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PubMed1994

Continent urinary diversion (Gotsadze Pouch) after pelvic exenteration for gynaecological malignancies.

The problem of urinary diversion is of major importance in patients requiring pelvic exenteration for advanced gynaecological malignancies. Eight patients underwent pelvic exenteration (4-total and 4-anterior) at the Georgian Oncologic Centre, 7 of them for recurrent cervical carcinoma after combined treatment and 1--for primary advanced cervical carcinoma. The original surgical technique for construction of detubalarized ileal reservoir with continent umbilical stoma (Gotsadze Pouch) is described. Six patients underwent this type of urinary diversion with successful results. Urination is patient-controlled via self-catheterization every 5 to 6 hours. The results obtained by operation can be considered as optimal for their functional and rehabilitational properties.

Adult↗
PubMed2001

Ileal neobladder for urinary bladder replacement following total pelvic exenteration for rectal carcinoma.

OBJECTIVE: The aim of this study was to determine the feasibility of using the ileal neobladder as a substitute for the urinary bladder following total pelvic exenteration for rectal carcinoma. PATIENTS AND METHODS: Between 1992 and 1998, we performed total pelvic exenteration with ileal neobladder in 5 men with rectal carcinoma. Four patients had primary tumors, and one had recurrent disease after low anterior resection for rectal carcinoma. Histological types were adenocarcinoma in 4 and squamous cell carcinoma in 1. Invaded organs were: the urinary bladder in 1, the urinary bladder and prostate in 2, the prostate and seminal vesicle in 1, and the prostate in 1. RESULTS: There was no operative death. In 1 patient, an ileal conduit was needed because of partial necrosis of the neobladder. Minor leakage on the dorsal wall of the neobladder occurred in 2 patients, which was successfully stopped with simple closure and a gluteus maximus fasciocutaneous flap, respectively. All except one patient with the ileal conduit could void via the urethra. Complete daytime urinary continence was achieved, but nocturnal continence was maintained with voiding once or twice per night. As the urodynamic state, the mean maximum flow rate was 20.9 ml/s (range 9.0-34.1), the mean average flow rate was 7.7 ml/s (range 3.0-11.0), and the mean voided volume was 285.5 ml (range 160-432). The mean length of follow-up was 47.8 months. One patient died of local recurrence 38 months postoperatively, and 1 died of pneumonia 10 months postoperatively. Both patients could void via the urethra until death. The other three patients are currently alive without any evidence of recurrence. CONCLUSIONS: Although total pelvic exenteration is a laborious surgical procedure, an ileal neobladder could be a good alternative to the urinary bladder enabling the patients to void via the urethra with urinary continence.

Adenocarcinoma↗
PubMed1995

Continent urinary reservoir using sigmoid colon and appendix after pelvic exenteration for bulky leiomyosarcoma: a case report.

We report on a man with bulky leiomyosarcoma occupying the entire pelvic cavity that was treated by pelvic exenteration. A urinary reservoir was constructed using a detubularized segment of sigmoid colon. The appendix was tunneled into the taenia to form a continent catheterizable stoma using the Mitrofanoff principle. Descending colostomy was also created. There is no evidence of recurrence 24 months after treatment and the patient has returned to full physical activity. Continence is complete with a capacity of up to 500 ml. and regular bowel movements. Because of the lack of intestinal anastomosis, this procedure may be recommended as an option for urinary diversion after pelvic exenteration.

Appendix↗
PubMed2001

Total pelvic exenteration for primary local advanced colorectal cancer.

Total pelvic exenteration (TPE) is an ultraradical operative procedure for locally advanced pelvic tumors with high morbidity and mortality rates. We retrospectively reviewed the results of TPE for primary locally advanced colorectal cancer in terms of mortality, morbidity, and long-term survival. Of 2952 patients with colorectal cancer, 50 underwent TPE for primary locally advanced colorectal cancer between 1986 and 1995. There was one operative death (2%). The other 49 cases were entered into a retrospective study. Thirty-two cases (65%) showed involvement of one or more adjacent organs. Thirty-one patients (97%) had urologic organs invaded by tumor. The overall 5-year survival rate was 49% and the overall morbidity was 37%. The survival rate for stage II was 62%, and that for stage III was 35%; there was no survival in stage IV. Early morbidity was noted in 24% of patients; late morbidity, in 15%. TNM stage appeared to be the only independent factor for survival (p = 0.022). Our study showed that TPE can be performed with relatively low operative mortality and acceptable morbidity. With thorough preoperative evaluation and adequate surgical dissection, satisfactory outcomes for a primary locally advanced colorectal cancer can be achieved, especially at the earlier stages.

