure without predisposing the patient to major urologic complications. The use of a segment of unirradiated bowel (transverse colon) in conjunction with these techniques constitutes the preferred method of supravesical urinary diversion in patients undergoing a pelvic exenteration.

Colon↗

PubMed2005

Laparoscopy-assisted vaginal pelvic exenteration.

OBJECTIVE: The aim of this study was to evaluate the feasibility, morbidity and survival outcome of laparoscopy-assisted vaginal pelvic exenteration. METHODS: Since 2000, we have performed 5 cases of en-bloc pelvic exenteration combining a vaginal or perineal approach and laparoscopic approach. All patients had received previous pelvic irradiation. One patient underwent a total type II exenteration with ileal-loop diversion, an omental flap and a temporary colostomy. Two patients underwent a middle and posterior exenteration: one was a type III exenteration with perineal rectal resection and a gracilis myocutaneous flap; the second one was a type II exenteration with a colorectal anastomosis and a vaginal reconstruction using a gluteal thigh flap. Two patients underwent a type I anterior and middle exenteration with continent Miami pouch and vaginal reconstruction by omental cylinder. RESULTS: Mean time of the procedure was 6 h (range: 4.5-9). Peroperative bleeding was less than 500 cm3. Two patients presented minor complications: a perineal abscess after perineal rectal resection and an abdominal wound abscess. Mean length of hospital stay was 27 days. Three patients are free of disease. Two patients presented groin metastasis. One patient died of disease after 8 months. CONCLUSION: Laparoscopic or laparoscopy-assisted vaginal pelvic exenteration followed by reconstruction is feasible with curative intent in selected patients.

Adult↗

PubMed1994

Pelvic exenteration for recurrent colorectal carcinoma: a review.

Pelvic recurrence following curative resection for colorectal carcinoma continues to pose a challenge to the oncologist despite current multimodality therapy. Pelvic exenteration with or without sacral resection may provide long-term disease-free survival and a chance of cure for a small subset of patients in whom the recurrent disease is confined to the pelvis and can be resected with "clear" margins. For others with residual disease, exenteration may offer good palliation for the intractable symptoms, but no survival advantage. The clinical decision to perform exenteration with palliative intent must be individualized. This is generally not advised because of the short life expectancy in the face of prolonged convalescence. This technically demanding procedure is associated with significant morbidity, especially in patients with prior pelvic radiation. Current advances in urinary diversion and methods of pelvic reconstruction may significantly reduce these problems. The surgeon's experience and careful patient selection remain the most important determinants of success with this operation.

Adult↗

PubMed2003

Total pelvic exenteration: effective palliation of perineal pain in patients with locally recurrent prostate cancer.

PURPOSE: Locally recurrent prostate cancer can be a debilitating disease. Perineal pain associated with rectal involvement by prostate cancer is difficult to palliate by conventional methods. We describe a group of patients who had intractable perineal pain due to locally recurrent prostate cancer and underwent total pelvic exenteration for palliation. MATERIALS AND METHODS: We retrospectively reviewed the data for men who underwent total pelvic exenteration with urinary and colonic diversion at our institution between October 1995 and October 2002 for the relief of perineal pain from prostate cancer. Patients were selected for consideration for surgical extirpation on the basis of the presence of biopsy proven recurrent prostate cancer and evidence of rectal invasion on sonography. All patients received radiation therapy and hormonal therapy and had intractable perineal or pelvic pain resistant to narcotics. RESULTS: A total of 14 men underwent total pelvic exenteration for palliation during the 7-year period evaluated. There were no perioperative deaths. There were 7 postoperative events, including pulmonary embolus in 2 patients, and ileus, wound infection, cholecystitis, stomal stenosis and pelvic abscess in 1 patient each. After exenteration all patients had significant relief of pain and 11 (79%) had complete relief of pain symptoms. For these 11 patients the average symptom-free period was 14.1 months (range 3 to 36). Seven patients eventually died of disease, with the median period from exenteration to death being 24 months. CONCLUSIONS: Total pelvic exenteration is effective therapy for palliation of perineal pain associated with locally recurrent prostate cancer and can also effectively palliate other local symptoms such as hematuria, ureteral obstruction, voiding dysfunction and rectal incontinence. This procedure can be performed with acceptable morbidity in a highly select group of patients.

