Pelvic exenteration and sphincter preservation: An analysis of 96 cases

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer

BACKGROUND AND OBJECTIVES

The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE.

METHODS

A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used.

RESULTS

Most conducts and management strategies reviewed were strongly recommended by the participants.

CONCLUSIONS

Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

Survival After Pelvic Exenteration for Cervical Cancer: A National Cancer Database Study

OBJECTIVE

To determine overall survival (OS) and factors associated with OS after pelvic exenteration for cervical cancer.

METHODS

Women with cervical cancer who underwent exenteration (n = 517) were identified from the 1998 to 2011 National Cancer Database. Kaplan-Meier and multivariate Cox proportional-hazards survival analyses were performed to test for associations of potential explanatory variables with OS. Analyzed confounders included age, insurance status, income, distance from home to treatment center, stage, exenteration type, surgical margin status, and treatment with adjuvant radiation and/or chemotherapy.

RESULTS

Among the entire cohort with clinical follow-up (n = 313), median OS was 24 months. Stage (P = 2.5 × 10), lymph node status (P = 1.3 × 10), insurance status (P = 1.5 × 10), and histologic type (P = 0.04) were significantly associated with OS by the log-rank test. Unadjusted median OS was 24.2 and 61.8 months for women with squamous and adenocarcinoma histologies, respectively. By multivariate Cox regression, age, insurance status, stage, margin status, and adjuvant radiation were associated with OS. Histology was not independently associated with OS on multivariate regression. Among women with node-negative disease, median OS was 73.2 months.

CONCLUSIONS

Exenteration may be curative for more than half of women with node-negative cervical cancer. Stage, insurance status, lymph node status, and surgical margin are independently associated with differential OS after exenteration.

Extended pelvic resections for the treatment of locally advanced and recurrent anal canal and colorectal cancer: technical aspects and morbimortality predictors aftet 24 consecutive cases

OBJECTIVE

to evaluate the profile of morbidity and mortality and its predictors related to extensive pelvic resections, including pelvic exenteration, to optimize the selection of patients and achieve better surgical results.

METHODS

we performed 24 major resections for anorectal pelvic malignancy from 2008 to 2015 in the Instituto do Câncer do Ceará. The factors analyzed included age, weight loss, resected organs, total versus posterior exenteration, angiolymphatic and perineural invasion, lymph node metastasis and overall and disease-free survival.

RESULTS

the median age was 57 years and the mean follow-up was ten months. Overall morbidity was 45.8%, with five (20.8%) serious complications. There were no deaths in the first 30 postoperative days. The median overall survival was 39.5 months, and disease-free survival, 30.7 months. Concomitant resection of the bladder was an isolated prognostic factor for higher risk of complications (87.5% vs. 26.7%, p = 0.009). Angiolymphatic invasion and lymph node metastasis did not reach significance with respect to disease-free survival.

CONCLUSION

treatment of advanced anorectal tumors is challenging, often requiring combined resections, such as cystectomy and sacrectomy, and complex reconstructions. The magnitude of the operation still carries a high morbidity rate, but is a procedure considered safe and feasible, with a low mortality and adequate locoregional tumor control when performed in referral centers.

OBJETIVOS

avaliar o perfil de morbimortalidade e seus fatores preditivos relacionados às ressecções pélvicas extensas, incluindo a exenteração pélvica, com o intuito de otimizar a seleção dos pacientes e obtenção de melhores resultados cirúrgicos.

MÉTODOS

foram realizadas 24 grandes ressecções pélvicas por neoplasia maligna anorretal de 2008 a 2015 no Instituto do Câncer do Ceará. Os fatores analisados incluíram idade, perda de peso, órgão ressecados, exenteração total versus posterior, invasão angiolinfática e perineural, metástase linfonodal e sobrevida global e livre de doença.

RESULTADOS

a mediana de idade foi 57 anos e o tempo médio de seguimento foi dez meses. A morbidade global foi 45,8%, com cinco (20,8%) complicações graves. Não houve óbito nos primeiros 30 dias de pós-operatório. A sobrevida global média foi 39,5 meses e a sobrevida livre de doença foi 30,7 meses. A ressecção concomitante da bexiga foi fator prognóstico isolado com maior risco para complicações (87,5% vs. 26,7%, p=0.009). Invasão angiolinfática e metástase linfonodal não alcançaram significância com relação à sobrevida livre de doença.

