Pelvic exenteration and sphincter preservation in the treatment of soft tissue sarcomas

Opportunities and Limitations of Pelvic Exenteration Surgery

PURPOSE

The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view.

METHODS

This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used.

RESULTS

A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes).

CONCLUSION

Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.

Elderly Patients Have Better Quality of Life but Worse Survival Following Pelvic Exenteration: A 25-Year Single-Center Experience

OBJECTIVE

To describe quality of life (QOL) and survival outcomes following pelvic exenteration (PE) in old and young patients.

BACKGROUND

PE is a management option for complete resection in locally advanced pelvic cancers. Few studies have examined the impact of age on the outcome in elderly patients following PE.

PATIENTS AND METHODS

Prospective cohort of consecutive patients undergoing partial and complete PE between 1994 and 2019. Patients were divided into a younger (< 65 years) or older cohort (≥ 65 years) based on their age. QoL was assessed using the SF-36 and FACT-C questionnaires and survival estimated using the Kaplan-Meier method.

RESULTS

For 710 patients who underwent PE during the study period, FACT-C total score was significantly better in the elderly during the whole follow-up period of 5 years. Mental component score (SF-36) was significantly better at baseline (p = 0.008) and at 24 months postoperatively (p = 0.042), in the elderly group. Median overall survival was 75 months in the younger cohort and 53 months in the older cohort (p = 0.004). In subgroup analysis, older patients with recurrent or primary rectal cancer had a median survival of 37 and 70 months, respectively. Postoperative cardiovascular complications were greater in the elderly cohort (p < 0.001).

CONCLUSIONS

Elderly patients had better overall QoL but lower survival that is probably related to cardiovascular complications rather than to cancer as both groups had similar R0 resection rate. Hence, the elderly population should be considered equally for PE.

Supralevator Total Pelvic Exenteration Without Colostomy — Case Report

Background: Pelvic exenteration is an ultra-radical surgical procedure described by Brunschwig in 1948, which attempts to surgically cure patients with recurrent pelvic cancer after radiotherapy. Several variants of pelvic exenteration are described that allow a more limited or extensive resection, depending on the stage of the disease.

Case report: We report the case of a 54-year-old woman, who was diagnosed with a tumoral rectovaginal fistula after a recurrent cervical cancer that had been treated with a total hysterectomy with bilateral adnexectomy and a left percutaneous nephrostomy, as well as interaortocaval lymph node resection. The patient had undergone a supralevator total pelvic exenteration with pelvic and interaortocaval lymphadenectomy. The reconstruction process included right ureterostomy, left nephrostomy, and colocutaneous anal anastomosis (Parks procedure).

Conclusions: Supralevator total pelvic exenteration provides hope for cure in patients with pelvic malignancies that reappear after radiotherapy. The restoration of the digestive tract and avoiding colostomy with a colocutaneous anastomosis increases the quality of life in these cases.

Pelvic exenteration for colorectal cancer: oncologic outcome in 59 patients at a single institution

Background

Pelvic exenteration (PE) continues to be the only curative option in selected patients with advanced or recurrent pelvic neoplasms. A current debate exists concerning the appropriate selection of patients for PE, with the most important factor being the absence of extrapelvic disease.

Aim

To evaluate the outcome of patients submitted to exenterative surgery.

Patients and methods

A review of the clinical charts of patients with colorectal cancer who underwent PE between January 1994 and June 2010 at the Institute National of Cancerología in Mexico City was performed.

Results

We selected 59 patients, 53 of whom were females (90%), and six of whom were males (10%). Mean age at the time of diagnosis was 50 years (range, 21–77 years). A total of 51 patients underwent posterior PE (86%), and eight patients underwent total PE (14%). Operative mortality occurred in two cases (3%), and 29 patients developed complications (49%). Overall, 11 patients (19%) experienced local failure with mean disease-free survival time of 10.2 months. After a mean follow-up of 28.3 months, nine patients are still alive without evidence of the disease (15%).

Conclusions

PE should be considered in advanced colorectal cancer without extrapelvic metastatic disease. PE is accompanied by considerable morbidity (49%) and mortality (3%), but local control is desirable. Overall survival justifies the use of this procedure in patients with primary or recurrent locally advanced rectal cancer.

Total pelvic exenteration for primary and recurrent malignancies

Introduction

Complete resection is the most important prognostic factor in surgery for pelvic tumors. In locally advanced and recurrent pelvic malignancies, radical margins are sometimes difficult to obtain because of close relation to or growth in adjacent organs/structures. Total pelvic exenteration (TPE) is an exenterative operation for these advanced tumors and involves en bloc resection of the rectum, bladder, and internal genital organs (prostate/seminal vesicles or uterus, ovaries and/or vagina).

Methods

Between 1994 and 2008, a TPE was performed in 69 patients with pelvic cancer; 48 with rectal cancer (32 primary and 16 recurrent), 14 with cervical cancer (1 primary and 13 recurrent), 5 with sarcoma (3 primary and 2 recurrent), 1 with primary vaginal, and 1 with recurrent endometrial carcinoma. Ten patients were treated with neoadjuvant chemotherapy and 66 patients with preoperative radiotherapy to induce down-staging. Eighteen patients received IORT because of an incomplete or marginal complete resection.

Results

The median follow-up was 43 (range, 1–196) months. Median duration of surgery was 448 (range, 300–670) minutes, median blood loss was 6,300 (range, 750–21,000) ml, and hospitalization was 17 (range, 4–65) days. Overall major and minor complication rates were 34% and 57%, respectively. The in-hospital mortality rate was 1%. A complete resection was possible in 75% of all patients, a microscopically incomplete resection (R1) in 16%, and a macroscopically incomplete resection (R2) in 9%. Five-year local control for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 89%, 38%, and 64%, respectively. Overall survival after 5 years for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 66%, 8%, and 45%.

Conclusions

Total pelvic exenteration is accompanied with considerable morbidity, but good local control and acceptable overall survival justifies the use of this extensive surgical technique in most patients, especially patients with primary locally advanced rectal cancer and recurrent cervical cancer.

Pelvic exenteration for gynaecological tumours: achievements and unanswered questions

Pelvic exenteration has been used for 60 years to treat cancers of the lower and middle female genital tract in radiated pelves. The mainstay for treatment success in terms of locoregional control and long-term survival is resection of the pelvic tumour with clear margins (R0). New ablative techniques based on developmentally derived surgical anatomy and laterally extended endopelvic resection have raised the number of R0 resections done, even for tumours that extend to the pelvic side wall, which were traditionally judged a contraindication for exenteration. Although mortality has fallen to less than 5%, treatment-related severe morbidity of pelvic exenteration still exceeds 50%, possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. The benefits of exenteration for patients who have advanced primary disease or recurrent tumours after surgery, versus those who have chemoradiotherapy, are not proven by results of controlled trials, but can be assumed from retrospective data. Comparative findings are missing, and arguments are unconvincing to favour pelvic exenteration over less extensive treatments and best supportive care for palliation of cancer symptoms in most patients.