Adenocarcinoma↗
PubMed1995

Pelvic exenteration for primary and recurrent vulvar cancer.

Twenty-one patients who underwent pelvic exenteration for primary (n = 8) or recurrent (n = 13) vulvar malignancy at the M. D. Anderson Cancer Center between 1956 and 1989 were evaluated. A posterior exenteration was performed in 12 patients, anterior exenteration was performed in 6, and total exenteration was performed in 3. In patients with primary tumors, radical vulvectomy and inguinal lymphadenectomy were also performed. The median patient age was 57 years. The mean tumor diameters were 5 cm (primary) and 4 cm (recurrent). Infections were the most frequent postoperative complications (n = 15), followed by pulmonary (n = 4) and cardiac problems (n = 3). There were no treatment-related deaths. Five patients required further surgery to correct late postoperative sequelae. Four of eight patients experienced recurrence after treatment of their primary tumor; the recurrences were local only (n = 1), in the inguinal area (n = 2), or local and in the pelvis (n = 1). Nine of the 13 patients treated for recurrent tumors developed a second recurrence; the second recurrences were all within the pelvis, although two also had a distant component. The 5-year survival rates were 70% for patients treated for primary disease and 38% for patients treated for recurrent disease. Pelvic exenteration is indicated for selected patients with advanced vulvar malignancy.

Adult↗
PubMed1990

Total pelvic exenteration with simultaneous bowel and urinary reconstruction.

The technique of total pelvic exenteration with simultaneous bowel and urinary reconstruction is described as a surgical option for the management of pelvic sarcoma in adults and for highly selected patients with other types of advanced pelvic malignancy. The surgical technique is presented in detail as performed in a 43-year-old man who presented with extensive primitive pelvic sarcoma. We believe that this approach may provide the benefits of an exenterative operation without the undesirable psychosocial sequelae of a permanent colostomy and external urinary diversion.

Adult↗
PubMed1996

Total pelvic exenteration for locally advanced colorectal carcinoma.

Twenty-six patients who underwent total pelvic exenteration for locally advanced colorectal cancer were studied retrospectively. The operative mortality rate was 8 per cent (two deaths). In patients with stage II primary disease the recurrence rate after curative surgery was three of seven, although the mean survival time was 58 months and the 5-year survival rate 71 per cent. Patients with stage III primary disease had a shorter mean survival time regardless of supposed curability (curative 14 months versus non-curative 9 months). Patients with stage IV disease had a mean survival time of 5 months. In patients who underwent curative surgery for recurrent disease the mean survival time was 33 months and 5-year survival rate 25 per cent, although in those receiving non-curative surgery the survival time was significantly shorter at 10 months (P < 0.05). Total pelvic exenteration is warranted for patients with stage II locally advanced colorectal carcinoma and is an option for those with recurrent carcinoma when performed with curvative intent.

Adenocarcinoma↗
PubMed2001

Choices in creating continent urostomies following pelvic exenteration for gynecologic malignancies.

OBJECTIVE: The purpose of this report was to describe a rationale for choosing from a variety of techniques to construct continent urinary diversions for patients who undergo pelvic exenterations. Moreover, this report evaluated the technique and utility of a continent urostomy created from a supracecal segment of colon. METHODS: The charts from patients who underwent pelvic exenterations and urinary diversions by DFS between September 1999 and December 2000 were reviewed after institutional review board approval. Data were recorded and evaluated. RESULTS: Four patients underwent total pelvic exenterations and one received an anterior exenteration. Recurrent vulvar, vaginal, and cervical cancers were diagnosed in one, one, and two of the patients. One patient had an unknown primary squamous cell carcinoma in the pelvis. Four of the five received prior pelvic radiotherapy either in the neoadjuvant setting or as treatment for their primary disease. All five patients chose to have continent urostomies constructed. One Kock (ileal) pouch, one Miami (iliocolonic) pouch, and three supracecal colonic continent urostomies (SCCCU) were built. All five maintained continence over the follow-up period (mean follow-up time = 8.2 months). No complications related to the urostomies required reoperation. A new technique to for the construction of a SCCCU is described. CONCLUSION: With a variety of procedures established to build continent urostomies, the choice of which to use should be individualized to the patient's situation as well as to the surgeon's experience. The use of a SCCCU requires moderately complex manipulations of the colon (described in the text) and a slight increase in the operative time; however, it results in successful continence and avoids complications related to radiation-injured bowel. It may be considered the procedure of choice for patients who have received prior radiation therapy. Long-term follow-up is needed.