CONCLUSÃO

o tratamento dos tumores anorretais avançados é desafiador, necessitando frequentemente de ressecções combinadas, como a cistectomia e sacrectomia, além de reconstruções complexas. A magnitude da cirurgia ainda carrega uma elevada taxa de morbidade, porém é um procedimento considerado seguro e factível, com uma baixa mortalidade e adequado controle locorregional tumoral quando realizado em centros de referência.

Morbidity and outcome of pelvic exenteration in locally advanced pelvic malignancies

Pelvic exenteration is a technically demanding surgical procedure performed for locally advanced cancers in the pelvis. Aim of the present study was to analyze morbidity, failure pattern and survival after pelvic exenteration during a period of 15 years in a dedicated cancer centre in South India. Retrospective analysis of case records of 50 patients who underwent pelvic exenteration from 1996 to 2011 in the Department of Surgical Oncology, Government Royapettah Hospital Chennai. Forty-six patients were females and 4 were males with a mean age of 48.3 years (range 21-72). Twenty six patients had cervical cancer,14 had rectal cancer, 3 had bladder cancer,2 had endometrial cancer, 2 had vaginal cancer, 1 had uterine sarcoma, 1 had anal cancer and 1 had ovarian cancer. The postoperative morbidity was 50%. 7 patients (14%) developed recurrence of which 5 had local and 2 had distant recurrence. The estimated 5 year overall survival for all patients in our series was 53.5% and for the patients with Ca rectum and Ca cervix was 60.6% and 40.1% respectively. Adjacent organ invasion had a significant impact over survival. Pelvic exenteration provides a curative form of treatment for carefully selected locally advanced cancer in the pelvis and it can be done safely with acceptable complications in centers experienced in multivisceral resections.

Pelvic exenteration for men with locally advanced rectal cancer: a morbidity analysis of complicated cases

BACKGROUND

The role of pelvic exenteration in locally advanced rectal cancer (LARC) has not been clearly defined. This procedure carries a mortality rate of approximately 10%. The challenges during pelvic surgery are different between men and women. The morbidity in men with LARC who received pelvic exenteration was analyzed.

METHODS

Medical records of men with LARC undergoing total pelvic exenteration or supralevator pelvic exenteration from January 1991 to December 2007 were retrospectively reviewed.

RESULTS

A total of 23 cases were included in the analysis. Thirteen patients had primary cancer; 10 had recurrent cancer. Microscopically clear surgical margins were obtained in 14 patients (60.9%). Sixteen patients (69.6%) experienced major or minor postoperative complications. The overall in-hospital mortality rate was 8.7%. Ten patients (43.5%) died within 1 year after surgery. All 10 patients with early mortality experienced refractory complications and repeated surgeries. The longest survival of patients with margin involvement was 25 months. The correlation between involved surgical margins and 1-year mortality was statistically significant (p = 0.001).

CONCLUSION

Resection margins with tumor involvement after pelvic exenteration is associated with poor prognosis and early mortality in men with locally advanced rectal cancer.

Double-barreled wet colostomy is a safe option for simultaneous urinary and fecal diversion. Analysis of 56 procedures from a single institution

BACKGROUND AND OBJECTIVES

Wide pelvic tumors need urinary and fecal diversion. We set out to assess the efficacy of the double-barreled wet colostomy (DBWC) in patients undergoing simultaneous double diversion.

MATERIAL AND METHODS

We reviewed 56 consecutive patients submitted to surgery, divided into two groups: (1) total pelvic exenteration plus DBWC (n = 26); (2) DBWC without simultaneous pelvic resection (n = 30). Pelvic tumor recurrences accounted for most patients (n = 53), whereas the remaining three patients suffered from actinic pelvic complications.

RESULTS

Surgical morbidity and mortality rates were 53.8% (14/26) and 11.5% (3/26) in Group 1, and 43.5% (13/30) and 3.3% (1/30) in Group 2, respectively. Only 2 patients out of 51 (3.9%) developed late postoperative urinary tract infection. Regression of the hydronephrosis was observed in 28 out of 33 assessable patients. Median survival in Groups 1 and 2 was 8.36 and 4.14 months, respectively. In the subgroup of patients submitted to curative surgery (n = 24), actuarial cancer-specific survival rate in 2 years was 58.78%.

CONCLUSION

DBWC is a safe and efficient alternative for simultaneous urinary and fecal diversion, with low morbidity and mortality rates, improvement of renal insufficiency, and low risk of postoperative urinary tract infection.