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Huepenbecker SP, Soliman PT, Meyer LA, Iniesta MD, Chisholm GB, Taylor JS, Wilke RN, Fleming ND. Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program. Gynecol Oncol 2024; 189:80-87. [PMID: 39042957 DOI: 10.1016/j.ygyno.2024.07.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols. METHODS We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006-12/30/2014) and after (1/1/2015-6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system. RESULTS Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%. CONCLUSIONS Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary B Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roni Nitecki Wilke
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Isohashi F, Yoshida K, Murakami N, Masui K, Ishihara S, Ohkubo Y, Kaneyasu Y, Kinoshita R, Kotsuma T, Takaoka Y, Tanaka E, Nagao A, Ogawa K, Yamazaki H. Reirradiation for recurrent gynecologic cancer using high-dose-rate brachytherapy in Japan: A multicenter survey on practice patterns and outcomes. Radiother Oncol 2024; 195:110269. [PMID: 38583719 DOI: 10.1016/j.radonc.2024.110269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE The aim of the study is to examine the present status of reirradiation with high-dose-rate (HDR) brachytherapy for recurrent gynecologic cancer in Japan and to determine the role of this therapy in clinical practice. MATERIALS AND METHODS A retrospective multicenter chart review was performed for reirradiation for gynecologic cancer using HDR brachytherapy. Each center provided information on patient characteristics, treatment outcomes, and complications. RESULTS The study included 165 patients treated at 9 facilities from 2000 to 2018. The analysis of outcomes included 142 patients treated with curative intent. The median follow-up time for survivors was 30 months (range 1-130 months). The 3-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 53 % (95 %CI: 42-63 %), 44 % (35-53 %), and 61 % (50-70 %) for cervical cancer; 100 % (NA), 64 % (30-85 %), and 70 % (32-89 %) for endometrial cancer; and 54 % (13-83 %), 38 % (6-72 %), and 43 % (6-78 %) for vulvar and vaginal cancer, respectively. In multivariate analysis, interval to reirradiation (<1 year) was a significant risk factor for OS, PFS and LC; Gross Tumor Volume (≥25 cm3) was a significant risk factor for OS. Toxicities were analyzed in all enrolled patients (n = 165). Grade ≥ 3 late toxicities occurred in 49 patients (30 %). A higher cumulative EQD2 (α/β = 3) was significantly associated with severe complications. CONCLUSION Reirradiation with HDR brachytherapy for recurrent gynecologic cancer is effective, especially in cases with a long interval before reirradiation.
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Affiliation(s)
- Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan.
| | - Ken Yoshida
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan; Department of Radiation Oncology, Juntendo University, Hongo, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunichi Ishihara
- Department of Radiology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan; Department of Radiology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yu Ohkubo
- Department of Radiation Oncology, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Hiroshima, Japan; Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Hiroshima, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiation Oncology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yuji Takaoka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Saito Yukoukai Hospital, Ibaraki, Osaka, Japan
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Vivod G, Omerzel M, Kovacevic N, Gasljevic G, Cilensek I, Sersa G, Cemazar M, Merlo S. Treatment of vulvar cancer recurrence with electrochemotherapy: a case-control study. Acta Oncol 2024; 63:351-357. [PMID: 38770722 PMCID: PMC11332505 DOI: 10.2340/1651-226x.2024.33241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/05/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Electrochemotherapy (ECT) is a combined treatment method based on electroporation and simultaneous chemotherapy. In cases where radiotherapy has previously been used, surgery is often the only treatment option for vulvar cancer recurrence with potential resection of clitoris, vagina, urethra or anal sphincter. The unique advantage of ECT is its selectivity for cancer cells while sparing the surrounding healthy tissue. The aim of the study was to compare the ECT treatment of vulvar cancer recurrence for non-palliative purposes with surgical treatment. MATERIALS AND METHODS Eleven patients with single vulvar cancer recurrence were treated with ECT and followed up for 12 months. As a control group, 15 patients with single vulvar cancer recurrence were treated with wide local excision. The following data were collected, analyzed and compared: Age, body mass index, comorbidities, histological type, location and size of vulvar cancer recurrence, treatment history, details of procedures and hospital stay. RESULTS The probability curves for local tumor control did not differ between the ECT group and the surgical group (p = 0.694). The mean hospital stay and the mean duration of procedure were statistically significantly shorter in the ECT group (p < 0.001). There were no statistically significant differences between the ECT and surgical groups in terms of mean body mass index, associated diseases, previous treatments, presence of lichen sclerosus, p16 status, gradus, anatomical site of the tumor, and type of anesthesia. CONCLUSION In this case-control study, treatment of vulvar cancer recurrence with ECT for non-palliative purposes was comparable to surgical treatment in terms of effectiveness. The results need to be confirmed in larger randomized trials.
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Affiliation(s)
- Gregor Vivod
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Masa Omerzel
- Department of Experimental Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Kovacevic
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gorana Gasljevic
- Department of Pathology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Ines Cilensek
- Institute of Histology and Embryology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gregor Sersa
- Department of Experimental Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia
| | - Maja Cemazar
- Department of Experimental Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Health Sciences, University of Primorska, Izola, Slovenia
| | - Sebastjan Merlo
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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Esmailzadeh A, Fakhari MS, Saedi N, Shokouhi N, Almasi-Hashiani A. A systematic review and meta-analysis on mortality rate following total pelvic exenteration in cancer patients. BMC Cancer 2024; 24:593. [PMID: 38750417 PMCID: PMC11095034 DOI: 10.1186/s12885-024-12377-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024] Open
Abstract
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.
