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Yatabe Y, Hanaoka M, Hanazawa R, Hirakawa A, Mukai T, Kimura K, Yamanoi K, Kono J, Yokota M, Takahashi H, Kobayashi A, Kobayashi K, Ichikawa N, Yasui M, Nakane K, Yamamoto M, Takenaka A, Nakamura Y, Takemasa I, Yabusaki N, Akamoto S, Tatarano S, Murata K, Manabe T, Fujimura T, Kawamura M, Egi H, Yamaguchi S, Terai Y, Inoue S, Ito A, Kinugasa Y. Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan. Surg Endosc 2024:10.1007/s00464-024-10966-w. [PMID: 38886231 DOI: 10.1007/s00464-024-10966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/26/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.
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Affiliation(s)
- Yusuke Yatabe
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Marie Hanaoka
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Hyogo, Japan
| | - Koji Yamanoi
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jin Kono
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Yokota
- Department of General Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Kenji Kobayashi
- Department of Gastroenterological Surgery, Kariya Toyota General Hospital, Aichi, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keita Nakane
- Department of Urology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Atsushi Takenaka
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuya Nakamura
- Department of Surgery, National Hospital Organization, Himeji Medical Center, Hyogo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Hokkaido, Japan
| | | | | | - Shuichi Tatarano
- Department of Urology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Egi
- Department of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Ehime, Japan
| | - Shigeki Yamaguchi
- Division of Colorectal Surgery, Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shigetaka Inoue
- Department of Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
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Khan JS, Piozzi GN, Rouanet P, Saklani A, Ozben V, Neary P, Coyne P, Kim SH, Garcia-Aguilar J. Robotic beyond total mesorectal excision for locally advanced rectal cancers: Perioperative and oncological outcomes from a multicentre case series. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108308. [PMID: 38583214 DOI: 10.1016/j.ejso.2024.108308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers. MATERIALS AND METHODS A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015-November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0-68.7) years and 24.0 (24.4-27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0-450.0) minutes. Median estimated blood loss was 150.0 (27.5-500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0-65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%. CONCLUSION Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.
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Affiliation(s)
- Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; University of Portsmouth, Portsmouth, UK.
| | | | - Philippe Rouanet
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier Cancer Research Institute, University of Montpellier, Montpellier, France.
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Volkan Ozben
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Acibadem Atakent Hospital, Istanbul, Turkey.
| | - Paul Neary
- Division of Colorectal Surgery, The Adelaide and Meath Hospital Ireland, Dublin, Ireland.
| | - Peter Coyne
- Department of Colorectal Surgery, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
| | - Seon Hahn Kim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA.
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Kamei J, Fujimura T. Current status of robot-assisted total pelvic exenteration focusing on the field of urology: a clinical practice review. Transl Cancer Res 2024; 13:453-461. [PMID: 38410226 PMCID: PMC10894324 DOI: 10.21037/tcr-23-1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/08/2023] [Indexed: 02/28/2024]
Abstract
Total pelvic exenteration (TPE) is a highly invasive surgery associated with high rates of perioperative morbidity and mortality and is commonly performed for several types of locally advanced or recurrent pelvic cancers. It involves multivisceral resection, including the rectum, sigmoid colon, bladder, prostate, uterus, vagina, or ovaries, and urologists normally perform radical cystectomy or radical prostatectomy and urinary diversion in collaboration with colorectal surgeons and gynecologists. In the urological field, robot-assisted surgeries have been widely performed as one of the main minimally invasive procedures because of their superior perioperative or oncological outcomes compared to open or laparoscopic surgeries. In pelvic exenteration (PE) surgery, laparoscopic surgeries have shown superior rates of mortality, morbidity, and R0 resection compared to open surgeries. Robot-assisted TPE for the treatment of locally advanced rectal cancer was first reported in 2014, and reports of its safety and usefulness have gradually increased. Robot-assisted PE, in which multivisceral resection in a narrow pelvic space is easier, will eventually be a standard minimally invasive procedure, although evidence has been limited to date. This clinical practice review summarizes the indications for surgery, perioperative complications, and oncological outcomes of robot-assisted TPE and highlights the current status of robot-assisted TPE for patients with urological malignancies and its surgical technique, focusing on the manipulation of urological organs.
