Pelvic exenteration of gynecologic malignancy: indications, and technical and reconstructive considerations

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.

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.

Current Therapeutic Approaches in Cervical Cancer Based on the Stage of the Disease: Is There Room for Improvement?

Cervical cancer continues to be among the most common malignancies in women, and in recent decades, important measures have been taken to reduce its incidence. The first and most important steps to achieve this goal are oriented toward prevention through screening programs and vaccination, mainly against oncogenic human papillomavirus (HPV) strains 16 and 18. The therapeutic approach is based on the diagnosis and treatment guidelines for cervical cancer, which establish for each stage (FIGO, TNM) specific conduct. These guidelines summarize quite precisely the elements of therapeutic practice, but, in some places, they leave optional variants based on which nuanced approaches could be established. Adherence to these guidelines, which include the performing of minor or major surgery, with or without chemotherapy and radiation therapy, combined with advanced imaging investigations, has been able to lead to a substantial increase in survival. The purpose of this literature review is to discuss the diagnosis and treatment options in cervical cancer depending on the histological type, FIGO staging, and patient performance index, taking into account the hospital resources available in middle-income countries (percentage of gross domestic product allocated to health services around 5.5%, in the case of Romania).

Pelvic exenteration for recurrent or persistent gynecologic malignancies: Clinical and histopathologic factors predicting recurrence and survival in a modern cohort

OBJECTIVES

To explore pre-operative factors and their impact on overall survival (OS) in a modern cohort of patients who underwent pelvic exenteration (PE) for gynecologic malignancies.

METHODS

A retrospective review was performed for all patients who underwent a PE from 1/1/2010 through 12/31/2018 at our institution. Inclusion criteria were exenteration due to recurrent or progressive carcinoma of the uterus, cervix, vagina or vulva, with histologically confirmed complete surgical resection of the malignancy. Exclusion criteria included PE for palliation of symptoms without recurrence, and for ovarian or rare histologic malignancies. Univariable and multivariable analysis were performed to identify factors predicting prolonged survival.

RESULTS

Overall, 71 patients met the inclusion criteria. Median age at time of exenteration was 62 years (range, 28-86 years). Vulvar cancer was the most common primary diagnosis (32%); 30% had cervical cancer; 23%, uterine cancer; 15%, vaginal cancer. Median OS was 55.1 months (95% confidence interval (CI): 36-not estimable) with a median follow-up time of 40.8 months (95% CI: 1-116.1). On univariable analysis, age > 62 years (hazard ratio (HR) 2.71, 95% CI 1.27-5.79), American Society of Anesthesia (ASA) 3-4 (HR: 3.41 (95% CI 1.03-11.29), and vulvar cancer (HR 4.19 (95% CI 1.17-14.96) predicted worse OS. Tumor size and prior progression-free interval (PFI) did not meet statistical significance in OS analyses. On multivariable analysis, there were no significant factors associated with worse OS.

CONCLUSIONS

PE performed with curative intent may be considered a treatment option in well-counseled, carefully selected patients, irrespective of tumor size and PFI before exenteration.

The role of imaging in pelvic exenteration for gynecological cancers

Pelvic exenteration (PE) is one of the most challenging gynecologic oncologic surgeries and is an overriding term for different procedures that entail radical en bloc resection of the female reproductive organs and removal of additional adjacent affected pelvic organs (bladder, rectum, anus, etc.) with concomitant surgical reconstruction to restore bodily functions. Multimodality cross-sectional imaging with MRI, PET/CT, and CT plays an integral part in treatment decision-making, not only for the appropriate patient selection but also for surveillance after surgery. The purpose of this review is to provide a brief background on pelvic exenteration in gynecologic cancers and to familiarize the reader with the critical radiological aspects in the evaluation of patients for this complex procedure. The focus of this review will be on how imaging can aid in treatment planning and guide management.