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Affiliation(s)
- Arezoo Esmailzadeh
- Department of Obstetrics & Gynecology, Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Nafise Saedi
- Fellowship of Perinatology, Department of Gynecologic Oncology, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Shokouhi
- Fellowship of Female Pelvic Medicine and Reconstructive Surgery, Yas Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Almasi-Hashiani
- Department of Epidemiology, Arak University of Medical Sciences, Arak, Iran.
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran.
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Milanko NA, Kelly ME, Turner G, Kong J, Behrenbruch C, Mohan H, Guerra G, Warrier S, McCormick J, Heriot A. Evaluating postoperative hernia incidence and risk factors following pelvic exenteration. Int J Colorectal Dis 2024; 39:70. [PMID: 38717479 PMCID: PMC11078832 DOI: 10.1007/s00384-024-04638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
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.
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Affiliation(s)
- Nicole Anais Milanko
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
| | - Michael Eamon Kelly
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Trinity St James Cancer Institute, Dublin, Ireland
| | - Greg Turner
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Auckland District Health Board, Auckland, New Zealand
| | - Joeseph Kong
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Cori Behrenbruch
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Glen Guerra
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Satish Warrier
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Jacob McCormick
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
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Denys A, Thielemans S, Salihi R, Tummers P, van Ramshorst GH. Quality of Life After Extended Pelvic Surgery with Neurovascular or Bony Resections in Gynecological Oncology: A Systematic Review. Ann Surg Oncol 2024; 31:3280-3299. [PMID: 38082164 DOI: 10.1245/s10434-023-14649-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/09/2023] [Indexed: 03/10/2024]
Abstract
BACKGROUND Extended pelvic surgery with neurovascular or bony resections in gynecological oncology has significant impact on quality of life (QoL) and high morbidity. The objective of this systematic review was to provide an overview of QoL, morbidity and mortality following these procedures. METHODS The registered PROSPERO protocol included database-specific search strategies. Studies from 1966 onwards reporting on QoL after extended pelvic surgery with neurovascular or bony resections for gynecological cancer were considered eligible. All others were excluded. Study selection (Rayyan), data extraction, rating of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers. RESULTS Of 349 identified records, 121 patients from 11 studies were included-one prospective study, seven retrospective studies, and three case reports. All studies were of very low quality and with an overall serious risk of bias. Primary tumor location was the cervix (n = 78, 48.9%), vulva (n = 30, 18.4%), uterus (n = 21, 12.9%), endometrium (n = 15, 9.2%), ovary (n = 8, 4.9%), (neo)vagina (n = 3, 1.8%), Gartner duct/paracolpium (n = 1, 0.6%), or synchronous tumors (n = 3, 1.8%), or were not reported (n = 4, 2.5%). Bony resections included the pelvic bone (n = 36), sacrum (n = 2), and transverse process of L5 (n = 1). Margins were negative in 70 patients and positive in 13 patients. Thirty-day mortality was 1.7% (2/121). Three studies used validated QoL questionnaires and seven used non-validated measurements; all reported acceptable QoL postoperatively. CONCLUSIONS In this highly selected patient group, mortality and QoL seem to be acceptable, with a high morbidity rate. This comprehensive study will help to inform eligible patients about the outcomes of extended pelvic surgery with neurovascular or bony resections. Future collaborative studies can enable the collection of QoL data in a validated, uniform manner.
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Affiliation(s)
- Andreas Denys
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Sofie Thielemans
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Rawand Salihi
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
- Department of Gynecology and Obstetrics, AZ St. Lucas Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
| | - Gabrielle H van Ramshorst
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.
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Lazarovich A, Drori T, Guttman Y, Rosenzweig B, Ben-Yaaqov A, Korach J, Nissan A, Dotan Z. Urological outcomes following pelvic exenteration for non-urological malignancies. Heliyon 2024; 10:e29640. [PMID: 38644885 PMCID: PMC11031810 DOI: 10.1016/j.heliyon.2024.e29640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/17/2023] [Accepted: 04/11/2024] [Indexed: 04/23/2024] Open
Abstract
Background Pelvic exenteration (PE) is a major surgical procedure used as a salvage therapy for patients with locally advanced or recurrent pelvic malignancies. Urinary reconstruction is a major part of PE and is often associated with high rates of post-operative complications. In the current study we evaluate the short and long-term urological outcomes following PE for Colo-Rectal (CR) and gyneco-oncological (GO) malignancies. Methods Study included 22 patients who underwent PE for recurrent or locally advanced CR and GO malignancies in our institution between the years 2010-2018. The endpoint was post-operative freedom from urological complications. Results Of 22 patients included, 13 (59 %) and 9 (41 %) underwent PE for CR and GO malignancies respectively. The mean age of the patients was 54 years. The median follow-up was 19 months. Seven (78 %) patients with GO malignancy and 11 (85 %) with CR malignancy underwent PE for local recurrence. Hydronephrosis prior to surgery existed in 8 (36.3 %) patients, of which, 5 patients required kidney drainage via nephrostomy tube. Two patients underwent posterior pelvic exenteration (PPE) with bladder preservation whereas the remaining 20 underwent cystectomy with urinary diversion by ileal conduit. Hydronephrosis post PE developed in 13 patients (59 %). eight (36 %) patients needed kidney drainage by nephrostomy tubes post PE, of these, 6 (75 %) had disease recurrence. The 2 years freedom from kidney drainage was 68 %, however the median time for kidney drainage was 0.5 months. The median overall survival was 12.5 months. Conclusion The rate of urological complications following PE is relatively high and associated with disease recurrence.