Adult↗
PubMed2004

Pelvic exenteration and sphincter preservation: an analysis of 96 cases.

BACKGROUND: Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results. METHODS: Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed. RESULTS: Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival. CONCLUSIONS: The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.

Adolescent↗
PubMed1998

Pelvic exenteration for advanced primary rectal cancer in male patients.

Between November 1987 and January 1996 pelvic exenteration for primary rectal cancer was carried out in 11 male patients. Two underwent a primary resection with subtotal cystectomy. In the remaining nine patients, the treatment commenced with a staging laparotomy and the fashioning of an end colostomy of the descending colon, followed by preoperative radiotherapy (50-56 Gy in 5 weeks). Total exenteration with uretero-ileo-cutaneostomy was carried out 4-6 weeks later. In two patients, the exenteration was performed despite the detection of hepatic metastases during the second laparotomy. The pathological staging was T4 in six and T3 in five patients. The immediate postoperative course was uneventful in eight patients and their hospital stay averaged 20 days. Serious postoperative complications prolonged the hospital stay of three patients. Three died during the first 6 months. Recurrent disease caused the death of three of the eight remaining patients: one locoregional (7.5 years after surgery), one from pre-existing hepatic metastases (18 months after surgery) and one from the combination of locoregional and distant recurrence (15 months after surgery). Four patients are on follow-up without evidence of disease, 96, 43, 23 and 22 months after surgery. One patient is alive 20 months after exenteration, with two pulmonary metastases having been recently excised. We conclude that, notwithstanding the morbidity rate, total pelvic exenteration is an acceptable option for advanced primary rectal cancer in male patients. Preoperative radiotherapy should be administered for cancers seated in the lower two-thirds of the rectum and perioperative chemotherapy should be considered seriously.

Adult↗
PubMed2000

[Prolapse of neovagina after anterior pelvic exenteration for urethral cancer].

The authors report the case of a patient undergoing anterior pelvic exenteration for cancer of the urethra with sigmoid colon urinary diversion and vaginal reconstruction using a colonic segment. The postoperative course was marked by prolapse of the neovagina requiring reoperation via a transvaginal approach. The modalities of this prolapse repair are described and the various possibilities for urinary diversion and vaginal reconstruction after pelvic exenteration in women are then discussed.

Female↗
PubMed1981

Intestinal fistula and obstruction following pelvic exenteration.

Intestinal fistulas and obstruction are the most common and most serious complication of pelvic exenteration for gynecologic cancer. In a series of 58 patients, early intestinal fistulas developed in seven and late fistulas in 13 of the patients. Early fistulas are more commonly secondary to surgical trauma or technical errors and were noted to occur more frequently in patients who had previously undergone irradiation. Late fistulas are usually associated with intestinal obstruction and with a high incidence of recurrent malignant growth. The management of choice for intestinal fistulas following pelvic exenteration appears to be prompt surgical intervention with bypass procedures in preference to intestinal resections. Although several technical modifications have been applied to the exenterative operation with a trend toward a decrease in early obstruction and fistula formation rate, additional technical efforts will be necessary if these problems are to be solved.

Adult↗
PubMedDate not supplied

Outcome of total pelvic exenteration for locally recurrent rectal cancer.

BACKGROUND/AIMS: Local recurrence occurs in 10 to 30% of patients with rectal cancer following curative resection. However treatment of choice remains controversial. We assessed the results of total pelvic exenteration for locally recurrent cancer of the rectum retrospectively. METHODOLOGY: We reviewed medical charts of 45 patients with rectal cancer who underwent curative total pelvic exenteration for local recurrence. The cause of recurrence was classified into four groups: anastomotic, surgical cut-end, implantation, and lymphatic based on pathologic findings and computed tomography. Long-term survival was correlated with clinicopathologic variables. RESULTS: Postoperative morbidity was 77.8% and in-hospital death occurred in 13.3% of patients. The overall 5-year survival rate was 14.1%. The 5-year survival rates stratified according to the expectation of curability were 31.6% for absolutely curative resection, 7.8% for relatively curative resection, and 0% for non-curative resection. Multivariate analysis revealed that the disease-free interval was the only independent prognostic factor. There was no benefit from perioperative radiation or intraoperative continuous pelvic peritoneal perfusion of the pelvis. CONCLUSIONS: Total pelvic exenteration for local recurrence of rectal cancer can achieve long-term survival when curative resection is possible and the disease-free interval is long.