Palliative pelvic exenteration using iliofemoral bypass with synthetic grafts for advanced cervical carcinoma

Objective

Recurrent cervical cancer can cause severe morbidity. Despite the severe morbidity after surgery, pelvic exenteration is still used today for mainly curative intent. This intention is neither based on randomized controlled trials (RCTs) nor high quality non-RCTs with adequate patient numbers comparing medical management with surgery. The same is true for exenteration for palliative intent, so the patient selection for either curative or palliative intent must be considered on a patient-by-patient basis.

Materials and Methods

A 35-year-old patient who had undergone primary chemo-radiotherapy for advanced cervical cancer presented with intractable pain on the swollen left leg and pelvis 8 months later. Left lower extremity Doppler ultrasound revealed echogenic thrombus in the external iliac, femoral, and popliteal veins, consistent with acute deep vein thrombus. She underwent total exenteration, end colostomy, ileal urinary conduit, pelvic lymphadenectomy, paraortic lymph node sampling, and ilio-femoral arterial and venous bypass.

Results

The procedure relieved her pain, the leg diameter dramatically decreased from 75 cm to 44 cm, and circulation of the leg was reestablished. The procedure deferred leg amputation for about five months.

Conclusion

To the best of our knowledge, this is the first report of a palliative pelvic exenteration for cervical cancer with combined iliofemoral arterial and venous bypasses. These procedures, with high morbidity and mortality, are also more controversial when undertaken for just palliation of symptoms. They must be considered in the basis of each patient, and the benefits and risks must be discussed thoroughly in a realistic perspective with the patient.

Pelvic exenteration for recurrent gynecologic malignancy: a study of 28 consecutive patients at a single institution

OBJECTIVE

The aim of this study was to assess the outcomes of patients undergoing pelvic exenteration (PE) for recurrent gynecologic malignancy.

METHODS

A retrospective review using all medical records of 28 consecutive patients who underwent PE between January 2002 and December 2011 at a single institution was conducted. Complications were graded according to Clavien-Dindo. Overall survival (OS) and disease-free survival (DFS) were estimated by the method of Kaplan-Meier.

RESULTS

Pelvic exenteration was performed for recurrent cancer in all patients. Distribution of primaries was as follows: cervix (n = 10), vagina (n = 5), ovary (n = 5), uterus (n = 4), tube (n = 2), Bartholin gland (n = 1), and vulva (n = 1). In all but 1 case, PE was performed with curative intent. Pelvic exenteration was total (n = 11), anterior (n = 2), or posterior (n = 15). Reconstructive procedures included urinary tract (n = 13), gastrointestinal tract (n = 26), pelvic floor (n = 6), and vagina (n = 5). There was no postoperative mortality within 30 days. All patients developed 1 or several early complications of various grades, and 22 patients (79%) developed late complications. Twelve patients (43%) underwent reoperation because of complications to PE, and 2 patients died within follow-up as a consequence of their PE. A complete tumor resection (R0) was obtained in 23 patients (82%). With a median follow-up of 27 months (range, 2-110 months), the 5-year OS and DFS rates were 70% and 41%, respectively. R0 resection was associated with increased OS (P < 0.001) and DFS (P = 0.015).

CONCLUSIONS

Pelvic exenteration for recurrent gynecologic malignancies can be associated with long-term survival in selected patients. However, postoperative complications are common and can be lethal.

Should pelvic exenteration for symptomatic relief in gynaecology malignancies be offered?

OBJECTIVE

To review the outcomes of pelvic exenterative surgery done with a palliative intent and evaluate its role in relapsed gynaecology malignancies.

METHOD

This is a retrospective cohort study between April 2009 and May 2012 in Oxford Gynaecological Cancer Centre. Patients were identified from the oncology surgical database.

RESULTS

18 patients were identified with a mean age 54 (26-79) years, who underwent surgery for symptomatic recurrent cancer. All except one patient had radiotherapy prior to surgery. 12 patients had cervical cancer, five had vulval cancer and one had endometrial cancer. About half of the patients had major surgical complications; however, majority was patients satisfied with the outcome.

CONCLUSION

Pelvic exenteration in this context carries considerable morbidity and in this series achieved good symptom control with a mean overall survival of 11 months. Careful patient selection, adequate counselling and ongoing support are imperative of successful outcome.