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Affiliation(s)
- A. Lazarovich
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - T. Drori
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y. Guttman
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B. Rosenzweig
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Ben-Yaaqov
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J. Korach
- Department of Gynecological Oncology (GO), Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Nissan
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Z.A. Dotan
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Loverro M, Aloisi A, Tortorella L, Aletti GD, Kumar A. Trends and current aspects of reconstructive surgery for gynecological cancers. Int J Gynecol Cancer 2024; 34:426-435. [PMID: 38438169 DOI: 10.1136/ijgc-2023-004620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the surrounding bony pelvis and pelvic musculature. As opposed to advanced ovarian cancer, where cytoreduction is the goal, in these scenarios, an oncologic approach to achieve negative margins is critical for benefit. Surgeries aimed at achieving a R0 resection in gynecologic oncology can have a significant impact on pelvic anatomy, and require reconstruction. Overall, it appears that these types of radical surgery are less frequently performed; however, when required, multidisciplinary teams at high-volume centers can potentially improve short-term morbidity. There are few data to examine the long-term, quality-of-life outcomes after reconstruction following oncologic resection in advanced and recurrent gynecologic cancers. In this review we outline considerations and approaches for reconstruction after surgery for gynecologic cancers. We also discuss areas of innovation, including minimally invasive surgery and the use of 3D surgical anatomy models for improved surgical planning.In the era of 'less is more', pelvic exenteration in gynecologic oncology is still indicated when there are no other curative-intent alternatives in persistent or recurrent gynecological malignancies confined to the pelvis or with otherwise unmanageable symptoms from fistula or radiation necrosis. Pelvic exenteration is one of the most destructive procedures performed on an elective basis, which inevitably carries a significant psychologic, sexual, physical, and emotional burden for the patient and caregivers. Such complex ultraradical surgery, which requires removal of the vagina, vulva, urinary tract, and/or gastrointestinal tract, subsequently needs creative and complex reconstructive procedures. The additional removal of sidewall or perineal structures, like pelvic floor muscles/vulva, or portions of the musculoskeletal pelvis, and the inclusion of intra-operative radiation further complicates reconstruction. This review paper will focus on the reconstruction aspects following pelvic exenteration, including options for urinary tract restoration, reconstruction of the vulva and vagina, as well as how to fill large empty spaces in the pelvis. While the predominant gastrointestinal outcome after exenteration in gynecologic oncology is an end colostomy, we also present some novel new options for gastrointestinal tract reconstruction at the end.
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Affiliation(s)
- Matteo Loverro
- Department of Gynecology and Obstetrics, Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Alessia Aloisi
- Department of Gynecology, European Institute of Oncology, IEO, IRCCS, Milan, Italy
| | - Lucia Tortorella
- Department of Women, Child and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Damiano Aletti
- Department of Gynecology, European Institute of Oncology, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Ubinha ACF, Pedrão PG, Tadini AC, Schmidt RL, dos Santos MH, Andrade CEMDC, Longatto Filho A, dos Reis R. The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature. Cancers (Basel) 2024; 16:817. [PMID: 38398208 PMCID: PMC10886894 DOI: 10.3390/cancers16040817] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Ana Carla Franco Ubinha
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | - Priscila Grecca Pedrão
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (P.G.P.); (A.L.F.)
| | - Aline Cássia Tadini
- Barretos School of Health Sciences, Dr. Paulo Prata-FACISB, Barretos 14785-002, Brazil;
| | - Ronaldo Luis Schmidt
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | - Marcelo Henrique dos Santos
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | | | - Adhemar Longatto Filho
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (P.G.P.); (A.L.F.)
