Laparoscopic salvage total pelvic exenteration: Is it possible post-chemo-radiotherapy?

Comprehensive analysis of patient outcome after local recurrence of locally advanced cervical cancer treated with concomitant chemoradiation and image-guided adaptive brachytherapy

INTRODUCTION

Since dose escalation allowed by image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer (LACC), local relapses have become a rare event. Only scarce data are available on the outcome of patients experiencing a local relapse after IGABT.

METHODS

Between 2004 and 2016, all consecutive patients treated at Gustave Roussy Institute for LACC and receiving concomitant chemoradiation and IGABT were analysed. Clinical and treatment-related prognostic factors for survival after local relapse were searched, in order to potentially identify patients requiring salvage treatment.

RESULTS

Two hundred and fifty-nine patients were treated during this period. With a median follow-up of 4.1 years, 10.8% (n = 28) had a local relapse. Among these patients, 53.6% had synchronous lymph nodes or distant metastatic relapse and only 13 patients (5% of all patients) had isolated local relapse. After local relapse, median survival was 47 months and three patients were alive at last follow-up. Only three patients with local relapse could receive salvage surgery (10.7%). Metastases occurrence and pelvic wall involvement were the main contraindications (67.9%) for salvage surgery. Among the three patients treated with surgery, two are still alive at last follow-up without significant complication. Improved survival was observed among the two patients who could have surgery (p = .02). Local progression led to serious symptoms in 75% of patients. Only the time interval between brachytherapy and relapse (<1 year) was prognostic for 2-year overall survival (p = .005).

CONCLUSION

Salvage surgery is feasible in a very low number of highly selected patients with local relapse following IGABT. Local failure is a major cause of severe local symptoms, confirming that every effort should be done to achieve long-term local control through dose escalation.

Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series

BACKGROUND

Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery. Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis, while achieving clear margins.

AIM

To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.

METHODS

We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles (SV). The da Vinci S robotic system was used. Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase. All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.

RESULTS

Case 1: 67-year-old with low rectal tumour 3cm from anal verge involving the prostate. He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy. Case 2: 66-year-old with low rectal tumour 3cm from anal verge involving prostate and bilateral SV. He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy. Case 3: 57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum, prostate and bilateral SV. He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy. Bladder neck margin revealed cauterized tumour cells, and he underwent total cystectomy and ileal conduit creation. Histology revealed no residual tumour. All patients are currently disease free

CONCLUSION

Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.

Critical evaluation of contemporary management in a new Pelvic Exenteration Unit: The first 25 consecutive cases

AIM

To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit.

METHODS

This retrospective observational study was conducted by analysing prospectively collected data for the first 25 patients (16 males, 9 females) who underwent PE for advanced pelvic tumours in our PE Unit between January 2012 and October 2016. Data evaluated included age, co-morbidities, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) status, preoperative adjuvant treatment, intra-operative blood loss, procedural duration, perioperative adverse event, lengths of intensive care unit (ICU) stay and hospital stay, and oncological outcome. Quantitative data were summarized as percentage or median and range, and statistically assessed by the χ² test or Fisher’s exact test, as applicable.

RESULTS

All 25 patients received comprehensive preoperative assessment via our dedicated multidisciplinary team approach. Long-course neoadjuvant chemoradiotherapy was provided, if indicated. The median age of the patients was 61.9-year-old. The median ASA and ECOG scores were 2 and 0, respectively. The indications for PE were locally invasive rectal adenocarcinoma (n = 13), advanced colonic adenocarcinoma (n = 5), recurrent cervical carcinoma (n = 3) and malignant sacral chordoma (n = 3). The procedures comprised 10 total PEs, 4 anterior PEs, 7 posterior PEs and 4 isolated lateral PEs. The median follow-up period was 17.6 mo. The median operative time was 11.5 h. The median volume of blood loss was 3306 mL, and the median volume of red cell transfusion was 1475 mL. The median lengths of ICU stay and of hospital stay were 1 d and 21 d, respectively. There was no case of mortality related to surgery. There were a total of 20 surgical morbidities, which occurred in 12 patients. The majority of the complications were grade 2 Clavien-Dindo. Only 2 patients experienced grade 3 Clavien-Dindo complications, and both required procedural interventions. One patient experienced grade 4a Clavien-Dindo complication, requiring temporary renal dialysis without long-term disability. The R0 resection rate was 64%. There were 7 post-exenteration recurrences during the follow-up period. No statistically significant relationship was found among histological origin of tumour, microscopic resection margin status and postoperative recurrence (P = 0.67). Four patients died from sequelae of recurrent disease during follow-up.

CONCLUSION

By utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.

Laparoscopic total pelvic exenteration for pelvic malignancies: the technique and short-time outcome of 11 cases

BACKGROUND

Previous reports about laparoscopic total pelvic exenteration (LTPE) are still limited. In the present study, we described our single-center experience of the initial 11 cases.

METHODS

Between April 2011 and September 2015, eight males and three females diagnosed as pelvic malignancies underwent LTPE by the same operation team. We retrospectively collected all cases' parameters about surgical technique. Thirty-seven patients who received open surgery were also retrospectively collected. A comparison between LTPE and open surgery was performed to evaluate the feasibility and safety of LTPE.

