Is En-Bloc Resection of Locally Recurrent Rectal Carcinoma Involving the Urinary Tract Indicated?

Long-term renal functional outcomes following ureteroureterostomy performed during multi-organ resection for non-urothelial cancers

Objectives

To evaluate the long‐term renal function outcomes after ureteroureterostomy (UU) in patients undergoing multi‐organ resection for non‐urothelial cancers. The secondary aim was to examine the length of ureteric defect that can be successfully bridged with UU.

Patients and methods

We retrospectively reviewed the charts of patients who underwent UU between 1995 and 2012 at our institution. Renal imaging studies performed before and after UU were used to determine whether hydronephrosis was present. Renal function was assessed by comparing estimated glomerular filtration rate (eGFR) before and at the last follow‐up after UU.

Results

Nineteen patients underwent UU during multi‐organ resection for non‐urothelial cancers. Median follow‐up time was 62 months. Overall, UU had a high success rate, with one patient (5.2%) developing progressive hydronephrosis with a >20% drop in eGFR from baseline due to UU failure. Four additional patients developed progressive hydronephrosis due to cancer recurrence involving the UU. There were no statistically significant differences between pre‐ and post‐UU eGFR in these patient cohort. All patients with a ureteric defect of ≤5 cm underwent successful reconstruction.

Conclusions

UU maintains long‐term renal function in the majority of patients undergoing multi‐organ resection for non‐urothelial cancers and can be successfully utilized if the resected ureteric length is ≤5 cm.

Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy

Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.

Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: a single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010

BACKGROUND

The benefits in terms of curative resection and survival of pelvic exenterations for specific extraluminal pelvic recurrences from rectal cancer in the era of total mesorectal excision were assessed.

METHODS

We conducted a single-center review of patients with extraluminal pelvic recurrence from colorectal cancer between March 2004 and November 2010. Twenty-seven pelvic exenterations (13 posterior and 14 total) were performed. Independent predicative factors such as age, sex, local control on first surgery, pelvic sidewall excision, initial International Union Against Cancer (UICC) staging, sphincter-preserving resection at first surgery, tumor presentation on computed tomography and magnetic resonance imaging (pelvis sidewall involvement, number of fixation sites, ureteral involvement), local disease-free interval, previous symptoms, and postoperative treatment were analyzed.

RESULTS

No operative mortality was noted in this series. Overall morbidity rate was 74%; 22% of the patients developed severe complications. Complete surgical clearance (R0) was obtained in 63% of the patients. The rate of R0 resections was lower in total pelvic exenteration (57%) than in posterior pelvic exenteration (69%). Three years overall survival and disease-free survival were 76% and 59%, respectively. Curative resection (R0) was the only independent prognostic factor for overall survival (P = .0016) and disease-free survival (P < .0001).

CONCLUSION

Pelvic exenterations for extraluminal pelvic recurrences from rectal cancer afford a high R0 resection rate with acceptable morbidity.

Utilization of Interventional Radiology in the Postoperative Management of Patients after Surgery for Locally Advanced and Recurrent Rectal Cancer

The surgical management of locally advanced primary rectal cancer and locally recurrent rectal cancer requires complex operations frequently resulting in complicated postoperative courses. We sought to evaluate the utilization of interventional radiologic (IR) procedures in the management of postoperative complications. Under Institutional Review Board approval, a prospective database of colorectal cancer patients undergoing resection from July 1999 to January 2010 was analyzed. Data collected included demographics, operative procedure, complications, length of stay, and IR utilization. Fisher's exact tests and logistic regression explored associations with necessitating an IR procedure during the postoperative period. Continuous variables were analyzed using Wilcoxon rank sum tests. One hundred and one patients underwent surgery and 66 received intraoperative electron radiotherapy (IOERT). Primary procedures included pelvic exenteration (n = 35), abdominoperineal resection (n = 25), low anterior resection (n = 23), paraaortic node dissection (n = 7), resection of isolated pelvic/retroperitoneal tumor (n = 7), and colectomy (n = 4). Sixty-two patients required multivisceral resection including partial/total cystectomy (n = 30), small bowel resection (n = 25), oophorectomy (n = 15), vaginectomy (n = 12), hysterectomy (n = 12), hepatectomy (n = 3), and nephrectomy (n = 3). Seventeen partial sacral resections and 47 pelvic sidewall resections were also required. One hundred and thirty-eight complications were identified in 72 patients, 30 of which required a procedural intervention. Twenty-seven IR procedures were performed including drainage of fluid collections (n = 14), nephrostomy tube placement (n = 8), arterial embolization (n = 2), inferior vena cava filter placement (n = 2), and pleural drainage (n = 1). Only three reoperations were required, none related to failure of IR procedures. There were no deaths. Estimated blood loss > 2000 mL ( P = 0.002), IOERT ( P = 0.03), and incomplete resection ( P = 0.02) were found to be associated with postoperative IR utilization. Surgery for locally advanced primary rectal cancer and locally recurrent rectal cancer is associated with significant morbidity but low mortality. IR procedures play a significant role in the postoperative management of these patients and may decrease the need for reoperation.

Multidisciplinary management of patients with advanced rectal cancer

The chance of lymph node involvement in T(3) and T(4) rectal cancers is 20% to 60%, a risk sufficiently high that most clinicians favor mesorectal excision rather than less aggressive approaches. Patients who have a complete clinical response of the primary lesions to neoadjuvant therapy may represent a special case. Total mesorectal excision can be accomplished without sacrifice of the anal sphincters, and continence can be preserved. Evolving understanding of patterns of tumor spread and mechanisms of anal continence have resulted in increased use of continence-preserving procedures. Removal of the anal sphincters seems to be advantageous only if the sphincters are directly involved. A few small series suggest that a segmental sphincter resection could result in good local control and continence preservation, even if the sphincters are involved. Areas of controversy currently include the role of neoadjuvant therapy for high rectal lesions, the role of lateral lymph node dissection, and methods of improving anal continence after rectal resection.