- Medical Laboratory of Medical Investigation (LIM), Department of Pathology, Medical School, University of São Paulo, São Paulo 01246-903, Brazil
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4805-017 Guimarães, Portugal
| | - Ricardo dos Reis
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
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10
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Watts R, Jackson D, Harris C, van Zundert A. Anaesthesia for pelvic exenteration surgery. BJA Educ 2024; 24:57-67. [PMID: 38304069 PMCID: PMC10829085 DOI: 10.1016/j.bjae.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 02/03/2024] Open
Affiliation(s)
- R. Watts
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - D. Jackson
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - C. Harris
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - A. van Zundert
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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11
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Yu JH, Tong CJ, Huang QD, Ye YL, Chen G, Li H, Wen YS, Yang F, Luo NB, Xu GY, Xiong Y. Long-term outcomes of pelvic exenterations for gynecological malignancies: a single-center retrospective cohort study. BMC Cancer 2024; 24:88. [PMID: 38229045 DOI: 10.1186/s12885-024-11836-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Recently, with the advancement of medical technology, the postoperative morbidity of pelvic exenteration (PE) has gradually decreased, and it has become a curative treatment option for some patients with recurrent gynecological malignancies. However, more evidence is still needed to support its efficacy. This study aimed to explore the safety and long-term survival outcome of PE and the feasibility of umbilical single-port laparoscopic PE for gynecologic malignancies in a single medical center in China. PATIENTS AND METHODS PE for gynecological cancers except for ovarian cancer conducted by a single surgical team in Sun Yat-sen University Cancer Center between July 2014 and December 2019 were included and the data were retrospectively analyzed. RESULTS Forty-one cases were included and median age at diagnosis was 53 years. Cervical cancer accounted for 87.8% of all cases, and most of them received prior treatment (95.1%). Sixteen procedures were performed in 2016 and before, and 25 after 2016. Three anterior PE were performed by umbilical single-site laparoscopy. The median operation time was 460 min, and the median estimated blood loss was 600 ml. There was no perioperative death. The years of the operations was significantly associated with the length of the operation time (P = 0.0018). The overall morbidity was 52.4%, while the severe complications rate was 19.0%. The most common complication was pelvic and abdominal infection. The years of surgery was also significantly associated with the occurrence of severe complication (P = 0.040). The median follow-up time was 55.8 months. The median disease-free survival (DFS) was 17.9 months, and the median overall survival (OS) was 25.3 months. The 5-year DFS was 28.5%, and the 5-year OS was 30.8%. CONCLUSION PE is safe for patient who is selected by a multi-disciplinary treatment, and can be a curative treatment for some patients. PE demands a high level of experience from the surgical team. Umbilical single-port laparoscopy was a technically feasible approach for APE, meriting further investigation.
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Affiliation(s)
- Jie-Hai Yu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Chong-Jie Tong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Qi-Dan Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Yun-Lin Ye
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Gong Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Head and Neck, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yong-Shan Wen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Fan Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Nan-Bin Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Guang-Yu Xu
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Ying Xiong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China.
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China.
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12
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Tortorella L, Marco C, Loverro M, Carmine C, Persichetti E, Bizzarri N, Barbara C, Francesco S, Foschi N, Gallotta V, Avesani G, Chiantera V, Ercoli A, Fanfani F, Fagotti A, Mele MC, Restaino S, Gueli Alletti S, Scambia G, Vizzielli G. Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: a large single-institution experience. J Gynecol Oncol 2024; 35:e4. [PMID: 37743057 PMCID: PMC10792212 DOI: 10.3802/jgo.2024.35.e4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/12/2023] [Accepted: 08/13/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE To evaluate pre-operative predictors of early (<30 days) severe complications (grade Dindo 3+) in patients with gynecological malignancy submitted to pelvic exenteration (PE). METHODS We retrospectively analyzed 129 patients submitted to surgery at Fondazione Policlinico Gemelli between 2010 and 2019. We included patients affected by primary or recurrent/persistent cervical, endometrial, or vulvar/vaginal cancers. Post-operative complications were graded according to the Dindo classification. Logistic regression was used to analyze potential predictors of complications. RESULTS We performed 63 anterior PE, 10 posterior PE, and 56 total PE. The incidence of early severe post-operative complications was 27.9% (n=36), and the early mortality rate was 2.3% (n=3). More frequent complications were related to the urinary diversion and intestinal surgery. In univariable analysis, hemoglobin ≤10 g/dL (odds ratio [OR]=4.2; 95% confidence interval [CI]=1.65-10.7; p=0.003), low albumin levels (OR=3.9; 95% CI=1.27-12.11; p=0.025), diabetes (OR=4.15; 95% CI=1.22-14.1; p=0.022), 2+ comorbidities at presentation (OR=5.18; 95% CI=1.49-17.93; p=0.012) were predictors of early severe complications. In multivariable analysis, only low hemoglobin and comorbidities at presentation were independent predictors of complications. CONCLUSION Pelvic exenteration is an aggressive surgery characterized by a high rate of post-operative complications. Pre-operative assessment of comorbidities and patient health status are crucial to better select the right candidate for this type of surgery.
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Affiliation(s)
- Lucia Tortorella
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Cintoni Marco
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Matteo Loverro
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Conte Carmine
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Eleonora Persichetti
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Nicolò Bizzarri
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Costantini Barbara
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Santullo Francesco
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nazario Foschi
- Clinica Urologica, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Valerio Gallotta
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Giacomo Avesani
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS Ospedali Civico Di Cristina Benfratelli, University of Palermo, Palermo, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Francesco Fanfani
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Cristina Mele
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics And Gynecology, Ospedale Buccheri La Ferla - Fatebenefratelli, Palermo, Italy
| | - Giovanni Scambia
- Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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13
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Zhuang M, Chen H, Li Y, Mei S, Liu J, Du B, Wang X, Wang X, Tang J. Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative. Tech Coloproctol 2023; 27:1109-1117. [PMID: 37243857 DOI: 10.1007/s10151-023-02824-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients. METHOD From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared. RESULTS A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295 min, p = 0.009), blood loss (100 vs. 300 ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13 days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR 1.02, p = 0.002), poor tumor differentiation (HR 3.05, p = 0.004), and (y)pT4b stage (HR 2.35, p = 0.035) were independent risk factors for disease-free survival. CONCLUSION LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.