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Affiliation(s)
- Jun Kamei
- Department of Urology, Jichi Medical University, Tochigi, Japan
- Department of Urology, The University of Tokyo Hospital, Tokyo, Japan
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Saqib SU, Raza MZ, Twigg J, Altan O, Bajwa AA. Feasibility of robotic platform to perform R0 resection for locally advanced multi-visceral pelvic malignancy: an institutional experience on outcomes of robotic pelvic exenteration. Langenbecks Arch Surg 2023; 409:9. [PMID: 38102305 DOI: 10.1007/s00423-023-03206-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/12/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Exenteration surgery for multi-visceral pelvic malignancy is a complex life-changing operation with high perioperative morbidity and mortality. Traditional open surgery has long been the standard approach for pelvic exenteration for achieving Ro resection which is the main aim of surgery. In the current era of minimally invasive surgery, robotic-assisted pelvic exenteration has provided a promising alternative, offering potential advantages in terms of improved oncological outcomes and enhanced postoperative recovery. This study aims to explore the feasibility of a robotic platform for locally advanced multi-visceral pelvic malignancy. METHODS A retrospective review from the prospectively maintained robotic colorectal surgery database at University Hospital Coventry and Warwickshire (UHCW) Trust was performed. Demographic details and clinical and surgical details were documented from the case records. Data was analysed using SPSS version 22. RESULTS Thirteen female patients diagnosed with primary or recurrent pelvic malignancy who underwent robotic pelvic exenteration at UHCW between February 2019 and April 2023 at UHCW were included. The mean age of our patients was 60.4 (± 10.1) years. Complete Ro resection was achieved in all 13 (100%) cases on final histopathology. The median length of hospital stay was 15 days after this extensive surgery. Grade 3 morbidity on Clavien-Dindo classification was observed in four (30.7%) patients, while zero percent 30-day mortality was experienced in this study. At a median follow-up of 21 (3-53) months, we observed tumor recurrence in three (23.7%) patients, while death in four (30.7%) patients. Only few studies have highlighted outcomes of robotic pelvic exenteration, and our results were quite comparable to them. CONCLUSION Robotic-assisted pelvic exenteration for primary or recurrent pelvic malignancy is feasible with improved oncological and acceptable postoperative outcomes.
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Affiliation(s)
| | | | - Jeremy Twigg
- University Hospital Coventry and Warwickshire Trust, Coventry, UK
| | - Omer Altan
- University Hospital Coventry and Warwickshire Trust, Coventry, UK
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Kearsey CC, Mathur M, Sutton PA, Selvasekar CR. Robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy: technical considerations and case vignette. Tech Coloproctol 2023; 27:1125-1130. [PMID: 37452925 PMCID: PMC10562300 DOI: 10.1007/s10151-023-02827-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/25/2023] [Indexed: 07/18/2023]
Abstract
When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less important for patient outcomes. We performed a minimally invasive approach to surgery for LARC invading the posterior vagina and sacrum. The patient was a 75-year-old lady who presented with a locally advanced rectal tumour staged T4N2 with invasion into the posterior wall of the vagina and coccyx/distal sacrum. We introduce a robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy using a purely perineal approach with no robotic adjuncts or intracorporal techniques. Final histology showed moderately differentiated adenocarcinoma invading the vagina and sacrum, ypT4b N0 TRG2 R0 and the patient entered surgical follow-up with no immediate intra- or postoperative complications. A literature review shows the need for more minimally invasive techniques when relating to major pelvic surgery and the benefits of a purely perineal approach include less expensive resource use, fewer training requirements and the ability to utilise this technique in centres that are not robotically equipped.
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Affiliation(s)
- C. C. Kearsey
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX UK
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - M. Mathur
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX UK
| | - P. A. Sutton
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C. R. Selvasekar
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX UK
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Alonso Casado O, Nuñez Mora C, Ortega Pérez G, López Rojo I. Robotic pelvic exenteration in males: systematization of the technique. Cir Esp 2023; 101:555-560. [PMID: 37487944 DOI: 10.1016/j.cireng.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/08/2023] [Indexed: 07/26/2023]
Abstract
Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.
