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Baboudjian M, Gondran-Tellier B, Michel F, Abdallah R, Rouy M, Gaillet S, Sichez PC, Boissier R, Bladou F, Lechevallier E, Karsenty G. Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion. Urology 2021; 152:178-183. [PMID: 33581233 DOI: 10.1016/j.urology.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use. PATIENTS AND METHODS A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC. RESULTS Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed. CONCLUSIONS For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.
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Affiliation(s)
- Michael Baboudjian
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France.
| | - Bastien Gondran-Tellier
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Floriane Michel
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Rony Abdallah
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Mathieu Rouy
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Sarah Gaillet
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Pierre Clement Sichez
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Romain Boissier
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Frank Bladou
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Eric Lechevallier
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
| | - Gilles Karsenty
- Aix-Marseille University, APHM, La Conception Academic Hospital, Department of Urology and Renal transplantation, Marseille, France
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Angeles MA, Mallet E, Rouanet P, Cabarrou B, Méeus P, Lambaudie E, Foucher F, Narducci F, Loaec C, Gouy S, Guyon F, Marchal F, Gladieff L, Martínez-Gómez C, Migliorelli F, Martinez A, Ferron G. Comparison of postoperative complications and quality of life between patients undergoing continent versus non-continent urinary diversion after pelvic exenteration for gynecologic malignancies. Int J Gynecol Cancer 2019; 30:233-240. [PMID: 31796531 DOI: 10.1136/ijgc-2019-000863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/26/2019] [Accepted: 10/01/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pelvic exenteration and its reconstructive techniques have been associated with high postoperative morbidity and a negative impact on patient quality of life. The aim of our study was to compare postoperative complications and quality of life in patients undergoing continent compared with non-continent urinary diversion after pelvic exenteration for gynecologic malignancies. METHODS We designed a multicenter study of patients from 10 centers who underwent an anterior or total pelvic exenteration with urinary reconstruction for histologically confirmed persistent or recurrent gynecologic malignancy after previous treatment with radiotherapy. From January 2005 to September 2008, we included patients retrospectively, and from September 2008 to May 2009, patients were included prospectively which allowed collection of quality of life data. Demographic, surgical, and follow-up data were analyzed. Postoperative complications were classified according to the Clavien-Dindo classification. Quality of life was assessed using the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C30 (V.3.0) and EORTC-QLQ-OV28 quality of life questionnaires. We compared patients who underwent a continent urinary diversion with those who underwent a non-continent reconstruction. RESULTS We included 148 patients, 92 retrospectively and 56 prospectively. Among them, 77.4% had recurrent disease and 22.6% persistent disease after the primary treatment. In 70 patients, a urinary continent diversion was performed, and 78 patients underwent a non-continent diversion. Median age of the continent and incontinent groups was 53.5 (range 33-78) years and 57 (26-79) years, respectively. There were no significant differences between the continent and non-continent groups in median length of hospitalization (28.5 vs 26 days, P=0.19), postoperative grade III-IV complications (42.9% vs 42.3%, P=0.95), complications needing surgical (27.9% vs 34.6%, P=0.39) or radiological (14.7% vs 12.8%, P=0.74) intervention, and complication type (digestive (23.2% vs 16.7%, P=0.32) and urinary (15.9% vs 16.7%, P=0.91)). There were no significant differences between the groups in global health, global quality of life, and body image perception scores 1 year after surgery. CONCLUSION Continent and incontinent urinary reconstructions are equivalent in terms of postoperative complications and quality of life scores.
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Affiliation(s)
- Martina Aida Angeles
- Surgical Oncology, Institut Claudius Regaud IUCT-oncopole, Toulouse, Occitanie, France
| | - Estelle Mallet
- Surgical Oncology, Centre Antoine-Lacassagne, Nice, Provence-Alpes-Côte d'Azu, France
| | - Philippe Rouanet
- Department of Surgical Oncology, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Bastien Cabarrou
- Biostatistics Unit, Institut Claudius Regaud, Toulouse, Occitanie, France
| | - Pierre Méeus
- Department of Surgical Oncology, Institut Léon Bérard, Lyon, France
| | | | - Fabrice Foucher
- Department of Surgical Oncology, Centre Eugene Marquis, Rennes, Bretagne, France
| | | | - Cécile Loaec
- Institut de Cancerologie de l'Ouest, Nantes, France
| | - Sebastien Gouy
- Institut Gustave-Roussy, Villejuif, Île-de-France, France
| | | | - Frédéric Marchal
- Surgical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-les-Nancy, Lorraine, France
| | - Laurence Gladieff
- Medical Oncology, Institut Claudius Regaud, Toulouse, Occitanie, France
| | - Carlos Martínez-Gómez
- Surgical Oncology, Institut Claudius Regaud IUCT-oncopole, Toulouse, Occitanie, France.,INSERM CRCT 1, Toulouse, France
| | - Federico Migliorelli
- Department of Women, Children and Adolescents, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - Alejandra Martinez
- INSERM CRCT 1, Toulouse, France.,Institut Claudius Regaud, Toulouse, Occitanie, France
| | - Gwenael Ferron
- Institut Claudius Regaud, Toulouse, Occitanie, France .,INSERM CRCT 19, Toulouse, France