Aged↗

PubMed1980

[Pelvic exenteration for carcinoma of the uterine cervix (author's transl)].

From 1953 to 1972, 149 patients at Centre Leon Bérard, were treated by pelvic exenteration for carcinoma of the cervix. A review of the literature and of our cases showed that the mortality rate varied between 12 and 38 per cent according to the authors. In our experience, the final cause of death has been essentially pelvic reccurences within 18 months of the operation. For Ketcham, the patients died principally from metastases. To illustrate these results, criteria for patient selection for pelvic exenteration are outlined, with some suggestions for operative and post-operative management. The pre-operative medical status, the roentgenographic studies and finally exploratory laparotomy eliminated all but a very small number of patients, 15 to 20 per cent. Pelvic exenteration is appreciably beneficial only for this small group. Indeed, the exenteration is acceptable only when it does not result in excessive mutilation disproportinate with the chances of survival. It is conceivable only as curative treatment requiring a radical loco-regional excision, not only for the involved viscerae but also for the pelvic lymph nodes.

Adult↗

PubMed2005

Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA.

OBJECTIVE: To retrospectively assess the outcome of patients undergoing pelvic exenteration for recurrent or persistence gynecologic malignancy and the clinical features associated with outcome and survival. METHODS: A review was conducted of patients who underwent pelvic exenteration over a 45-year period (1956-2001) at the UCLA Medical Center. Numerous clinical variables were analyzed, including time to relapse, type of exenteration and reconstructive operation, early (<60 days) and late (>60 days) morbidity, and survival. Variables were analyzed by chi-square and life-table analysis. RESULTS: Seventy-five patients (ages 26-74 years) had persistent cervical and vaginal (67) and uterine (8) cancer. Forty-six patients underwent total exenteration, 23 anterior, and 6 posterior. Sixty-nine (92%) patients underwent urinary diversion or neocystoplasty, 54 (72%) patients had a simultaneous neovagina created, and 43 of 52 (83%) patients who had a low colon resection had a primary reanastomosis. Twenty-nine patients died from recurrent malignancy, 28 were alive without disease, 11 were alive with disease, and 7 died from other causes at last follow-up. Survival for patients with cervical and vaginal cancer was 73% at 1 year, 57% at 3 years, and 54% at 5 years. Survival for patients with uterine cancer was 86% at 1 year, 62% at 3 and 5 years. The most frequent early morbidity was urinary tract infection, wound infection, and intestinal fistula; the most frequent late morbidity was urinary tract infection and intestinal obstruction. CONCLUSION: Pelvic exenteration in patients with recurrent cervical and vaginal malignancy is associated with a durable > 50% 5-year survival. Simultaneously performed pelvic reconstructive operations with a continent urinary diversion, the creation of a neovagina, and the reanastomosis of the colon with the formation of a J-pouch is now our standard; and these operations tend to improve the outcome of patients. Based on our initial experience, recurrent uterine corpus cancer in young women (< 55 years) should be included as an indication for the surgery.

Adult↗

PubMed2003

Laparoscopic total pelvic exenteration for cervical cancer relapse.

BACKGROUND: Laparoscopy classically reduces morbidity and invasiveness. To decrease the operative morbidity associated with exenteration, we considered the possibility of performing a total pelvic exenteration by the laparoscopic approach. CASE: A 34-year-old woman presented with a cervical cancer relapse. The bladder, uterus, vagina, ovaries, and rectum were mobilized en bloc from the pelvic sidewall. We used vascular endoscopic staplers for the control of sigmoid vessels and anterior branches of internal iliac vessels. The specimen was removed through the vulva. A colo-anal anastomosis and an ileal-loop conduit for urinary tract diversion were made. The operative time was 9 h. The postoperative course was uneventful. Specimen margins were free of disease. CONCLUSION: With laparoscopic surgical knowledge and new endoscopic staplers, laparoscopic pelvic exenteration procedure is feasible.

Adult↗