Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases

Laparoscopic Ureteric Reconstruction After Partial Ureterectomy for Locally Advanced and Recurrent Pelvic Malignancies (with Video)

BACKGROUND

The urinary tract is one of the most frequently involved organs in advanced non-urologic pelvic malignances. Extensive resection of ureteric organs is mandatory during a curative surgery. Urinary reconstruction after partial ureterectomy, the most challenging situation, is associated with a higher incidence of complication than cystectomy, especially when performed with laparoscopy. Furthermore, to date, no generally accepted strategy for urinary reconstruction after extensive tumor resection with partial ureterectomy has been established.

METHODS

The study identified and scrutinized intraoperative videos and clinical records of patients with locally advanced or recurrent pelvic malignancies who underwent segmental ureterectomy during en bloc resection of advanced tumors between February 2020 and February 2024.

RESULTS

The study enrolled nine patients, including four cases managed by ureteroureteral anastomosis, two cases managed by ureteroneocystomy, two cases managed by Boari flap reconstruction, and one case managed by ileal interposition. In all nine cases, R0 margins were obtained, and no case needed conversion to laparotomy. No clinical evidence of postoperative urinary leakage was identified. The median follow-up period was 14 months (range, 5-19 months). In three of the nine cases, recurrence was identified, at the 3rd, 18th, and 19th month follow-up evaluations, respectively. One patient died of systemic metastasis.

CONCLUSIONS

Laparoscopic ureteric reconstruction is feasible for patients who undergo segmental ureterectomy during extensive surgery for locally advanced or recurrent pelvic malignancies. A low anastomotic leakage rate and favorable postoperative renal function could be achieved in this study when anastomosis was performed laparoscopically.

The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report

BACKGROUND

Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.

CASE PRESENTATION

A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.

CONCLUSION

Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.

Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do?

INTRODUCTION

In patients with locally advanced (LARC) or locally recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially offer a cure. The study aim was to compare PC and RC in PE patients in terms of oncological outcome, post-operative complications and quality-of-life (QoL).

MATERIALS & METHODS

This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC cancer with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC.

RESULTS

60 PC patients and 269 RC patients were included. Overall R0 resection was 84.3%. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (P = 0.008). Overall, 1-, 3- and 5-year OS was 90.8%, 68.1% and 58.6% after PC, and 88.7%, 62.2% and 49.5% after RC. Rates of urinary sepsis or urological leaks did not differ between groups, however, RC patients experienced significantly higher rates of perineal wound- and flap-related complications (39.8% vs 25.0%, P = 0.032).

CONCLUSION

PC as part of PE can be performed safely with good oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group.

Clinical efficacy and safety analysis of CT-guided 125I implantation in the treatment of recurrent or metastatic pelvic malignant tumor

PURPOSE

This study was conducted to evaluate the clinical efficacy and safety of computed tomography (CT)-guided ¹²⁵I implantation in the treatment of recurrent or metastatic pelvic malignant tumor.

METHODS AND MATERIALS

This retrospective study analyzed the data of 30 patients with recurrent and metastatic pelvic malignant tumor who were treated with CT-guided ¹²⁵I implantation between January 2016 and December 2020. Disease control rate, objective remission rate, overall survival (OS), pain relief rate, quality of life score, and complications were evaluated after the followup.

RESULTS

Median followup was 20.1 (7-30) months. Disease control rate was 86.67% at 6 months. Objective response rates at 1, 3, and 6 months were 36.67%, 60%, and 56.67%, respectively. OS rates at 12 and 24 months were 76.67% (23/30) and 33.33% (10/30), respectively. Progression-free survival rates at 12 and 24 months were 63.33% (19/30) and 33.33% (10/30), respectively. Postoperative pain relief rate was 86.67% (26/30). There were no major bleeding, pelvic abscess, intestinal fistula, intestinal perforation, and other serious complications.

