Pelvic exenteration

Quality of Life After Extended Pelvic Surgery with Neurovascular or Bony Resections in Gynecological Oncology: A Systematic Review

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.

Quality of life after extended pelvic exenterations

BACKGROUND

The aim of the study was to compare health-related quality of life (QoL) and oncological outcome between gynaecological cancer patients undergoing pelvic exenteration (PE) and extended pelvic exenteration (EPE). EPEs were defined as extensive procedures including, in addition to standard PE extent, the resection of internal, external, or common iliac vessels; pelvic side-wall muscles; large pelvic nerves (sciatic or femoral); and/or pelvic bones.

METHODS

Data from 74 patients who underwent PE (42) or EPE (32) between 2004 and 2019 at a single tertiary gynae-oncology centre in Prague were analysed. QoL assessment was performed using EORTC QLQ-C30, EORTC CX-24, and QOLPEX questionnaires specifically developed for patients after (E)PE.

RESULTS

No significant differences in survival were observed between the groups (P > 0.999), with median overall and disease-specific survival in the whole cohort of 45 and 49 months, respectively. Thirty-one survivors participated in the QoL surveys (20 PE, 11 EPE). No significant differences were observed in global health status (P = 0.951) or in any of the functional scales. The groups were not differing in therapy satisfaction (P = 0.502), and both expressed similar, high willingness to undergo treatment again if they were to decide again (P = 0.317).

CONCLUSIONS

EPEs had post-treatment QoL and oncological outcome comparable to traditional PE. These procedures offer a potentially curative treatment option for patients with persistent or recurrent pelvic tumour invading into pelvic wall structures without further compromise of patients´ QoL.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

Pelvic sarcomas are rare and there are very few effective therapeutic alternatives. A complete resection is considered the main factor associated to a good prognosis, which justifies the employment of a pelvic exenteration (PE) in selected cases.

METHODS

Between 1980 and 2000, 96 PE were performed, nine of which were for sarcomas. The clinical characteristics, surgical and anatomopathological aspects and the patients' evolution were described.

RESULTS

The median follow-up time was 24 months (ranging from 1 to 57 months). In relation to the sphincters preservation, at least one sphincter was preserved in five patients. There were two post-operative deaths. In the last follow-up, six patients were alive without any evidence of the disease.

CONCLUSION

Pelvic exenterations should be performed for the treatment of selected cases of locally advanced pelvic sarcomas. Sphincter preservation may be performed, provided that oncological resection principles are obeyed.

Pelvic exenteration and sphincter preservation: An analysis of 96 cases

BACKGROUND

Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results.

METHODS

Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed.

RESULTS

Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival.

CONCLUSIONS

The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.

Laterally extended endopelvic resection. Novel surgical treatment of locally recurrent cervical carcinoma involving the pelvic side wall

OBJECTIVES

To demonstrate the therapeutic potential of the laterally extended endopelvic resection (LEER) especially for patients with recurrent cervical carcinomas involving the side wall of an irradiated pelvis. These patients, suffering from the most common situation of local failure, have so far no longer been considered for curative therapy.

METHODS

Extending the lateral resection plane of pelvic exenteration to the medial aspects of the lumbosacral plexus, sacrospinous ligament, acetabulum, and obturator membrane enables the complete removal of a subset of locally advanced and recurrent tumors of the lower female genital tract fixed to the pelvic wall with free margins (R0). Patients selected for LEER were accrued to a prospective outcome trial.

RESULTS

Thirty-six patients with recurrent (n = 29) or primary advanced (n = 7) gynecologic malignancies involving the side wall of the lesser pelvis underwent LEER from July 1996 until October 2002. The majority of the patients suffered from cervical carcinoma (n = 29) and had received previous pelvic irradiation (n = 24). Tumor-free (R0) lateral margins were obtained in 34 patients. Severe postoperative complications occurred in 14 patients with one treatment-related death. Five-year survival probability is 49% for the whole group and 46% for those patients considered only for palliation with current treatment options. Most patients without evidence of disease at least 1 year after LEER achieved good quality of life.

CONCLUSIONS

LEER can be offered as novel surgical salvage therapy to a selected subset of patients with locally advanced and recurrent cervical carcinoma involving the pelvic wall.

Management of advanced pelvic cancer by exenteration

AIM

To describe our results in managing locally advanced primary or recurrent pelvic malignancies.

METHOD

Investigations included: clinical, laboratory, endoscopic (rectoscopy and colonoscopy) examinations, ultrasound scan, and CT scan or MRI of the abdomen and pelvis, to determine the extent of the pelvic malignancy. A careful explorative laparatomy of abdomen and pelvis was performed, followed by anterior, posterior or total pelvic exenteration.

RESULTS

In the period June 1995-Jan 2002, 7 anterior, 2 posterior and 51 total pelvic exenterations were performed in 60 patients, distributed as follows: 28 for rectal cancer (12 primary, 16 recurrent), 20 for cervical cancer (9 primary, 11 recurrent) and 12 for other pelvic malignancies. The median survival time and overall 5-year survival rates were as follows: primary rectal cancer--50 months and 32%; recurrent rectal cancer--31 months and 17%; primary cervical cancer--46.4 months and 41% and recurrent cervical cancer--23.4 months and 16%. During the same period, 559 of our patients were treated for primary or recurrent rectal cancer by different types of straightforward resection.

CONCLUSION

Pelvic exenteration is justifiable in cases of locally advanced primary and recurrent malignancies of rectum, cervical cancer and possibly in cases of other pelvic malignancies.