RESULTS

Eleven cases successfully underwent the LTPE without any intraoperative complication. No open conversion was required. Eight patients underwent Bricker's procedure. Three patients were performed with the cutaneous ureterostomy. Anus preservation operation was performed in three patients. Compared with open surgery, LTPE had longer mean operative time (565.2 vs 468.2 min, p = 0.004) but less mean blood loss (547.3 vs 1033.0 ml, p < 0.001) and shorter postoperative hospitalization time (15.3 vs 22.4 days, p = 0.004). One patient died of pulmonary embolism in the 7th month of follow-up time. One patient died of recurrence in the 12th month of follow-up time. Nine patients are still alive without recurrence and metastasis. The mean follow-up time was 11.1 months.

CONCLUSIONS

The technique of LTPE seems to be feasible and safe in the treatment of carefully selected patients of pelvic malignancies. LTPE can also decrease the blood loss, the recovery time, and the hospital stay. But the oncological safety and long-term outcome of LTPE still need to be explored.

Laparoscopic Total Pelvic Exenteration for Locally Recurrent Rectal Cancer

BACKGROUND

Extended surgery for locally recurrent rectal cancer is technically demanding because of the severe fibrosis around the tumor, which makes it difficult to achieve R0 resection. Although laparoscopic total pelvic exenteration has been carried out in patients with primary rectal cancer,1 (,) 2 to our knowledge ours is the first report of this laparoscopic procedure for locally recurrent rectal cancer.

METHODS

A 70-year-old man who underwent laparoscopic low anterior resection for stage II rectal cancer was diagnosed as having two separate local recurrences near the anastomotic site. We decided to perform laparoscopic total pelvic exenteration after neoadjuvant chemoradiotherapy. The branches of the internal iliac vessels were carefully identified and divided. Presacral dissection behind the neorectum was carried out above the anastomotic site. Ligation of the dorsal vein complex was performed under direct visualization, with the patient in the jack-knife position. The perineal defect was reconstructed using a bilateral V-Y advancement of the musculocutaneous flaps of the gluteus maximus. An ileal conduit was constructed extracorporeally via an umbilical incision, after placing the patient in the lithotomy position.

RESULTS

The total operative time was 18 h and 5 min, with an estimated blood loss of 750 mL. Final pathology showed negative resection margins.

CONCLUSIONS

Laparoscopic total pelvic exenteration for locally recurrent rectal cancer is a technically challenging procedure requiring a long operative time. However, as demonstrated by this case, it can provide a very clear view of the operative field, allowing precise dissection, less blood loss, and a smaller abdominal wound.

First report: Robotic pelvic exenteration for locally advanced rectal cancer

AIM

The aim of this study was to present the feasibility and surgical outcome of robotic en bloc resection of the rectum and with prostate and seminal vesicle invaded by rectal cancer.

METHOD

The details of three consecutive cases involving male patients in their forties, with locally invasive low rectal cancers are presented. The da Vinci robotic system was used by experienced colorectal and urological surgeons to perform en bloc resection of the rectum, prostate and seminal vesicles.

RESULTS

In the first case, coloanal and vesico-urethral anastomoses were performed, and the second included an end colostomy and vesico-urethral anastomosis. The bladder and bulbar urethra were also removed en bloc in the third case, with robotic intracorporeal ileal conduit formation and end colostomy. There was no major complication postoperatively. In the second patient there was a minor leakage at the vesico-urethral anastomosis. The third was readmitted the following week with a urinary infection which settled with intravenous antibiotics. In the first case, the circumferential resection margin was microscopically positive but the patient is currently free of recurrence after 14 months. In the second and third cases, all margins were clear.

CONCLUSION

This the first report of the use of the da Vinci robotic system for pelvic exenteration in patients with locally advanced rectal cancer invading the prostate and seminal vesicles. The robot may have a potential role in selected patients requiring exenterative pelvic surgery particularly in men.

Laparoscopic surgery for rectal cancer: current status and future perspective

Although laparoscopic surgery for colon cancer is accepted in the treatment guidelines, the laparoscopic approach for rectal cancer is recommended only in clinical trials. Thus far, several trials have shown favorable short-term results such as early recovery and short hospital stay, but long-term results remain a critical concern for laparoscopic rectal cancer surgery. To date, no randomized control trials have shown an increased local recurrence after laparoscopic surgery for rectal cancer. Additionally, according to previous studies, open conversion, which is more frequent in laparoscopic rectal surgery than in laparoscopic colon surgery, may affect short-term and long-term survival. The evidence on male sexual function has been contradictory. Long-term results from ongoing multicenter trials will be available within several years. Based on accumulated evidence from well-organized clinical trials, laparoscopic surgery will likely be accepted as a treatment choice for rectal cancer. In the future, extended laparoscopic rectal surgery might be feasible for additional procedures such as laparoscopic lateral pelvic lymph node dissection and laparoscopic total pelvic exenteration for rectal cancer invading the adjacent pelvic organ.