Comparison of postoperative complications and quality of life between patients undergoing continent versus non-continent urinary diversion after pelvic exenteration for gynecologic malignancies

Five-year quality-of-life assessment by urinary diversion type after pelvic Exenterations

OBJECTIVE

To determine whether urinary diversion procedures performed at time of pelvic exenteration affect quality of life in patients with recurrent gynecologic malignancies.

METHODS

We performed a retrospective secondary longitudinal analysis of quality of life according to type of urinary diversion patients received. Participants completed a series of validated questionnaires at various time points. We allocated patients based on urinary diversion type to either the continent group (CD; 29 [55 %]) or noncontinent group (NCD; 24 [45 %]).

RESULTS

We noted a significant improvement in global health scores from baseline over time (time p = 0.027). Physical functioning scores showed a statistically significant difference over time (at 24 months: NCD, -4.3 [95 % CI, -14.1 to 5.4]; CD, 0.4 [95 % CI, -7.1 to 7.9]. p < 0.001). Social functioning scores were persistently higher for the CD vs NCD group at all time points but did not differ significantly between the groups at baseline (p = 0.75) or over time within the same group (time p = 0.122). Body image scores significantly decreased (reduced burden) over time for both groups (p = 0.044) and were consistently higher in the NCD vs CD group.

CONCLUSIONS

Patients experienced a return to their baseline quality of life within a year of surgery. Clinicians should prioritize and improve identifying and discussing postoperative challenges such as changes in physical and social functioning and body image.

Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program

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.

Quality of life following pelvic exenteration in neoplasms

BACKGROUND

Pelvic exenteration (PE) is an extensive surgical treatment reserved for advanced or recurrent pelvic neoplasms, with potential impacts on patients' quality of life (QoL) poorly referenced in the literature.

OBJECTIVES

This study aimed to evaluate QoL outcomes among three types of PE.

METHODS

A cross-sectional study assessed 106 patients divided into anterior PE (APE), posterior PE (PPE), or total PE (TPE) groups. QoL was measured using e short form 36 version 2 (SF-36) and the European Organization for Research and Treatment of Cancer QoL Quality of Life Questionnaire Core 30 (QLQ-C30) QoL questionnaires. Descriptive and inferential analyses compared questionnaire scores.

RESULTS

The findings unveiled a balance among the three groups concerning demographic variables and comorbidities, with the exception of a male predominance in the APE and TPE cohorts. Notably, the APE group exhibited elevated scores in overall health (assessed via SF-36) and social functioning and diarrhea domains (assessed via QLQ-C30). Moreover, in terms of the fatigue and nausea/vomiting domains (assessed via QLQ-C30), the APE group demonstrated superior QoL compared to the PPE group. Conversely, the PPE group manifested a notably lower QoL in the constipation domain (assessed via QLQ-C30) compared to the other two groups. Additionally, disease recurrence was significantly associated with diminished QoL across multiple domains.

CONCLUSION

APE patients exhibited better QoL than PPE and TPE groups, with disease recurrence adversely affecting QoL.

Trends and current aspects of reconstructive surgery for gynecological cancers

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.

Laterally extended endopelvic resection for gynecological malignancies, a comparison between laparoscopic and laparotomic approach

INTRODUCTION

The historical approach to LEER is laparotomic, but recently laparoscopy has been proposed. The objective of this study was to compare surgical and oncological outcomes between the two approaches and to assess the overall quality of life (QoL).

MATERIALS AND METHODS

Women submitted to LEER between October 2012 and March 2020 were retrospectively recruited. Peri-operative data were analyzed and compared. Recurrence-free (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, QLQ-CX24, and QLQ-OV28 questionnaires were administered 6 months after surgery in women with no evidence of recurrence after LEER.

RESULTS

Of the included 41 patients, 20 were submitted to laparoscopic LEER (L-LEER) and 21 to open LEER (O-LEER). Median operating time (442 vs 630 min, p = 0.001), median blood loss (275 vs 800 ml, p < 0.001), and median length of hospital stays (10 vs 16 days, p = 0.002) were shorter in the laparoscopic group, while tumor resection rate and peri-operative complications were similar. After a median follow-up of 27.5 months, no differences, in terms of DFS (p = 0.83) and OS (p = 0.96) were observed between the two approaches. High functional scores and low levels of adverse symptoms were observed on the surviving women.

CONCLUSION

QoL after LEER is acceptable, and laparoscopy provides better surgical and similar oncological outcomes when compared to laparotomy. L-LEER can be considered a further option of treatment for women with gynecological tumors infiltrating the pelvic sidewall.