The role of palliative surgery in gynecologic cancer cases

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

The effect of body mass index on surgical outcomes and survival following pelvic exenteration

OBJECTIVE

We sought to evaluate whether preoperative body mass index (BMI) impacts surgical outcomes, complication rates, and/or recurrence rates in women undergoing pelvic exenteration.

METHODS

All women who underwent pelvic exenteration for gynecologic indications at our institution from 1993 through 2010 were included. Women were stratified into 3 groups based on BMI. Baseline characteristics, surgical outcomes, early (<60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were collected. Multivariate logistic regression analyses were performed. Kaplan-Meier survival curves were compared using log-rank test.

RESULTS

161 patients were included (59 normal weight, 44 overweight, 58 obese). Median follow-up times were 22, 29, and 25 months. Most patients underwent total pelvic exenteration (68%); 64.6% had a vaginal reconstruction. On multivariate analysis, both overweight and obese patients had a higher risk of early superficial wound separation compared to normal weight patients - OR 10.74 (3.33-34.62, p<0.001) and OR 4.35 (1.40-13.52, p=0.011), respectively. Length of surgery was significantly longer for overweight (9.6h, OR 1.26, 1.02-1.55, p=0.032) and obese (10.1h, OR 1.24, 1.04-1.47, p=0.014) patients than for normal weight patients (8.7h). Late postoperative complications for patients in the normal weight, overweight, and obese groups were 47.5%, 45.5%, and 43.1% (p=0.144). There were no differences in time to recurrence (p=0.752) or overall survival (p=0.103) between groups.

CONCLUSION

Although operative times were longer and risk for superficial wound separation was significantly higher, pelvic exenteration appears to be feasible and safe in overweight and obese women with overall complication rates and survival outcomes comparable to normal weight women.

Pelvic exenteration in gynecologic oncology: a single institution study over 20 years

OBJECTIVE

The profile of women with gynecologic malignancies treated with pelvic exenteration has changed since the initial description of this procedure. We sought to evaluate our experience with pelvic exenteration over the last 20 years.

METHODS

Patients who underwent anterior, posterior, or total pelvic exenteration for vulvar, vaginal, and cervical cancer at Barnes-Jewish Hospital between January 1, 1990 and August 1, 2009 were identified through hospital databases. Patient characteristics, the indications for the procedure, procedural modifications, and patient outcomes were retrospectively assessed. Categorical variables were analyzed with chi-square method, and survival data was analyzed using the Kaplan-Meier method and log rank test.

RESULTS

Fifty-four patients were identified who had pelvic exenteration for cervical, vaginal, or vulvar cancer. Recurrent cervical cancer was the most common procedural indication. One year overall survival from pelvic exenteration for the entire cohort was 64%, with 44% of patients still living at 2 years and 34% at 50 months. Younger age was associated with improved overall survival after exenteration (p = 0.01). Negative margin status was associated with a longer disease-free survival (p=0.014). Nodal status at the time of exenteration was not associated with time to recurrence or progression, site of recurrence, type of post-operative treatment, early or late complications, or survival.

CONCLUSIONS

Despite advances in imaging and increased radical techniques, outcomes and complications after total pelvic exenteration in this cohort are similar to those described historically. Pelvic exenteration results in sustained survival in select patients, especially those that are young with recurrent disease and pathologically negative margins.

Laparoscopic salvage total pelvic exenteration: Is it possible post-chemo-radiotherapy?

Indications for total pelvic exenteration in a male (removal of the bladder, prostate and rectum) and in a woman (removal bladder, uterus, vagina, ovaries and rectum) are rare. The advanced stage generally dictates that the patient has some form of chemotherapy or radiotherapy, or a combination of two to shrink/debulk the tumour. We report the first two cases of a salvage laparoscopic total pelvic exenteration in a male for rectal adenocarcinoma invading into the bladder and prostate, post-chemo-radiotherapy and in a woman for squamous cell carcinoma of cervix invading the bladder and rectum post-chemo-radiotherapy. Salvage surgery is often difficult and has been noted to have high morbidity. Applying a laparoscopic approach to this group may have advantages for the patient and the surgeon, i.e. less pain, early recovery and magnified views. As we have technically shown it to be possible, perhaps laparoscopic approaches should be discussed if the teams in these centres are of advanced laparoscopic surgeons working in multi-skilled groups.

