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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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Bizzarri N, Chiantera V, Loverro M, Sozzi G, Perrone E, Gueli Alletti S, Costantini B, Gallotta V, Tortorella L, Fagotti A, Fanfani F, Ercoli A, Scambia G, Vizzielli G. Minimally invasive versus open pelvic exenteration in gynecological malignancies: a propensity-matched survival analysis. Int J Gynecol Cancer 2023; 33:190-197. [PMID: 36593063 DOI: 10.1136/ijgc-2022-003954] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The primary endpoint of this study was to compare the disease-free survival of patients undergoing open versus minimally invasive pelvic exenteration. The secondary endpoints were cancer-specific survival and peri-operative morbidity. METHODS A multi-center, retrospective, observational cohort study was undertaken. Patients undergoing curative and palliative anterior or total pelvic exenteration for gynecological cancer by a minimally invasive approach and an open approach between June 2010 and May 2021 were included. Patients with distant metastases were excluded. A 1:2 propensity match analysis between patients undergoing minimally invasive and open pelvic exenteration was performed to equalized baseline characteristics. RESULTS After propensity match analysis a total of 117 patients were included, 78 (66.7%) and 39 (33.3%) in the open and minimally invasive group, respectively. No significant difference in intra-operative (23.4% vs 10.3%, p=0.13) and major post-operative complications (24.4% vs 17.9%, p=0.49) was evident between the open and minimally invasive approach. Patients undergoing open pelvic exenteration received higher rates of intra-operative transfusions (41.0% vs 17.9%, p=0.013). Median disease-free survival was 17.0 months for both the open and minimally invasive groups (p=0.63). Median cancer-specific survival was 30.0 months and 26.0 months in the open and minimally invasive groups, respectively (p=0.80). Positivity of surgical margins at final histology was the only significant factor influencing the risk of recurrence (hazard ratio (HR) 2.38, 95% CI 1.31 to 4.31) (p=0.004), while tumor diameter ≥50 mm at the time of pelvic exenteration was the only significant factor influencing the risk of death (HR 1.83, 95% CI 1.08 to 3.11) (p=0.025). CONCLUSION In this retrospective study no survival difference was evident when minimally invasive pelvic exenteration was compared with open pelvic exenteration in patients with gynecological cancer. There was no difference in peri-operative complications, but a higher intra-operative transfusion rate was seen in the open group.
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Affiliation(s)
- Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Matteo Loverro
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Emanuele Perrone
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Fanfani
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Ercoli
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Medical Area (DAME), University of Udine, Udine, Friuli-Venezia Giulia, Italy.,Clinic of Obstetrics and Gynecology - "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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Restaino S, Vargiu V, Rosati A, Bruno M, Dinoi G, Cola E, Moroni R, Scambia G, Fanfani F. 4K versus 3D total laparoscopic hysterectomy by resident in training: a prospective randomised trial. Facts Views Vis Obgyn 2021; 13:221-229. [PMID: 34555876 PMCID: PMC8823275 DOI: 10.52054/fvvo.13.3.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background The introduction of ultra-high-definition laparoscopic cameras (4K), by providing stronger monocular depth perception, could challenge the existing 3D technology. There are few available studies on this topic, especially in gynaecological setting. Objectives Prospective, single institution, randomised clinical trial (NCT04209036). Materials and Methods The two laparoscopes utilised were the 0°ULTRA Telescopes with 4K technology and the 0°3D-HD by Olympus. The surgeons were all trainees and in their last year of residency and who had obtained the certificate of first or second level of the Gynaecological Endoscopic Surgical Education and Assessment program - GESEA program. Twenty-nine patients with benign uterine pathology were enrolled. Main outcome measures To compare if the use three-dimensional (3D) versus ultra-high-definition laparoscopic vision system (4K) for total laparoscopic hysterectomy performed by trainees was associated with a shorter operative time. Results The 3D vision system did not prove to be superior to the 4K vision system. Operators reported significantly more vision-related side effects when using 3D than 4K. Completing the GESEA training program was the only factor with a positive and statistically significant impact on the overall time of the procedure, especially when greater dexterity and tissue handling were required. Conclusions Neither technology used proved superior to the other, although operators showed a preference for 4K over 3D due to the lower number of visual side effects. Attendance at courses on laparoscopic simulators and training programs allowed trainees to demonstrate excellent surgical skills.
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Vizzielli G, Tortorella L, Conte C, Chiantera V, Gallotta V, Foschi N, Arcieri M, Ferrandina G, Fagotti A, Zattoni F, Scambia G, Ercoli A. Is a Vaginectomy Enough or is a Pelvic Exenteration Always Required for Surgical Treatment of Recurrent Cervical Cancer? A Propensity-Matched Study. Ann Surg Oncol 2020; 28:3281-3290. [PMID: 33063258 DOI: 10.1245/s10434-020-09207-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Reporting the perioperative and survival outcomes of vaginectomy with respect to a matched series of pelvic exenteration (PE) in women with isolated recurrent cervical cancer. METHODS The records of vaginal recurrent cervical cancer patients admitted at Fondazione Policlinico "Agostino Gemelli" IRCCS in Rome from January 2010 to June 2019 were retrospectively analyzed. A propensity-matched score analysis was performed by age, clinical stage, disease-free interval, and R0 resection. Postsurgical complications and survival rates were evaluated. RESULTS Fifteen women underwent vaginectomy, and 30 patients were submitted to PE. No statistical differences were observed between the two groups at baseline characteristics. The vaginectomy procedures were successfully performed in all women, and no case required conversion to PE. Moreover, a higher rate of major postoperative complications after PE with respect to vaginectomy (p = 0.027) was recorded. Among them, three women required reoperation within 30 postoperative days, and four experienced two or more complications. Twenty-five (55.6%) women experienced recurrence: 8 of 25 (32.0%) in the vaginectomy group, and 17 of 25 (68%) in the PE group, with a median progression-free survival of 20 months and 13 months, respectively (p = 0.169). In total, 5 of 15 (33.3%) died of disease in the vaginectomy group and 13/30 (43.3%) in the PE group, with a median overall survival of 39 and 18 months for vaginectomy and PE, respectively (p = 0.161). CONCLUSIONS The vaginectomy seems to allow for salvage treatment, such as radiotherapy and/or PE, but with a minimal impact on the quality of life in appropriately selected women with local recurrent cervical cancer.
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Affiliation(s)
- Giuseppe Vizzielli
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy. .,Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Padua, Italy.
| | - Lucia Tortorella
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Carmine Conte
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Vito Chiantera
- Division of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Valerio Gallotta
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Nazario Foschi
- Division of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Martina Arcieri
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Gabriella Ferrandina
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy.,Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy.,Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filiberto Zattoni
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Padua, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy.,Dipartimento Scienze della Salute della Donna e del Bambino e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
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