Survival after breast cancer local recurrence according to therapeutic strategies.

AIMS: To compare survival outcomes after mastectomy (Mt) and lumpectomy plus interstitial brachytherapy (LpIB) in the treatment of breast cancer local recurrence (LR) occurring after conservative surgery. METHODS: Medical records of patients treated for an isolated LR from January 1, 1981 to December 31, 2009 were reviewed. To overcome the bias due to the fact that treatment choice (Mt or LpIB) was based on prognostic factors with LpIB proposed preferentially to women with good prognosis, Mt and LpIB populations were matched and compared with regard to overall survival (OS) and metastasis free survival (MFS). RESULTS: Among 348 patients analyzed, 66.7% underwent Mt, 17.8% LpIB and 15.5% Lp alone. After a median follow-up of 73.3 months, 65 patients had died (42/232 Mt, 8/62 LpIB, 15/54 Lp). Before matching, OS and MFS at 5 years were significantly better in the LpIB compared to the Mt group, due to significantly more frequent poor prognostic factors in the latter (p = 0,07 and p = 0,09 respectively, log-rank significance limit of 10%). After matching, the benefits of LpIB disappeared since MFS and OS rates were not significantly different in both groups (p = 0.68 and 0.88 respectively). After LpIB, the second LR rate was 17% at 5 years and 30% at 10 years. CONCLUSION: A second conservative breast cancer treatment associating lumpectomy and interstitial brachytherapy is possible for selected patients with LR, without decrease in neither OS nor MFS compared to mastectomy.

Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes.

CONTEXT: Even if neoadjuvant chemotherapy (NACT) and oncoplastic techniques have increased the breast conserving surgery rate, mastectomy is still a standard for multifocal or extensive breast cancers (BC). In the prospect of increasing breast reconstruction, an alternative therapeutic protocol was developed combining NACT with neoadjuvant radiation therapy (NART), followed by mastectomy with immediate breast reconstruction (IBR). The oncological safety of this therapeutic plan still needs further exploration. We assessed pathological complete response (pCR) as a surrogate endpoint for disease free survival. METHODS: Between 2010 and 2016, 103 patients undergoing mastectomy after NACT and NART were recruited. After CT and RT were administrated, a completion mastectomy with IBR by latissimus dorsi flap was achieved 6 to 8 weeks later. pCR was defined by the absence of residual invasive disease in both nodes and breast. Histologic response was analyzed for each immunohistochemical subset. RESULTS: pCR was obtained for 53.4% of the patients. This pCR rate was higher in hormonal receptor negative (HER2 and triple negative) patients when compared to luminal tumours (69.7% vs 45.7%, p=0.023). DISCUSSION: The pCR rate found in this study is higher than those published in studies analyzing NACT (12.5%-27.1%). This can be explained by the combination of anthracycline and taxane, the use of trastuzumab when HER2 was overexpressed but also by RT associated to NACT. CONCLUSION: Inverting the sequence protocol for BC, requiring both CT and RT, allows more IBR without diminishing pCR and should therefore be considered as an acceptable therapeutic option.

[Sentinel lymph node-multicentric and multifocal tumors: a valid technique?]. / Ganglion sentinelle et tumeurs multifocales-multicentriques : une technique valide ?

Sentinel node biopsy without complementary axillary lymph node dissection was validated for T1-2 N0 unifocal breast cancer without previous treatment since several years. In the situation of multifocal multicentric breast tumors, this procedure was considered as a contraindication. The aim of this work was to analyse literature results to determine if sentinel lymph node biopsy can be considered as a valid option without complementary axillary lymph node dissection for negative sentinel lymph node.

[Conservation of the nipple-areola complex in case of mastectomy]. / Conservation de la plaque aréolo-mamelonnaire en cas de mastectomie.

Nipple-Sparing Mastectomy (NSM) is a procedure with skin-sparing mastectomy and nipple-areolar complex preservation in association with immediate reconstruction. The aim of this publication is to perform a review of oncological results, technical procedure, complications and indications of NSM with discussion of post-mastectomy radiotherapy indication. Local areolar recurrence is rare and treatment is performed by resection of the nipple-areolar complex. The nipple-areolar complex necrosis rate is a specific complication, observed between 1 to 30% in literature studies. Incisions and surgical procedure of dissection are discussed.

[Single-port surgery and adnexal procedures: which indications in oncological surgery?]. / Cœlioscopie par mono-trocart et chirurgie annexielle : quelles applications en chirurgie oncologique ?