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Affiliation(s)
- M Zhuang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - H Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Y Li
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - S Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - J Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - B Du
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - X Wang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - J Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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14
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Macciò A, Sanna E, Piras R, Lavra F, Vallerino V, Maricosu G, Giglio E, Mura A, Tidore M, Madeddu C. Survival as a clinical outcome and its spiritual significance in a cohort of patients with advanced central pelvic neoplastic disease undergoing total pelvic evisceration: a poorly debated issue. Front Med (Lausanne) 2023; 10:1173687. [PMID: 37359011 PMCID: PMC10288149 DOI: 10.3389/fmed.2023.1173687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Background Patients with either treatment-resistant or relapsing advanced central pelvic neoplastic disease present with a condition responsible for debilitating symptoms and consequently poor quality of life (QoL). For these patients, therapeutic strategies are very limited and total pelvic evisceration is the only option for relieving the symptoms and increasing survival. Of note, taking charge of these patients cannot be limited to increasing their lifespan but must also be aimed at improving the clinical, psychological, and spiritual conditions. This study aimed to prospectively evaluate the improvement in survival and QoL, focusing on spiritual wellbeing (SWB), in patients with poor life expectancy who underwent total pelvic evisceration for advanced gynecological cancers at our center. Patients and methods The QoL and SWB were assessed using the European Organisation for Research and Treatment of Cancer QoL questionnaire (EORTC QLQ-C30), EORTC QLQ-SWB32, and SWB scale, which were repeatedly administered: 30 days before surgery, 7 days after the procedure, 1 and 3 months after surgery, and then every 3 months until death or the last follow-up assessment. Operative outcomes (blood loss, operative time, hospitalization, and incidence of complications) were evaluated as secondary endpoints. The patients and their families were included in a dedicated psycho-oncological and spiritual support protocol, which was managed by specifically trained and specialized personnel who accompanied them during all phases of the study. Results A total of 20 consecutive patients from 2017 to 2022 were included in this study. Of these patients, 7 underwent total pelvic evisceration by laparotomy and 13 underwent laparoscopy. The median survival was 24 months (range: 1-61 months). After a median follow-up of 24 months, 16 (80%) and 10 patients (50%) were alive at 1 year and 2 years after surgery, respectively. The EORTC-QLQ-C30 scores significantly improved yet at 7 days and at 1, 3, 6, and 12 months, as compared with the preoperative values. In particular, an early improvement in pain, overall QoL, and physical and emotional functions was observed. With respect to the SWB, the global SWB item score of the EORTC QLQ-SWB32 questionnaire significantly increased after 1 month and 3 months, as compared with preoperative values (p = 0.0153 and p = 0.0018, respectively), and remained stable thereafter. The mean SWB scale score was 53.3, with a sense of low overall SWB in 10 patients, a sense of moderate SWB in eight patients, and a sense of high SWB in two patients. The SWB scale score significantly increased after 7 days, 1 month, and 3 months, as compared with the preoperative value (p = 0202, p = 0.0171, and p = 0.0255, respectively), and remained stable thereafter. Conclusion Total pelvic evisceration is a valid approach for improving both survival and QoL in selected patients with advanced pelvic neoplasms and poor life expectancy. Our results particularly underline the importance of accompanying the patients and their families during the journey with dedicated psychological and spiritual support protocols.
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Affiliation(s)
- Antonio Macciò
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Elisabetta Sanna
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | - Roberta Piras
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | - Fabrizio Lavra
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | - Valerio Vallerino
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | - Giovanni Maricosu
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | - Emanuela Giglio
- Unit of Obstetrics and Gynecology, Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, Italy
| | | | | | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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15
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Vivod G, Bosnjak M, Kovacevic N, Sersa G, Merlo S, Cemazar M. Safety and Feasibility of Vulvar Cancer Treatment with Electrochemotherapy. Cancers (Basel) 2023; 15:3079. [PMID: 37370690 DOI: 10.3390/cancers15123079] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Electrochemotherapy is a local ablative therapy used for the treatment of various superficial and deep-seated tumors. Electrochemotherapy involves the application of electric pulses locally to tumors to destabilize cell membranes and facilitate the entry of cytotoxic drugs, thereby enhancing their cytotoxicity locally. The aim of our study is to investigate the safety and feasibility of electrochemotherapy in patients with vulvar cancer recurrence used for nonpalliative purposes. Ten patients with single local vulvar cancer recurrence were treated with intravenous bleomycin, followed by a local application of electric pulses (electrochemotherapy) to the tumor. Adverse events were determined using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The feasibility of treating vulvar cancer with electrochemotherapy was determined by an appropriate selection of electrodes based on the size and location of the tumor with safety margins included. Electrochemotherapy was feasible in all patients. No electrochemotherapy-related or other serious adverse events occurred. Our data suggest that electrochemotherapy is a feasible and safe technique for the treatment of vulvar cancer recurrence for nonpalliative purposes. Based on our results, electrochemotherapy might be a viable therapeutic tool for patients who would otherwise undergo surgery involving a mutilation of the external genitalia.