CONCLUSIONS

CT-guided ¹²⁵I seed implantation in the treatment of patients with pelvic malignant tumor is a simple operation and less traumatic and can improve patients' quality of life and reduce tumor load.

Complications and survival after total pelvic exenteration

BACKGROUND

Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival.

METHODS

Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed.

RESULTS

The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients.

CONCLUSION

The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.

Pelvic exenteration, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy: experience and outcomes from an exenterative and peritonectomy unit

PURPOSE

Pelvic exenteration (PE) for locally advanced pelvic malignancy is well established, though high rates of morbidity and mortality exist. Such a complication profile has often deterred the surgical community from offering exenteration in combination with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). We aimed to evaluate the perioperative outcomes following pelvic exenteration when combined with CRS and HIPEC for peritoneal surface malignancy (PSM) in a tertiary referral centre.

METHODS

A review of a prospectively maintained PSM database from June 2015 to December 2020 at a tertiary referral institution was performed. Patients who underwent CRS, PE, and HIPEC were matched with patients who underwent PE alone. Primary endpoints were perioperative morbidity and mortality.

RESULTS

From June 2015 to December 2020, 20 patients required PE as part of their CRS and HIPEC for PSM. The majority of patients were female (n = 16, 80%) with a median age of 52 (range 21-70). Colorectal cancer was the predominant pathology (n = 12, 60%). Median PCI was 11.5 (range 3-39). CC0 and R0 resections were achieved in all patients. CRS, PE, and HIPEC and PE-alone groups were well matched for clinicopathological variables. There was no difference in perioperative major morbidity (HIPEC: 30% vs PE: 15% p = 0.256) and mortality (HIPEC: 0 vs PE: 5% p = 0.311) between groups. Median follow-up was 17.5 months (range 7-68). Eight patients (40%) died from disease-related issues during the study period.

CONCLUSION

An aggressive surgical strategy with complete resection is feasible and safe in select patients with complex PSM involving the pelvis.

The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration

BACKGROUND

Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE.

METHODS

A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme.

RESULTS

145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03).

CONCLUSIONS

The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.

Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events

BACKGROUND

Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer.

OBJECTIVE

To assess urological reconstructive outcomes and adverse events in this setting.

DESIGN, SETTING, AND PARTICIPANTS

A total of 104 patients underwent TPE from 2004 to 2016 in this single-centre, retrospective study. Electronic and paper records were evaluated for data extraction. Mean follow-up was 36.5 mo.

INTERVENTION

TPE.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Urological complications were analysed using two-tailed t and chi-square tests, binary logistic regression analysis.

RESULTS AND LIMITATIONS

Sixty-three (61%) patients received radiotherapy prior to TPE. Incontinent diversions included ileal conduit (n = 95), colonic conduits (n = 4), wet colostomy (n = 1), and cutaneous ureterostomy (n = 1). Three patients had a continent diversion. The overall urological complication rate was 54%. According to Clavien-Dindo classification, 30 patients, five patients, and one patient had grade III, IV, and V complications, respectively. The commonest complication was urinary tract infection (in 32 [31%] patients). Anastomotic leaks were seen in 14 (13%) cases, of which eight (8%) were urinary leaks. Fistulas were seen in three (3%) patients, involving the urinary system. A return to theatre was required in 12 (12%) patients. Ureteroenteric strictures were seen in seven (7%). No differences were seen in urological outcomes in patients with primary or recurrent rectal cancer (p = 0.69), or by radiation status (p = 0.24). The main limitation is the retrospective nature of the study.

CONCLUSIONS

TPE is complex with recognised high risk of morbidity. In this cohort, there was no significant difference in outcomes between primary and recurrent disease, and surgery after radiation.

PATIENT SUMMARY

In this study, we assessed urological complications following total pelvic exenteration. Urinary complications affected more than half of patients. Urinary tract infection is the commonest risk. Approximately one-third of patients required surgical, radiological, or endoscopic intervention ± intensive care admission. Radiation prior to the operation did not affect urinary complications.