Effect of Intelligent Medical Management Platform Combined with Perioperative Detailed Nursing on Cognitive Ability, Postoperative Complications, and Quality of Life of Patients Undergoing Hysterectomy

Objective. To analyze the effect of an intelligent medical management platform combined with perioperative detailed nursing on cognitive ability, postoperative complications, and quality of life (QOL) of patients undergoing hysterectomy. Methods. The clinical data of 76 patients undergoing hysterectomy in our hospital from December 2019 to December 2021 were selected for the retrospective analysis, and the patients were divided into the experimental group (EG, $n=38$ , intelligent medical management platform+perioperative detailed nursing) and the routine group (RG, $n=38$ , routine nursing) according to their admission order, and the cognition of disease and QOL after intervention of patients in the two groups were evaluated by the self-proposed questionnaire on cognition of disease of our hospital and the MOS 36-item short-form health survey (SF-36). Results. After intervention, the scores on cognitive ability, various nursing items, and QOL were significantly higher in EG than in RG ( $P<0.001$ ), and during the study, the total incidence rate of complications was significantly lower in EG than in RG ( $P<0.05$ ). Conclusion. Combining an intelligent medical management platform with perioperative detailed nursing is a reliable method to improve QOL and reduce postoperative complications for patients undergoing hysterectomy. Further research will be conducive to providing a reliable perioperative intervention scheme for such patients.

Postoperative health-related quality of life of patients with gynecological malignancy: a meta-analysis

OBJECTIVE

We sought to describe the short-term (1, 3, 6, 12 months) QoL changes after surgery for patients with gynecological malignancies in a meta-analysis.

METHODS

We collected studies based on the PICOS (patients, intervention, comparison, outcome, and study design) framework (P: patients with gynecological malignancy; I: surgery; C: presurgery; O: QoL scores; S: randomized controlled trials, case-control studies, or cohort studies) in the Cochrane Library, MEDLINE, EMBASE, Web of Science, EBSCO, and China National Knowledge Infrastructure (CNKI) databases up to June 28, 2020. Then, two reviewers independently performed article screening, data extraction, and study quality evaluation. Stata 15.0 software was utilized for data analysis.

RESULTS

Nine studies with 1476 patients were ultimately included. QoL in global health status improved until 12 months after surgery with a maximum improvement (6.99 [0.31, 13.68], P = 0.04), and QoL in emotional functioning reduced significantly until 12 months after surgery with a maximum reduction (14.87 [10.29, 19.45], P < 0.00001). All of the symptom scales were reduced significantly until 12 months postoperation, indicating quality of life improvement. There was a clinical reduction in QoL but symptom experience (-3.31 [-5.51, -1.12], P=0.003) at six months after surgery compared with baseline (presurgery), with only sexual worry being statistically significant (4.61 [0.95, 8.27], P=0.01).

CONCLUSIONS

The recovery time varied among each dimension of the postoperative QoL of patients with gynecological malignancies; only a few functions and symptoms began to improve at 1 month postoperation and more at 12 months postoperation. Therefore, it is vitally important to develop extended care programs targeting the multidimensional aspects of QoL for patients with gynecological malignancies after surgery.

Urinary diversion after pelvic exenteration for gynecologic malignancies

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.

Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US

BACKGROUND

Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample.

METHODS

Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality.

RESULTS

Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4).

CONCLUSIONS

TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.

Pelvic exenteration associated with future renal dysfunction

PURPOSE

This study aimed to clarify the long-term change in the renal function after pelvic exenteration (PE) and to evaluate the risk factors for any future dysfunction.

METHODS

This study comprised 40 patients. A greater than 25% decline in the estimated glomerular filtration rate (eGFR) at 3 years was defined as early renal function disorder (ERFD), possibly predicting future chronic kidney disease (CKD).

RESULTS

In the entire cohort, the median eGFR decreased by 23% at 3 years, and CKD developed in 50%. The patients were divided into the ERFD (n = 16) and non-ERFD (n = 24) groups. In the ERFD group, the eGFR significantly decreased by 28% during the first 1.5 years and continued to decline after that, resulting in 81.3% of patients reaching CKD, whereas it was 4% and 37.5%, respectively, in the non-ERFD group. In a growth model analysis, late urinary tract complications (UTC) and small bowel obstruction were shown to be risk factors for ERFD.

CONCLUSION

Although PE was associated with a high incidence of future CKD, ERFD could predict it. Close observation of the eGFR decline over 1.5 years might be beneficial to identify ERFD patients. High-risk patients with late UTC and small bowel obstruction should, therefore, be observed carefully.