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Affiliation(s)
- Gregor Vivod
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Masa Bosnjak
- Department of Experimental Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Nina Kovacevic
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Health Care Angela Boskin, 4270 Jesenice, Slovenia
| | - Gregor Sersa
- Department of Experimental Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Sebastjan Merlo
- Department of Gynecological Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Maja Cemazar
- Department of Experimental Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Health Sciences, University of Primorska, 6000 Izola, Slovenia
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16
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Moolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhuijzen LRCW, Mom CH, Zaal A. Clinical outcomes of pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2023; 171:114-120. [PMID: 36870097 DOI: 10.1016/j.ygyno.2023.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES The aim of this study was to analyze morbidity and survival after pelvic exenteration for gynecologic malignancies and evaluate prognostic factors influencing postoperative outcome. METHODS We retrospectively reviewed all patients who underwent a pelvic exenteration at the departments of gynecologic oncology of three tertiary care centers in the Netherlands, the Leiden University Medical Centre, the Amsterdam University Medical Centre, and the Netherlands Cancer Institute, during a 20-year period. We determined postoperative morbidity, 2- and 5-year overall survival (OS) and 2- and 5-year progression free survival (PFS), and investigated parameters influencing these outcomes. RESULTS A total of 90 patients were included. The most common primary tumor was cervical cancer (n = 39, 43.3%). We observed at least one complication in 83 patients (92%). Major complications were seen in 55 patients (61%). Irradiated patients had a higher risk of developing a major complication. Sixty-two (68.9%) required ≥1 readmission. Re-operation was required in 40 patients (44.4%). Median OS was 25 months and median PFS was 14 months. The 2-year OS rate was 51.1% and the 2-year PFS rate was 41.5%. Tumor size, resection margins and pelvic sidewall involvement had a negative impact on OS (HR = 2.159, HR = 2.376, and HR = 1.200, respectively). Positive resection margins and pelvic sidewall involvement resulted in decreased PFS (HR = 2.567 and HR = 3.969, respectively). CONCLUSION Postoperative complications after pelvic exenteration for gynecologic malignancies are common, especially in irradiated patients. In this study, a 2-year OS rate of 51.1% was observed. Positive resections margins, tumor size, and pelvic sidewall involvement were related to poor survival outcomes. Adequate selection of patients who will benefit from pelvic exenteration is important.
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Affiliation(s)
- L R Moolenaar
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E van Rangelrooij
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - M I E van Poelgeest
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - M van Beurden
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - W J van Driel
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - L R C W van Lonkhuijzen
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - C H Mom
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands.
| | - A Zaal
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
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Xu C, Garda AE, Kumar A. R0 Resection in Recurrent Gynecologic Malignancy: Pelvic Exenteration and Beyond. Curr Treat Options Oncol 2023; 24:262-273. [PMID: 36847987 DOI: 10.1007/s11864-023-01055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 03/01/2023]
Abstract
OPINION STATEMENT Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more conservative therapies. Mortality and morbidity outcomes have improved over time, but there are still significant peri-operative risks. Considerations before pursing pelvic exenteration must include the likelihood of oncologic cure and patients' fitness to undergo such a procedure, particularly given the high rate of surgical morbidity. Pelvic sidewall tumors have been a traditional contraindication for pelvic exenteration due to the difficulty in obtaining negative margins, but the use of laterally extended endopelvic resection and intra-operative radiation therapy allows for more radical resection of recurrent disease. We believe that these procedures to achieve R0 resection can expand the use of curative-intent surgery in recurrent gynecologic cancer, but require the surgical expertise of colleagues in orthopedic and vascular surgery and collaboration with plastic surgery for complex reconstruction and optimization of post-operative healing. Surgery of recurrent gynecologic cancer including pelvic exenteration, requires careful patient selection, pre-operative medical optimization and prehabilitation, and thorough counseling to optimize outcomes, both oncologic and peri-operative. We believe the creation of a well-developed team, including surgical teams and supportive care services, can lead to the best patient outcomes and improved professional satisfaction amongst providers.
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Affiliation(s)
- Conway Xu
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amanika Kumar
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
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Terao Y. Cutting-edge Treatment for Gynecological Malignancies. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2023; 69:86-91. [PMID: 38854450 PMCID: PMC11153064 DOI: 10.14789/jmj.jmj22-0044-r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/16/2023] [Indexed: 06/11/2024]
Abstract
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.
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Harji DP, Houston F, Cutforth I, Hawthornthwaite E, McKigney N, Sharpe A, Coyne P, Griffiths B. The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2022; 104:611-617. [PMID: 35639482 PMCID: PMC9680687 DOI: 10.1308/rcsann.2022.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. METHODS A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. RESULTS In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001). CONCLUSIONS Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.
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Affiliation(s)
| | | | | | | | | | - A Sharpe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - P Coyne
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - B Griffiths
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Ling H, Wang G, Yi B, Li Z, Zhu S. Clavien-Dindo classification and risk prediction model of complications after robot-assisted radical hysterectomy for cervical cancer. J Robot Surg 2022; 17:527-536. [PMID: 35913623 DOI: 10.1007/s11701-022-01450-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
Although significant progress has been made with surgical methods, the incidence of complications after minimally invasive surgery in patients with cervical cancer remains high. Established as a standardized system, Clavien-Dindo classification (CDC) has been applied in a variety of surgical fields. This study is designed to evaluate the complications after robot-assisted radical hysterectomy (RRH) for cervical cancer using CDC and further establish a prediction model. This is a study on the development of prediction model based on retrospective data. Patients with cervical cancer who received RRH treatment in our hospital from January 2016 to April 2019 were invited to participate in the study. The demographic data, laboratory and imaging examination results and postoperative complications were collected, and the logistic regression model was applied to analyze the risk factors possibly related to complications to establish a prediction model. 753 patients received RRH. The overall incidence of complications was 32.7%, most of which were grade I and grade II (accounting for 30.6%). The results of multivariate analysis showed that the preoperative neoadjuvant chemotherapy (OR = 1.693, 95%CI: 1.210-2.370, P = 0.002), preoperative ALT (OR = 1.028, 95%CI: 1.017-1.039, P < 0.001), preoperative urea nitrogen (OR = 0.868, 95%CI: 0.773-0.974, P = 0.016), preoperative total bilirubin (OR = 0.958, 95%CI: 0.925-0.993, P = 0.0.018), and preoperative albumin (OR = 0.937, 95%CI: 0.898-0.979, P = 0.003) were related to the occurrence of postoperative complications. The area under the curve (AUC) of receiver-operating characteristic (ROC) in the prediction model of RRH postoperative complications established based on these five factors was 0.827 with 95% CI of 0.794-0.860. In patients undergoing robot-assisted radical hysterectomy for cervical cancer, preoperative ALT level, urea nitrogen level, total bilirubin level, albumin level, and neoadjuvant chemotherapy were significantly related to the occurrence of postoperative complications. The regression prediction model established on this basis showed good prediction performance with certain clinical promotion and reference value.