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Affiliation(s)
- Oscar Alonso Casado
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center, Madrid, Spain.
| | | | - Gloria Ortega Pérez
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center, Madrid, Spain
| | - Irene López Rojo
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center, Madrid, Spain
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Calvo Manuel FÁ, Serrano J, Solé C, Cambeiro M, Palma J, Aristu J, Garcia-Sabrido JL, Cuesta MA, Del Valle E, Lapuente F, Miñana B, Morcillo MÁ, Asencio JM, Pascau J. Clinical feasibility of combining intraoperative electron radiation therapy with minimally invasive surgery: a potential for electron-FLASH clinical development. Clin Transl Oncol 2023; 25:429-439. [PMID: 36169803 PMCID: PMC9873754 DOI: 10.1007/s12094-022-02955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Local cancer therapy by combining real-time surgical exploration and resection with delivery of a single dose of high-energy electron irradiation entails a very precise and effective local therapeutic approach. Integrating the benefits from minimally invasive surgical techniques with the very precise delivery of intraoperative electron irradiation results in an efficient combined modality therapy. METHODS Patients with locally advanced disease, who are candidates for laparoscopic and/or thoracoscopic surgery, received an integrated multimodal management. Preoperative treatment included induction chemotherapy and/or chemoradiation, followed by laparoscopic surgery and intraoperative electron radiation therapy. RESULTS In a period of 5 consecutive years, 125 rectal cancer patients were treated, of which 35% underwent a laparoscopic approach. We found no differences in cancer outcomes and tolerance between the open and laparoscopic groups. Two esophageal cancer patients were treated with IOeRT during thoracoscopic resection, with the resection specimens showing intense downstaging effects. Two oligo-recurrent prostatic cancer patients (isolated nodal progression) had a robotic-assisted surgical resection and post-lymphadenectomy electron boost on the vascular and lateral pelvic wall. CONCLUSIONS Minimally invasive and robotic-assisted surgery is feasible to combine with intraoperative electron radiation therapy and offers a new model explored with electron-FLASH beams.
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Affiliation(s)
| | - Javier Serrano
- Department of Oncology, Clinica Universidad de Navarra, Madrid-Pamplona, Spain
| | - Claudio Solé
- Instituto RadioMedicina, Santiago del Chile, Chile
| | - Mauricio Cambeiro
- Department of Oncology, Clinica Universidad de Navarra, Madrid-Pamplona, Spain
| | - Jacobo Palma
- Department of Oncology, Clinica Universidad de Navarra, Madrid-Pamplona, Spain
| | - Javier Aristu
- Department of Oncology, Clinica Universidad de Navarra, Madrid-Pamplona, Spain
| | | | | | | | - Fernando Lapuente
- Department of Surgery, Clinica Universidad de Navarra, Madrid, Spain
| | - Bernardino Miñana
- Department of Urology, Clinica Universidad de Navarra, Madrid, Spain
| | | | | | - Javier Pascau
- Department of Bioengineering and Aerospace Engineering, Universidad Carlos III de Madrid, Getafe, Spain
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Minimally invasive surgery for maximally invasive tumors-pelvic exenterations for rectal cancers: are we prepared? JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:127-128. [PMID: 36601489 PMCID: PMC9763478 DOI: 10.7602/jmis.2022.25.4.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Despite the public awareness of colorectal cancer screening with more and more early premalignant or malignant lesions detected, surgeons still face the challenges of operating for a patient suffering from locally advanced rectal carcinoma which required pelvic exenterations, and surgical outcomes mostly influenced by margin status, adjuvant chemotherapy, positive lymph nodes and liver metastasis, etc. Open pelvic exenteration has been the adopted approach in the past and laparoscopic surgery is another option in expert centers. A study in this issue of the Journal of Minimally Invasive Surgery demonstrated promising results of minimally invasive approaches for pelvic exenteration in patients with locally advanced rectal carcinoma, with overall complication rate of 28.2% with a 7.3% circumferential resection margin positivity and with no distal margin involvement, with local recurrence rate of 8.1% and overall survival of 85.2% by 2-year follow-up. We are expecting more results in the future to support the routine implementation of minimally invasive pelvic exenterations.
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Kihara K, Koyama Y, Hanaki T, Miyatani K, Matsunaga T, Yamamoto M, Morizane S, Tokuyasu N, Sakamoto T, Fujiwara Y. Robot-assisted total pelvic exenteration for rectal cancer after neoadjuvant chemoradiotherapy: a case report. Surg Case Rep 2022; 8:191. [PMID: 36205818 PMCID: PMC9547043 DOI: 10.1186/s40792-022-01547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background There are numerous indications for minimally invasive surgery. However, the laparoscopic approach for extended pelvic surgery is currently provided by only a few institutions specializing in cancer treatment, primarily because of technical difficulties that arise in cases involving a narrow pelvis and rigid forceps. We report a case of robot-assisted total pelvic exenteration for rectal cancer involving the prostate. We assessed the feasibility of robot-assisted total pelvic exenteration and compared the short-term outcomes of other conventional and minimally invasive approaches. Case presentation A 67-year-old man was referred to our hospital after positive fecal blood test results. The initial diagnosis was clinical T4bN2aM0, Stage IIIC rectal cancer involving the prostate. The patient underwent neoadjuvant chemoradiotherapy. Consequently, robot-assisted total pelvic exenteration with an ileal conduit and end colostomy creation were performed. The total operative duration was 9 h and 20 min. The durations of robot console usage by the colorectal and urological teams were 2 h 9 min and 2 h 23 min, respectively. The patient was discharged on postoperative day 21. The pathological diagnosis was T4b (prostate) N0M0, Stage IIC. The resection margin was 2.5 mm. During reassessment at 2 years after resection, no evidence of recurrence was observed. Conclusions Robot-assisted total pelvic exenteration was performed for a patient with advanced rectal cancer without serious complications. Robot-assisted total pelvic exenteration may provide the advantages of minimally invasive surgery, particularly in the enclosed space of the pelvis.