Current developments for pelvic exenteration in gynecologic oncology

PURPOSE OF REVIEW

The present review aims to update new techniques of pelvic exenteration including minimal invasive surgery, and discuss other aspects of this radical surgery, including worldwide differences.

RECENT FINDINGS

Major advances are made since the first description of pelvic exenteration and the operation is still under evolution. Explorative laparoscopy prior to exenteration is a valuable alternative to laparotomy to elect candidates for pelvic exenteration. There are considerable differences with respect to indications, contraindications, preoperative staging and adjuvant therapy after exenteration in different countries. Advances in laparoscopic instruments also led to the laparoscopic exenteration. The main limiting step of the operation is urinary diversion. New techniques of laparoscopic-assisted and robotic-assisted techniques of urinary diversion have been reported that decrease the operation time. Vascularized muscle flaps are preferred by many surgeons to fill the empty pelvis and provide an acceptable vaginal reconstruction. J-pouch seems to be a safer technique than end-to-end coloanal anastomosis for bowel reconstruction. Developments in the bioengineering tissue for pelvic reconstruction are required.

SUMMARY

Laparoscopy has the advantages of decreased blood loss, improved convalescence, lower incidence of wound infection and incisional hernia, short recovery periods, rapid return of bowel function, better pain control and improved cosmetics compared with laparotomy for pelvic exenteration. Magnification and improved visualization permits en-bloc dissection of tumor and good anastomosis technique. New techniques of urinary diversion, orthotopic neobladder and coloanal are promising.

Primary pelvic exenteration in cervical cancer patients

Despite the reports of a number of leading institutions concerning the use of primary exenteration, there are differences in regard to definition, indications, and interpretation of results of this treatment approach to cervical cancer. In this paper we present our own experience with 41 cervical cancer patients treated with primary exenteration at St. Stephen Hospital Budapest. We explore some important unsettled aspects (definition, indications, and quality of life consequences) of this treatment modality in view of our own experience and the literature. Between January 1993 and June 2006, 2540 invasive cervical cancer patients were seen at the gynecologic oncology service of the St. Stephens Hospital Budapest. Two hundred twelve (8%) of these patients were surgically explored with the plan of an exenterative surgery. Exenteration was the primary treatment in 41 (25%) of 166 completed exenterations; these 41 cases included 2 cases of supralevator total exenteration, 9 cases of supralevator anterior exenteration, and 30 cases of partial supralevator anterior exenteration. In the 2 total exenteration patients, anal function was restored with a low rectal anastomosis, with a temporary defunctioning colostomy in 1 patient. Urethral function was restored in 9 out of 11 supralevator exenteration cases with the Budapest pouch bladder replacement technique. In the remaining 2 cases, a Bricker conduit was used for urinary diversion. There was no operation-related mortality in this cohort of patients. An external fecal or urinary stoma was avoided in 38 (93%) out of the 41 primary exenteration patients; in 1 patient a temporary defunctioning colostomy was used; and in 2 patients a permanent ileal conduit was created. In 9 patients (22%), complications (ileus and peritonitis, occlusion of the femoral artery, stricture of the implanted ureter, and postoperative ureterovaginal fistula) necessitated surgical intervention. A quality of life study revealed the need for prolonged self-catheterization, partial (mainly night time) incontinence, and lymphedema in 7 patients. We consider and suggest that an en bloc resection of part(s) of the urinary bladder and/or the rectum with the uterine cervix should be considered an exenteration (partial exenteration). A 50% survival rate of a select group of stage IVA cervical cancer patients treated with primary exenteration can be considered significant, but cannot be considered superior to that of chemoradiation therapy. The same applies when considering treatment-related mortality and complications that require operative interventions. Low rectal anastomosis and orthotopic bladder replacement with a relative low risk of fistula formation in non-irradiated patients constitute a strong quality of life argument in favor of primary exenteration in a select group of stage IVA cervical cancer patients.