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Affiliation(s)
- Hao Ling
- The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China.,College of Mechanical and Electrical Engineering, Central South University, Changsha, 410082, Hunan, People's Republic of China
| | - Guohui Wang
- The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Bo Yi
- The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Zheng Li
- The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Shaihong Zhu
- The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China.
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Pleth Nielsen CK, Sørensen MM, Christensen HK, Funder JA. Complications and survival after total pelvic exenteration. Eur J Surg Oncol 2022; 48:1362-1367. [PMID: 34998633 DOI: 10.1016/j.ejso.2021.12.472] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/26/2021] [Accepted: 12/29/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival. METHODS Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed. RESULTS The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients. CONCLUSION The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
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22
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Persson P, Chong P, Steele C, Quinn M. Prevention and management of complications in pelvic exenteration. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2277-2283. [PMID: 35101315 DOI: 10.1016/j.ejso.2021.12.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
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Utilization and perioperative outcome of minimally invasive pelvic exenteration in gynecologic malignancies: A national study in the United States. Gynecol Oncol 2021; 161:39-45. [PMID: 33402282 DOI: 10.1016/j.ygyno.2020.12.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/22/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy. METHODS This comparative effectiveness study is a retrospective population-based analysis of the National Inpatient Sample from 10/2008-9/2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were evaluated based on the use of laparoscopic or robotic-assisted surgery. Patient demographics and intraoperative/postoperative complications related to a minimally invasive surgical approach were assessed. RESULTS Among 1376 women who underwent pelvic exenteration, 49 (3.6%) had the procedure performed via a minimally invasive approach. The majority of minimally invasive cases were robotic-assisted (51.0%). Women in the minimally invasive group were more likely to be old, white, have cervical/uterine cancers, and receive urinary diversion, but less frequently received vaginal reconstruction or colostomy when compared to those in the open surgery group (P < 0.05). Overall perioperative complication rates were similar between the minimally invasive and open surgery groups (79.6% versus 77.7%, P = 0.862), but the minimally invasive group had a decreased risk of high-risk complications compared to the open surgery group (adjusted-odds ratio 0.19, 95% confidence interval 0.07-0.51). Specifically, a minimally invasive approach was associated with decreased incidence of sepsis and thromboembolism compared to an open approach (P < 0.05). The minimally invasive group had a shorter length of stay (median, 9 versus 14 days) and lower total charge (median, $127,875 versus $208,591) compared to the open surgery group (P < 0.05). CONCLUSION Laparotomy remains the main surgical approach for pelvic exenteration for gynecologic malignancy and minimally invasive surgery was infrequently utilized during the study period in the United States. Before widely adopting this surgical approach, the utility and role of minimally invasive pelvic exenteration requires further investigation.
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Martínez-Gómez C, Angeles MA, Martinez A, Malavaud B, Ferron G. Urinary diversion after pelvic exenteration for gynecologic malignancies. Int J Gynecol Cancer 2021; 31:1-10. [PMID: 33229410 PMCID: PMC7803898 DOI: 10.1136/ijgc-2020-002015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/03/2022] Open
Abstract
Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.