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Affiliation(s)
- Kyoichi Kihara
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Yuri Koyama
- grid.265107.70000 0001 0663 5064Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Takehiko Hanaki
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Kozo Miyatani
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Tomoyuki Matsunaga
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Manabu Yamamoto
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Shuichi Morizane
- grid.265107.70000 0001 0663 5064Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Naruo Tokuyasu
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Teruhisa Sakamoto
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
| | - Yoshiyuki Fujiwara
- grid.265107.70000 0001 0663 5064Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishimachi, Yonago City, Tottori 683-8504 Japan
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The role of surgery for loco-regional and advanced urological cancers. Curr Opin Urol 2022; 32:634-642. [PMID: 36101519 DOI: 10.1097/mou.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a general misconception that surgery is the antithesis of palliation. However, symptom mitigation, the basic tenet of palliative interventions, can be achieved by invasive procedures. Surgical care, thus, plays an important role in palliative oncology, alongside radiation and systemic therapy. There is global movement to improve palliation in oncology, and thus it is timely to evaluate the role of surgical interventions can play in this setting. RECENT FINDINGS Many of the surgical interventions done with palliative intent were first established as curative options. Most studies looked at interventions for local control of primary tumour including extirpative surgeries, while some studies studied pain relief for bone metastases. Results show that patients have an acceptable survival outcome and complication rate comparable to those done in the curative setting. However, not all studies report functional outcomes and symptom-relief consistently, highlighting an unmet need. SUMMARY More studies are needed to further define the role of surgery in palliative care. Randomized controlled trials studying surgical intervention in the palliative setting will be challenging because of lack of equipoise, inherent bias in patient and disease characteristics in those who undergo surgery. Nonetheless, studies should endeavour to study symptom-free survival and PROMs as meaningful endpoints of interventions performed in a palliative setting rather than solely focus on hard oncological endpoints of survival.
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Casey L, Larach JT, Waters PS, Kong JCH, McCormick JJ, Heriot AG, Warrier SK. Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2330-2337. [DOI: 10.1016/j.ejso.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 07/26/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022]
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Larach JT, Flynn J, Fernando D, Mohan H, Rajkomar A, Waters PS, Kong J, McCormick JJ, Heriot AG, Warrier SK. Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short-term outcomes. Colorectal Dis 2022; 24:821-827. [PMID: 35373888 DOI: 10.1111/codi.16136] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/03/2022] [Accepted: 03/28/2022] [Indexed: 12/29/2022]
Abstract
AIM To explore the feasibility and safety of robotic beyond total mesorectal excision (TME) surgery for primary and recurrent pelvic malignancy. METHODS Patients undergoing robotic beyond TME resections for primary or recurrent pelvic malignancy between July 2015 and July 2021 in a public quaternary and a private tertiary centre were included. Demographic and clinical data were recorded and outcomes analysed. RESULTS Twenty-four patients (50% males) were included, with a median age of 58 (45-70.8) years, and a BMI of 26 (24.3-28.1) kg/m2 . Indication for surgery was rectal adenocarcinoma in nineteen, leiomyosarcoma in two, anal squamous cell carcinoma in one and combined rectal and prostatic adenocarcinoma in two patients. All patients required resection of at least one adjacent pelvic organ including genitourinary structures (n = 23), internal iliac vessels (n = 3) and/or bone (n = 2). Eleven patients had a restorative procedure. Of the 13 nonrestorative cases, nine needed perineal reconstruction with a flap. There was one conversion due to bleeding. The mean operating time was 370 (285-424) min, and the median blood loss was 400 (200-2,000) ml. The median length of stay was 16 (9.3-23.8) days. Fourteen patients (58.3%) had postoperative complications; eight of them (33.3%) were Clavien-Dindo III or more complication. Twenty-three (95.8%) patients had an R0 resection. During a median follow-up of 10 (7-23.5) months, five patients (20.8%) had systemic recurrences. No local recurrences were identified during the study period. CONCLUSION Implementation of robotic beyond TME surgery for primary and recurrent pelvic malignancy is feasible within a highly specialised setting.