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Komori K, Okuno N, Kinoshita T, Oshiro T, Ouchi A, Ito S, Abe T, Senda Y, Misawa K, Ito Y, Uemura N, Natsume S, Higaki E, Okuno M, Hosoi T, An B, Hayashi D, Uchino T, Kunitomo A, Oki S, Takano J, Suenaga Y, Maeda S, Dei H, Numata Y, Shimizu Y. Ileal conduit necrosis after total pelvic exenteration for recurrence of gastrointestinal stromal tumor. NAGOYA JOURNAL OF MEDICAL SCIENCE 2019; 81:529-534. [PMID: 31579343 PMCID: PMC6728196 DOI: 10.18999/nagjms.81.3.529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a case of ileal conduit necrosis after total pelvic exenteration for recurrence of gastrointestinal stromal tumor. A 47-year-old man was diagnosed with recurrence of gastrointestinal stromal tumor adjacent to the prostate after abdominoperineal resection 10 years prior. With imatinib administration for 18 months, the local recurrence decreased in size but did not separate from the prostate. We performed urinary diversion with conventional total pelvic exenteration. Ileal conduit necrosis was suspected the following day and emergency surgery was performed. The serosa of the ileal conduit showed segmental necrosis extending about 10 cm from the orifice. The ureterointestinal anastomotic site was opposite the orifice and was not necrotic. We resected the necrotic ileum and reconstructed an ileal conduit. The patient was discharged without any symptoms 46 days after surgery for further adjustment to use of a urostomy.
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Affiliation(s)
- Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozumi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takashi Kinoshita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Taihei Oshiro
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Akira Ouchi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshiki Senda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazunari Misawa
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yuichi Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Norihisa Uemura
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Eigi Higaki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masataka Okuno
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Byonggu An
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Daisuke Hayashi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tairin Uchino
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Aina Kunitomo
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Satoshi Oki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Jin Takano
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhito Suenaga
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shingo Maeda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hideyuki Dei
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshihisa Numata
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
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Pelvic exenterations for gynecologic cancers: A retrospective analysis of a 30-year experience in a cancer center. Eur J Surg Oncol 2018; 44:1929-1934. [PMID: 30262326 DOI: 10.1016/j.ejso.2018.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The objective of this study was to report a 30-year experience of PE for gynecologic malignancies in a cancer center. MATERIALS AND METHODS A retrospective study was conducted at Institut Paoli-Calmette including patients who underwent PE for gynecologic malignancies. Four periods were evaluated: P1 before 1992, P2 between 1993 and 1999, P3 between 2000 and 2006 and P4 after 2006. The study evaluated the number of PE performed during each period, the type of PE, its level, indication, location of the primary tumor, patient age, previous radiotherapy ≥45 Gy, the rate of "curative" PE and exenteration-related reconstructive techniques. 90-day post-operative mortality and morbidity using the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) v 4.03 were reported. RESULTS 277 PE were performed. The number of PE performed for recurrences rose during the study period (p = 0.042), PE performed for central tumors increased during P3 (64.4%) and P4 (67.4%) (p < 0.0001) and administration of radiotherapy ≥45 Gy was more frequent (p < 0.0001). The rate of "curative" PE increased (p < 0.0001). In multivariate analysis, "curative" PE were correlated with PE type, central locations and study period. Pelvic filling was progressively more frequently performed (p = 0.002). 90-day complication rate was 56.3%. In multivariate analysis there was a significant difference in distribution of CTCAE grade 3-4-5 morbidity depending on the period. Overall survival (OS) improved during the 2 last periods (p = 0.008). CONCLUSION A better selection of eligible patients for PE, namely through improvement in imaging techniques, has enabled to raise the rate of curative PE.
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Abstract
BACKGROUND Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).
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Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: a single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010. Am J Surg 2014; 209:352-62. [PMID: 25524284 DOI: 10.1016/j.amjsurg.2014.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 12/05/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefits in terms of curative resection and survival of pelvic exenterations for specific extraluminal pelvic recurrences from rectal cancer in the era of total mesorectal excision were assessed. METHODS We conducted a single-center review of patients with extraluminal pelvic recurrence from colorectal cancer between March 2004 and November 2010. Twenty-seven pelvic exenterations (13 posterior and 14 total) were performed. Independent predicative factors such as age, sex, local control on first surgery, pelvic sidewall excision, initial International Union Against Cancer (UICC) staging, sphincter-preserving resection at first surgery, tumor presentation on computed tomography and magnetic resonance imaging (pelvis sidewall involvement, number of fixation sites, ureteral involvement), local disease-free interval, previous symptoms, and postoperative treatment were analyzed. RESULTS No operative mortality was noted in this series. Overall morbidity rate was 74%; 22% of the patients developed severe complications. Complete surgical clearance (R0) was obtained in 63% of the patients. The rate of R0 resections was lower in total pelvic exenteration (57%) than in posterior pelvic exenteration (69%). Three years overall survival and disease-free survival were 76% and 59%, respectively. Curative resection (R0) was the only independent prognostic factor for overall survival (P = .0016) and disease-free survival (P < .0001). CONCLUSION Pelvic exenterations for extraluminal pelvic recurrences from rectal cancer afford a high R0 resection rate with acceptable morbidity.