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Affiliation(s)
- Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Team 1, Tumor Immunology and Immunotherapy, Cancer Research Center of Toulouse (CRCT) - INSERM UMR 1037, Toulouse, France
| | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Team 1, Tumor Immunology and Immunotherapy, Cancer Research Center of Toulouse (CRCT) - INSERM UMR 1037, Toulouse, France
| | - Bernard Malavaud
- Department of Urology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Gwenael Ferron
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Team 19, ONCOSARC - Oncogenesis of Sarcomas, Cancer Research Center of Toulouse (CRCT) - INSERM UMR 1037, Toulouse, France
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25
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Pelvic Exenteration for Primary Advanced and Recurrent Vaginal Cancer: Clinical Outcome for 37 Patients. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Matsuo K, Matsuzaki S, Mandelbaum RS, Matsushima K, Klar M, Grubbs BH, Roman LD, Wright JD. Hospital surgical volume and perioperative mortality of pelvic exenteration for gynecologic malignancies. J Surg Oncol 2020; 121:402-409. [PMID: 31746006 PMCID: PMC7523231 DOI: 10.1002/jso.25770] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES To examine the association between hospital surgical volume and perioperative mortality of pelvic exenteration performed for gynecologic malignancies. METHODS A population-based retrospective study utilizing the Nationwide Inpatient Sample was conducted to examine pelvic exenteration for gynecologic malignancies from 2001 to 2011. Annualized hospital surgical volume was defined as the average number of procedures a hospital performed per year in which at least one case was performed, and this was correlated to perioperative mortality. RESULTS A total 1912 exenterations performed at 181 centers were included. Nearly two thirds of exenteration-performing centers had a minimum surgical volume of one case per year (121 centers, 66.9%). Perioperative mortality rate was 1.8%. In multivariable analysis surgical volume remained an independent factor for perioperative mortality (adjusted-odds ratio 0.21; 95% confidence interval, 0.09-0.49; P < .001). Perioperative mortality rates were 3.7% for the centers with minimum surgical volume (1 exenteration a year), 1.4% for the centers performing more than one but two or less exenterations a year, and 0% for the top decile centers (>2 exenterations a year), respectively (P < .001). CONCLUSION Pelvic exenteration for gynecologic malignancy is a rare surgical procedure with most hospitals performing few cases annually. A higher surgical volume of pelvic exenteration was associated with lower perioperative mortality.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Rachel S. Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany
| | - Brendan H. Grubbs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Lynda D. Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jason D. Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases. Tech Coloproctol 2020; 24:181-190. [DOI: 10.1007/s10151-019-02141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
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Peacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, Heriot AG, Frizelle FA, McCormick JJ. Complications After Extended Radical Resections for Locally Advanced and Recurrent Pelvic Malignancies: A 25-Year Experience. Ann Surg Oncol 2019; 27:409-414. [PMID: 31520213 DOI: 10.1245/s10434-019-07816-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The oncological role of pelvic exenteration for locally advanced and recurrent pelvic malignancies arising from the anorectum, gynaecological, or urological systems is now well-established. Despite this, the surgical community has been slow to accept pelvic exenteration, undoubtedly due to concerns about high morbidity and mortality rates. This study assessed the general major complications and predictors of morbidity following extended radical resections for locally advanced and recurrent pelvic malignancies. METHODS Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were major complications (Clavien-Dindo 3 or above) and predictors for morbidity. RESULTS A total of 646 consecutive patients required extended surgery for local advanced pelvic malignancies. The median age was 63 (range 19-89) years, and the majority were female (371; 57.4%). One or more major complications were observed in 106 patients (16.4%). The most common major complications were intra-abdominal collection (43.7%; n = 59/135) and wound infection (14.1%; n = 19/135). The overall inpatient mortality rate was 0.46% (n = 3/646). Independent predictors for major morbidity following surgery for locally advanced or recurrent pelvic malignancies were squamous cell carcinoma of anus, sacrectomy, and blood transfusion requirement. CONCLUSIONS This series adds increasing evidence that good outcomes can be achieved for extended radical resections in locally advanced and recurrent pelvic malignancies. A coordinated approach in specialist centres for beyond TME surgery demonstrates that this is a safe and feasible procedure, offering low major complication rates.
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Affiliation(s)
- Oliver Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joseph C Kong
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Satish K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Chris Wakeman
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Tim Eglinton
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Alexander G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Frank A Frizelle
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Jacob J McCormick
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 412] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Matsuo K, Mandelbaum RS, Adams CL, Roman LD, Wright JD. Performance and outcome of pelvic exenteration for gynecologic malignancies: A population-based study. Gynecol Oncol 2019; 153:368-375. [PMID: 30792003 DOI: 10.1016/j.ygyno.2019.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/29/2019] [Accepted: 02/04/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine changes in performance and outcomes of pelvic exenteration for gynecologic malignancies. METHODS This is a population-based retrospective study examining the Nationwide Inpatient Sample between 2001 and 2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were examined. Comorbidity, perioperative complications, total charges, length of stay, and mortality were assessed. RESULTS There were 2647 cases included. Cervical cancer was the most common malignancy (45.1%), followed by vaginal cancer (27.6%). 26.9% of women had a Charlson Comorbidity Index ≥3, which significantly increased from 23.3% in 2001-2005 to 33.3% in 2011-2015 (42.9% relative increase, P < 0.001). Obese women undergoing exenteration increased significantly from 4.5% in 2001-2005 to 19.4% in 2011-2015 (3.3-fold relative increase, P < 0.001). The perioperative complication rate was 68.1%, including 38.7% with multiple complications. The mortality rate was 1.9%. The number of women with multiple perioperative complications increased from 29.4% in 2001-2005 to 52.8% in 2011-2015 (78.6% relative increase, P < 0.001). More recent year of surgery, obesity, higher comorbidity, higher household income, surgery at large bedsize hospital, urinary diversion, vaginal reconstruction, and vulvar cancer were associated with an increased risk of multiple complications on multivariable analysis (all, P < 0.05). Median length of stay was 14 (IQR 9-21) days, and the number of women hospitalized ≥28 days significantly increased from 12.6% in 2001-2005 to 19.1% in 2011-2015 (51.6% relative increase, P < 0.001). The median corrected total charges increased from $121,854 to $185,100 between 2001 and 2015 (net difference +$63,246, 51.9% relative increase, P < 0.001). CONCLUSION Women undergoing pelvic exenteration for gynecologic malignancies became more obese and comorbid during the study period. Pelvic exenteration for women with gynecologic malignancies is associated with high morbidity and mortality as well as substantial treatment-related costs.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Crystal L Adams
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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