Complications and survival after total pelvic exenteration

Pelvic exenteration for locally advanced and recurrent prostate cancer

Locally advanced or recurrent prostate cancer which invades adjacent pelvic organs, bone or other soft tissue structures is a rare situation. This study aimed to report the outcomes of ten consecutive patients who underwent total pelvic exenteration for prostate cancer at a high-volume specialist centre. Two patients had locally advanced primary tumours, while eight had locally recurrent prostate cancer. Median operating time, blood loss, ICU stay, and hospital stay was 12.2 h (range 9.6-13.8), 2500 ml (500-3000), 4.5 days (2-7) and 36 days (21-78), respectively. There was no inpatient, 30-day, or 90-day mortality. Six patients developed a Clavien-Dindo III complication. R0 resection was achieved in eight patients. Median follow up was 16 months (range 2-77). At last follow up, five patients were alive without disease. These findings suggest that pelvic exenteration for locally advanced and recurrent prostate cancer is safe and represents a potentially curative treatment option for highly selected patients.

Outcomes Following Treatment of Pelvic Exenteration for Rectal Cancer in a Tertiary Care Center

Pelvic exenteration is potentially curative for operable locally advanced primary and locally recurrent rectal cancers. R0 resection is associated with higher survival. This procedure is associated with low mortality rates but high postoperative morbidity proportional to the extent of resection. This study was done to find out the survival outcome and morbidity associated with this procedure and to determine prognostic factors associated with postoperative outcomes. Seventy-three patients with rectal cancer underwent pelvic exenteration between January 2009 and December 2020. Sixty-six patients had locally advanced rectal cancer and 7 patients had recurrent cancer. All patients with primary tumors were evaluated with MRI pelvis and CT scan of the chest and abdomen while patients with recurrence were evaluated with a PET scan. The median follow-up duration was 39 months. The majority of patients were in the age group 40-69 years. Thirty patients were males and 43 were females. The 30-day postoperative major morbidity was reported in 28 patients (38.4%). The most common morbidity was wound dehiscence. The mean overall survival (OS) was 110.6 months (95% CI, 97.5-123.7) and mean disease free survival (DFS) was 85 months (95% CI, 71.0-100.4). R0 resection was associated with favorable overall survival. Tailored exenterations were associated with low morbidity. En bloc partial sacrectomy helped achieve R0 resection in patients who underwent the procedure. Extended resections yielded high R0 resection rates with favorable survival (65 months) but were associated with high morbidity. These procedures shall be best practiced in high-volume institutes of expertise.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01918-w.

A systematic review and meta-analysis on mortality rate following total pelvic exenteration in cancer patients

BACKGROUND

Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including female reproductive organs, lower urological organs and involved parts of the digestive system. The aim of this meta-analysis is to estimate the intra-operative mortality, in-hospital mortality, 30- and 90-day mortality rate and overall mortality rate (MR) following TPE in colorectal, gynecological, urological, and miscellaneous cancers.

METHODS

This is a systematic review and meta-analysis in which three international databases including Medline through PubMed, Scopus and Web of Science on November 2023 were searched. To screen and select relevant studies, retrieved articles were entered into Endnote software. The required information was extracted from the full text of the retrieved articles by the authors. Effect measures in this study was the intra-operative, in-hospital, and 90-day and overall MR following TPE. All analyzes are performed using Stata software version 16 (Stata Corp, College Station, TX).

RESULTS

In this systematic review, 1751 primary studies retrieved, of which 98 articles (5343 cases) entered into this systematic review. The overall mortality rate was 30.57% in colorectal cancers, 25.5% in gynecological cancers and 12.42% in Miscellaneous. The highest rate of mortality is related to the overall mortality rate of colorectal cancers. The MR in open surgeries was higher than in minimally invasive surgeries, and also in primary advanced cancers, it was higher than in recurrent cancers.

CONCLUSION

In conclusion, it can be said that performing TPE in a specialized surgical center with careful patient eligibility evaluation is a viable option for advanced malignancies of the pelvic organs.

Evaluating postoperative hernia incidence and risk factors following pelvic exenteration

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.

METHOD

A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.

RESULTS

A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.

CONCLUSION

This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

Robotic surgery after total neoadjuvant therapy for rectal cancer: pitfalls of beyond total mesorectal excision for patients with sidewall invasion

AIM

Total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) is rapidly spreading. The robotic surgical techniques to approach lateral invasion, such as that of the pelvic plexus, have not yet been established. In this technical note, we present a video illustrating a surgical technique for lateral invasion using our novel technique and discuss its pitfalls.

METHOD

We present the case of a 65-year-old man with LARC. Robotic surgery was performed after TNT using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical procedure was as follows: (1) D3 lymph node dissection around the inferior mesenteric artery using a medial-to-lateral approach; (2) rectal mobilization; (3) dissection of the ureterohypogastric fascia and ureter; and (4) combined resection of the hypogastric nerve and pelvic plexus. The key surgical point for sidewall invasion is the resection extent. Dividing the resection extent into three areas is important: zone A, which contains the pelvic plexus and is closest to the tumour; zone B, which contains the iliac vessels; and zone C, the most lateral zone, which contains the obturator nerves. This allows organ and function preservation by resecting only the smallest organ that truly requires R0 resection.

RESULTS

The operating time was 333 min, console time was 232 min, and blood loss was 0 mL. The circumferential resection margin was 10 mm, and an R0 resection was achieved.

CONCLUSION

We introduced a novel approach for robotic surgery after TNT for LARC with sidewall invasion. This technique can be performed safely and may help standardize 'beyond total mesorectal excision'.

Multimodality Imaging to Direct Management of Primary and Recurrent Rectal Adenocarcinoma Beyond the Total Mesorectal Excision Plane

Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.