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Short-term outcomes after incontinent conduit for gynecologic cancer: Comparison of ileal, sigmoid, and transverse colon. Gynecol Oncol 2014; 133:563-7. [DOI: 10.1016/j.ygyno.2014.03.568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/25/2014] [Accepted: 03/26/2014] [Indexed: 11/19/2022]
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Urh A, Soliman PT, Schmeler KM, Westin S, Frumovitz M, Nick AM, Fellman B, Urbauer DL, Ramirez PT. Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2013; 129:580-5. [PMID: 23480870 PMCID: PMC3935607 DOI: 10.1016/j.ygyno.2013.02.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/13/2013] [Accepted: 02/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare outcomes of patients undergoing continent or incontinent urinary diversion after pelvic exenteration for gynecologic malignancies. METHODS Data on patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 were collected. A multivariate logistic regression model was used and statistical significance was P<0.05. RESULTS A total of 133 patients were included in this study. The mean age at exenteration was 47.6 (range, 30-73) years in the continent urinary diversion group and 57.2 (range, 27-86) years in the incontinent urinary diversion group (P<0.0001). Forty-six patients (34.6%) had continent urinary diversion, and 87 patients (65.4%) had incontinent urinary diversion. The rates of postoperative complications in patients with continent and incontinent urinary diversion, respectively, were as follows: pyelonephritis, 32.6% versus 37.9% (P=0.58); urinary stone formation, 34.8% versus 2.3% (P<0.001); renal insufficiency, 4.4% versus 14.9% (P=0.09); urostomy stricture, 13.0% versus 1.2% (P=0.007); ureteral (anastomotic) leak, 4.4% versus 6.9% (P=0.71); ureteral (anastomotic) stricture, 13.0% versus 23% (P=0.25); fistula formation, 21.7% versus 19.5% (P=0.82); and reoperation because of complications of urinary diversion, 6.5% versus 2.3% (P=0.34). Among patients with continent urinary diversion, the incidence of incontinence was 28.3%, and 15.2% had difficulty with self-catheterization. CONCLUSION There were no differences in postoperative complications between patients with continent and incontinent conduits except that stone formation was more common in patients with continent conduits.
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Affiliation(s)
- Anze Urh
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas 77030, United States
| | - Pamela T. Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Shannon Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Alpa M. Nick
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Bryan Fellman
- Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Diana L. Urbauer
- Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
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Abstract
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.
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Affiliation(s)
- Joanie Mayer Hope
- Department of Obstetrics and Gynecology, New York University School of Medicine, 550 First Avenue, NBV 9E2, New York, NY 10016, USA
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Ferenschild FTJ, Vermaas M, Verhoef C, Ansink AC, Kirkels WJ, Eggermont AMM, de Wilt JHW. Total pelvic exenteration for primary and recurrent malignancies. World J Surg 2009; 33:1502-8. [PMID: 19421811 PMCID: PMC2691931 DOI: 10.1007/s00268-009-0066-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- F T J Ferenschild
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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11
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Ungar L, Palfalvi L, Novak Z. Primary pelvic exenteration in cervical cancer patients. Gynecol Oncol 2008; 111:S9-12. [PMID: 18775558 DOI: 10.1016/j.ygyno.2008.07.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 07/07/2008] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Laszlo Ungar
- Gynecologic Oncology Department, Hungarian National Cancer Institute, Hungary.
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Stolzenburg JU, Schwalenberg T, Liatsikos EN, Sakelaropoulos G, Rödder K, Hohenfellner R, Fisch M. Colon pouch (Mainz III) for continent urinary diversion. BJU Int 2007; 99:1473-7. [PMID: 17346278 DOI: 10.1111/j.1464-410x.2007.06767.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended. PATIENTS AND METHODS The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion. RESULTS The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea. CONCLUSIONS The Mainz pouch III is an alternative to other types of continent urinary diversion.
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Marnitz S, Köhler C, Müller M, Behrens K, Hasenbein K, Schneider A. Indications for primary and secondary exenterations in patients with cervical cancer. Gynecol Oncol 2006; 103:1023-30. [PMID: 16890276 DOI: 10.1016/j.ygyno.2006.06.027] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 05/08/2006] [Accepted: 06/15/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Simone Marnitz
- Department of Radiooncology, Charite Universitätsmedizin, Berlin, Germany
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Höckel M, Dornhöfer N. How to manage locally advanced primary and recurrent cancer of the uterine cervix: The surgeon's view. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.rigp.2005.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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