Outcomes of colorectal anastomoses during pelvic exenteration for gynaecological malignancy

BACKGROUND

Although pelvic exenteration is frequently indicated during surgery for gynaecological malignancy, performing a colorectal anastomosis remains contentious because of concern about leakage. This study evaluated the safety of performing a low colorectal anastomosis during pelvic exenteration for gynaecological malignancy.

METHODS

Between April 2001 and December 2006, 145 consecutive patients underwent low colorectal anastomosis without (122) or with (23) a stoma after pelvic exenteration for advanced primary or recurrent gynaecological malignancy. Subjects were assessed in terms of five patient-, four disease- and two surgery-related variables. The proportion of patients with each risk factor for leakage was found, and the rate of symptomatic anastomotic leakage was determined.

RESULTS

The mean age of the patients was 53.5 (range 10-77) years and the most common diagnosis was ovarian cancer (77.9 per cent). The mean operating time was 453 (range 145-845) min and the mean blood loss was 1080 (range 110-10 500) ml; 95 patients (65.5 per cent) required a blood transfusion. Of the 145 patients, 81 (55.9 per cent) had patient-related, 94 (64.8 per cent) had disease-related and 67 (46.2 per cent) had surgery-related variables associated with a risk of leakage. Symptomatic anastomotic leakage developed in three patients (2.1 per cent).

CONCLUSION

Although patients with gynaecological malignancy carry considerable risks associated with anastomotic leakage, carefully executed low colorectal anastomosis during pelvic exenteration was found to be safe.

Indications for primary and secondary exenterations in patients with cervical cancer

OBJECTIVE

Fifty years after the introduction of exenterative surgery in gynecologic oncology, the indication for primary and secondary exenteration is controversially discussed in cervical cancer patients. In addition, the term "palliative exenteration" is not precisely defined. We evaluate the role of primary exenteration in patients with stage IVA cervical cancer and the role of secondary palliative exenteration.

METHODS

The study retrospectively analyzed surgical and oncologic data of 55 patients who underwent exenterative surgery in the Department of Gynecology at the University of Jena between February 1998 and January 2004. Primary surgery was performed in 20 patients with laparoscopically confirmed stage IVA cervical cancer, while 35 patients with recurrent cervical cancer underwent secondary exenteration. Fifty-one had total, 3 posterior and 1 anterior exenteration. Survival was analyzed in relation to the patient's age, indication (primary versus secondary, curative versus palliative), previous therapy (operation, radiation, chemotherapy, radiochemotherapy), histology, resection margins, pelvic nodal involvement, time interval from primary therapy to recurrence, type of exenteration and adjuvant therapy. Early and late postoperative complications as well as perioperative mortality were reviewed.

RESULTS

The overall cumulative survival of all patients after exenteration was 36.8% at 5 years with 52.5% in the primary group and 26.7% in the recurrent one (p=0.0472). Complications were noted in 56.9% of patients, most commonly fistulas or gastrointestinal complications. Operative mortality was 5.5%. Survival correlated significantly with the time interval between primary treatment and recurrence (within 1-2 years 16.8% five-year survival, 2-5 years 28%, >5 years 83.2%, p=0.0105) as well as with curative or palliative intention (2-year survival rate of 60% in patients with curative intent, 10.5% in those with palliative intent, p=0.0001) and with tumor-free resection margins (2-year survival of 10.2% for positive margins, 5-year survival of 55.2% for negatives ones, p=0.0057). The age, the type of exenteration, the histologic type and the metastatic spread to pelvic lymph nodes had no significant influence on long-term survival.

CONCLUSION

In patients with histopathologically confirmed stage IVA cervical cancer primary, exenteration is a valid alternative to primary chemoradiation. In patients with persistent or recurrent tumor limited to the pelvis, secondary exenteration should be offered in the absence of other therapeutic options. Palliative and curative attempts can best be differentiated by the resection margin status.