The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature

Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some cases of advanced tumors, it is associated with several perioperative complications. We believe that careful patient selection is related to better oncologic outcomes and lower complication rates. The objectives of this review are to identify the most current indications for this intervention, suggest criteria for case selection, evaluate recommendations for perioperative care, and review oncologic outcomes and potential associated complications. To this end, an analysis of English language articles in PubMed was performed, searching for topics such as the indication for pelvic exenteration for recurrent gynecologic neoplasms selection of oncologic cases, the impact of tumor size and extent on oncologic outcomes, preoperative and postoperative surgical management, surgical complications, and outcomes of overall survival and recurrence-free survival.

Is an uncomplicated postoperative recovery following total pelvic exenteration a more important prognostic factor than achieving R0 in the first 2 years?

AIM

Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously.

METHOD

This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS.

RESULTS

A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years.

CONCLUSIONS

In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.

Is preoperative sarcopenia associated with postoperative complications after pelvic exenteration surgery?

PURPOSE

Pelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery.

METHODS

This retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3.

RESULTS

In total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis.

CONCLUSION

Sarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.

Cutting-edge Treatment for Gynecological Malignancies

Gynecological malignant tumors can develop in the vulva, vagina, uterus, fallopian tubes, or ovaries in the female reproductive tract. The cervix, uterine body, and ovaries are particularly common sites for malignant tumors. Surgery, radiation, and drug therapy are the main treatment modalities for gynecological cancers, with surgery being the most important of them. We started laparoscopic surgery for uterine endometrial cancer as an advanced medical treatment in 2011 and contributed to its insurance coverage. We were able to reproduce our laparoscopic surgery more easily using the da Vinci Xi system for robotic surgery. We have now switched from laparoscopic surgery for endometrial cancer to robotic surgery and have been able to perform them safely and reliably. In the case of cervical cancer, the results of the Laparoscopic Approach to Cervical Cancer (LACC) trial, which compared the prognosis of two groups of radical hysterectomy for early-stage cervical cancer: conventional open surgery and laparoscopic/robotic (minimally invasive) surgery, showed that minimally invasive surgery resulted in more pelvic recurrences and had a worse prognosis compared with open surgery. The trend toward minimally invasive surgery for cervical cancer has stagnated worldwide. Ovarian cancer has few symptoms in the early stages and is often found at stage III or IV, when the cancer has spread throughout the abdominal cavity. As residual tumor after surgery correlates with prognosis in ovarian cancer, debulking surgery should be performed to achieve complete resection. Therefore, peritoneal or bowel resection is often required to remove disseminated or metastatic tumors. We also performed prophylactic salpingo-oophorectomy to prevent ovarian and fallopian tube cancers in patients with BRCA1/2 gene variants. The uterus and ovaries are organs necessary for pregnancy and childbirth, and cancer of the uterus or ovaries in women of childbearing age may result in infertility. Surgery and adjuvant treatment may affect marriage, childbirth, and sexual life; therefore, it is important to ensure the cure of cancer and to provide patients with treatment methods that allow them to live their lives as women.

Total Pelvic Exenteration surgery - Considerations for healthcare professionals

BACKGROUND

Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care.

METHOD

Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team.

RESULTS

This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities.

CONCLUSION

Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.

Minimally invasive surgery for maximally invasive tumors-pelvic exenterations for rectal cancers: are we prepared?

Despite the public awareness of colorectal cancer screening with more and more early premalignant or malignant lesions detected, surgeons still face the challenges of operating for a patient suffering from locally advanced rectal carcinoma which required pelvic exenterations, and surgical outcomes mostly influenced by margin status, adjuvant chemotherapy, positive lymph nodes and liver metastasis, etc. Open pelvic exenteration has been the adopted approach in the past and laparoscopic surgery is another option in expert centers. A study in this issue of the Journal of Minimally Invasive Surgery demonstrated promising results of minimally invasive approaches for pelvic exenteration in patients with locally advanced rectal carcinoma, with overall complication rate of 28.2% with a 7.3% circumferential resection margin positivity and with no distal margin involvement, with local recurrence rate of 8.1% and overall survival of 85.2% by 2-year follow-up. We are expecting more results in the future to support the routine implementation of minimally invasive pelvic exenterations.

Using Bakri balloon as a visceral replacement for occupying pelvic cavity in pelvic exenteration, a case report

Introduction and importance

Total pelvic exenteration is the choice treatment for locally advanced or recurrent cervical cancers. However, the procedure is usually associated with serious complications. One of the most common complications is “empty pelvic syndrome”. In this case report, we described a novel method to investigate its efficacy in prevention of empty pelvic syndrome.

Case presentation

A 51-year-old woman presented with recurrent cervical cancer underwent TPE after chemoradiotherapy. After removing the organs of the pelvic cavity, a silicone-made Bakri balloon was placed in there through the laparotomy incision. The balloon was removed 5 days later through the vaginal canal. She was followed for 6 months after the surgery and did not experience neither complications nor the recurrence of the cervical cancer.

Clinical discussion

We intended to use a novel technique by placing a Bakri balloon in the pelvic cavity after the total pelvic exenteration. The silicone-made balloon creates an appropriate physical barrier to support colon and small intestine loops and other pelvic contents.

Conclusion

Bakri balloon, which has been used to control the post-partum hemorrhage, can be a useful tool to provide a physical barrier to prevent the descending of intestinal loops and a breeding ground for reconstruction of the pelvic floor.

•

Total pelvic exenteration is the choice treatment for locally advanced or recurrent cervical cancers.

•

One of the most common complications is “empty pelvic syndrome”.

•

Bakri balloon can be used as physical barrier to prevent the descending of intestinal loops.