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Affiliation(s)
- José Tomás Larach
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Julie Flynn
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Diharah Fernando
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Helen Mohan
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Amrish Rajkomar
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Peadar S Waters
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph Kong
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Fukata K, Akiyoshi T, Numao N, Komai Y, Mukai T, Hiyoshi Y, Yamaguchi T, Nagasaki T, Konishi T, Fukunaga Y. Robotic-assisted laparoscopic surgery for synchronous primary rectal and prostate cancer: Initial case series. Asian J Endosc Surg 2022; 15:678-682. [PMID: 35285155 DOI: 10.1111/ases.13048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
Few studies have reported the simultaneous resection of synchronous rectal and prostate cancers. Here, we report five patients undergoing simultaneous robotic-assisted laparoscopic surgery (RALS) for synchronous rectal and prostate cancer. Rectal cancer operative procedures were high anterior (n =1), intersphincteric (n =2), or abdominoperineal (n =2) resection, followed by radical prostatectomy with vesico-urethral anastomosis. There were no conversions to open surgery, with R0 resection achieved for all rectal cancer cases. The median operative time was 629 (range, 431-764) minutes, and the median estimated blood loss was 100 (range, 20-345) mL. There was one case of colorectal anastomotic leakage requiring covering ileostomy, and two cases of vesico-urethral anastomotic leakage requiring Foley catheter reinsertion. Ileostomies were finally closed in all patients. Pad-free or safety-pad usage for post-surgical urinary incontinence at 6 and 12 months was 3/5 and 5/5, respectively. Simultaneous RALS for synchronous rectal and prostate cancer may offer a safe and feasible approach in selected patients.
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Affiliation(s)
- Koji Fukata
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Noboru Numao
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiki Mukai
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukiharu Hiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Yamaguchi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities. Curr Treat Options Oncol 2022; 23:961-979. [PMID: 35438444 PMCID: PMC9174118 DOI: 10.1007/s11864-022-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/09/2022]
Abstract
The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.
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Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative. Cancers (Basel) 2022; 14:cancers14051161. [PMID: 35267469 PMCID: PMC8909015 DOI: 10.3390/cancers14051161] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.
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Chang TP, Chok AY, Tan D, Rogers A, Rasheed S, Tekkis P, Kontovounisios C. The Emerging Role of Robotics in Pelvic Exenteration Surgery for Locally Advanced Rectal Cancer: A Narrative Review. J Clin Med 2021; 10:jcm10071518. [PMID: 33916490 PMCID: PMC8038538 DOI: 10.3390/jcm10071518] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/02/2021] [Accepted: 04/04/2021] [Indexed: 11/16/2022] Open
Abstract
Pelvic exenteration surgery for locally advanced rectal cancers is a complex and extensive multivisceral operation, which is associated with high perioperative morbidity and mortality rates. Significant technical challenges may arise due to inadequate access, visualisation, and characterisation of tissue planes and critical structures in the spatially constrained pelvis. Over the last two decades, robotic-assisted technologies have facilitated substantial advancements in the minimally invasive approach to total mesorectal excision (TME) for rectal cancers. Here, we review the emerging experience and evidence of robotic assistance in beyond TME multivisceral pelvic exenteration for locally advanced rectal cancers where heightened operative challenges and cumbersome ergonomics are likely to be encountered.
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Affiliation(s)
- Tou Pin Chang
- Department of Colorectal Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (T.P.C.); (A.R.); (S.R.); (P.T.)
| | - Aik Yong Chok
- Department of Surgery and Cancer, Imperial College, London W2 1NY, UK; (A.Y.C.); (D.T.)
| | - Dominic Tan
- Department of Surgery and Cancer, Imperial College, London W2 1NY, UK; (A.Y.C.); (D.T.)
| | - Ailin Rogers
- Department of Colorectal Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (T.P.C.); (A.R.); (S.R.); (P.T.)
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (T.P.C.); (A.R.); (S.R.); (P.T.)
| | - Paris Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (T.P.C.); (A.R.); (S.R.); (P.T.)
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (T.P.C.); (A.R.); (S.R.); (P.T.)
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
- Correspondence:
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