Adenocarcinoma↗
PubMed2004

Major complications of urinary diversion after pelvic exenteration for gynecologic malignancies: a 23-year mono-institutional experience in 124 patients.

OBJECTIVE: The objective of this study was to analyze the postoperative outcome of patients undergoing urinary diversion at the time of pelvic exenteration. METHODS: Between January 1980 and December 2002, 232 pelvic exenterations for gynecologic malignancies were performed in our hospital. One hundred and twenty-four included a urinary diversion. There were locally advanced or recurrent cancers including 101 cervical, 11 endometrial, 5 vagina, 2 ovarian malignancies and 5 pelvic sarcoma. RESULTS: Ninety patients (72.5%) had a history of previous irradiation. Exenterations were 69 anterior and 55 total. Urinary diversion included 14 bilateral ureterostomies, 62 trans-intestinal diversion and 48 continent diversion using distal ileum and right colon. Pelvic filling was performed in 56 patients (45%). Low colorectal anastomosis was performed in 42 of 48 supralevator pelvic exenteration (87.5%). Postoperative mortality rate was 8% (10/124). Overall 12-week postoperative morbidity rate was 52% (65/124) and appears to be significantly higher in irradiated patients and after total exenteration. In trans-intestinal noncontinent group, eight patients were reoperated for a complication directly related to urinary diversion procedure. No reoperation for such a complication was performed in the continent urinary diversion group. CONCLUSIONS: Ileocolic continent pouch seems to be the safer urinary diversion procedure after exenteration for gynecological malignancies especially in irradiated patients and after total exenteration.

Adult↗
PubMed1985

Pelvic exenteration--Medical College of Georgia experience.

Between 1959 and 1983, 42 pelvic exenterations were performed. The early experience shows a rather high surgical mortality; 7 out of the first 10 cases. This has been improved with experience and better pre- and postoperative care. There has been no postoperative mortality in the last 20 patients. The combined published reports show an operative mortality of 15-17%.

Female↗
PubMed1999

[Repair of vagina with segment of vascularized ileal graft following pelvic exenteration for carcinoma of rectum].

OBJECTIVE: To introduce a method to repair the vagina following pelvic exenteration for carcinoma of rectum in which the posterior wall of the vagina and cervix of the uterus were often involved. METHODS: From 1990 to 1997 segment of the vascularized ileum was used to repair the vagina in 5 cases, and in 2 of which the whole vagina was repaired while in the other 3 cases only the posterior wall of the vagina was repaired. RESULTS: All of the patients had successful results after operation repair. CONCLUSION: Vascularized graft was an ideal material for the repair of vagina defect following pelvic exenteration for carcinoma of rectum, because this material was easily accessible, and its vascular pedicle was long enough for its transferring to the perineal region and the ileum had good blood supply which made healing easy. The vagina following repair had a thick posterior wall, good elasticity and very little scar tissue surrounded.

Adult↗
PubMed1993

Pelvic exenteration: a treatment for failed rectal cancer surgery.

Local-regional recurrences of the pelvis occur as an isolated event in 4 to 24 per cent of rectal cancer patients. While radiation therapy may provide temporary relief of pain due to recurrence, only a salvage pelvic exenteration offers hope of cure in these patients. We identified and reviewed 16 rectal cancer cases with local-regional recurrence who underwent salvage pelvic exenteration for cure. There were eight men and eight women. The primary cancer was treated by AP resection (3), low anterior resection (6), Hartman's resection (6), or local excision (1). Tumor at primary resection was Stage I for two patients, II for five patients, and nine patients were Stage III. Adjuvant radiation had been given to nine patients. The type of exenteration required for curative resection was anterior (3), posterior (6), total (4), or total-sacral (3). One patient died postoperatively. Survival calculations were from time of salvage exenteration until death or last follow-up. Only six deaths have occurred with a 5-year survival of 49 per cent. Mean survival for the total group was 31 months. Salvage pelvic exenteration should be given high priority in managing local-regional recurrences of the pelvis and provides worthwhile survival.

Adult↗