OBJECTIVE: To show the interest of single trocar in order to perform uni- or bilateral salpingo-oophorectomies. PATIENTS AND METHODS: A descriptive study monocentric. RESULTS: A total of 79 unilateral or bilateral salpingo-oophorectomies were performed by single-port laparoscopy between January 2010 and September 2012 at the Institut Paoli-Calmettes (Marseille). There are three surgical indications: diagnostic, therapeutic and prophylactic. The median age was 50 years (22-78 years). The median BMI was 22.4 kg/m(2) (17.5 to 37.7 kg/m(2)). The median blood loss was 0cc (0cc-50cc). The median hospital stay of patient was one day (0-6 days). The conversion rate in this study was 8.8%. DISCUSSION AND CONCLUSION: The single-port laparoscopic approach to perform uni- or bilateral salpingo-oophorectomies is a natural evolution of the conventional laparoscopy. If the cosmetic role seems obvious, its therapeutic value compared to traditional technique must be demonstrated by prospective studies with larger numbers.

[Feasibility study about the single-port in gynecologic oncology surgery]. / Étude de faisabilité sur le mono-trocart en chirurgie gynécologique oncologique.

OBJECTIVES: To describe our single-port experience in gynecologic oncology surgery, and emphasize the feasibility to use the single-port in this surgery. PATIENTS AND METHODS: It is a retrospective, feasibility study, monocentric. All patients who were operated by the single-port, between 1st January 2010 to 1st November 2011, were included. RESULTS: We note that 107 patients were included. We made different interventions: uni- and bilateral salpingo-ovariectomy, hysterectomy, pelvic and para-aortic lymph node sampling or lymphadenectomy in gynecologic malignancies. The median age of the population and the body mass index were respectively 52 and 22.6 kg/m(2). In total, six interventions will be converted. The median hospital stay of patients, all procedures combined, was 2 days. We find low rate of postoperative complications. CONCLUSION: Gynecological cancer surgery appears feasible for single-port. However, we need other studies to confirm a benefit of using the single-port compared to conventional laparoscopy.

[Robot-assisted laparoscopy in the management of recurrent pelvic cancer]. / Place de la cœlioscopie robot-assistée dans la prise en charge des récidives de cancers pelviens.

OBJECTIVES: The aim of this study is to establish the feasibility of the management of recurrent pelvic cancers by robot-assisted laparoscopy, and particularly the feasibility of robot-assisted laparoscopy anterior pelvic exenteration, from a single center series of seven patients. PATIENTS AND METHODS: From February 2007 to April 2010, all patients cared for recurrent pelvic cancer have been included (n=7). Five patients have been cared for a cervical cancer recurrence, one patient for recurrent VAIN 3, and one patient for squamous cell carcinoma of the vaginal vault after hysterectomy for cervical carcinoma in situ. All patients were benefited from robot-assisted laparoscopy: two had surgery such as anterior pelvic exenteration with Miami Pouch urinary reconstruction, and five had colpectomy with or without lymph node removal, including one with vaginal preparation first before vaginal cuff resection. Data were collected prospectively identifying treatment history, intraoperative data, immediate outcomes, pathological findings, and long-term outcomes. RESULTS: From February 2007 to April 2010, 195 patients underwent robot-assisted laparoscopy at the Institut Paoli-Calmettes. Among them, seven patients had pelvic cancer recurrence. The median age was 53 years (44 to 67). The median BMI was 25 (19.7 to 35.3). The median Karnofsky index was 100 (80-100). The median operative time was 210 min (90 to 300) for colpectomy, 480 min for pelvectomy, 240 min (90-480) for the serie. The mean duration of the installation of the robot, all procedures combined, is estimated at 22.5 min (±4.8 min). There was no conversion to laparotomy, the median blood loss was 340 ml (100 to 800). One patient was transfused with two red blood cells. There was a surgical complication (wound of the inferior mesenteric artery). There were no early postoperative complications and the median hospital stay was 6 days (3-24). There was a late postoperative complication: a patient who underwent anterior pelvic exenteration had impaired wound healing, with scarring requiring led by the VAC system. On pathological findings, the average number of nodes removed in the pelvic was 8.5 (±2) on the left, and 4 (±1.4) on the right. Three patients had involved margins; it was an anterior pelvic exenteration and two colpectomy. There was no hospital mortality, neither post-operative mortality at D30 and D90. After a median follow up of 22 months (9-34), the recurrence rate was 71% (5 patients out of 7), and one patient died 10 months after the intervention of a pulmonary embolism. DISCUSSION AND CONCLUSION: The surgical management of recurrent cervical cancer by laparoscopy-assisted robot is feasible for selected indications, and could be proposed as an alternative to laparotomy. Monitoring data in this series raise the question of the validity of conservative treatment in cases of recurrent pelvic cancer. The possibilities in terms of urinary and vaginal reconstruction remain to be defined. The impact of this surgical approach on oncological data must be confirmed.

Sentinel lymphadenectomy for the staging of clinical axillary node-negative breast cancer before neoadjuvant chemotherapy.

BACKGROUND: Several authors reported sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NC). Nevertheless, the ideal time of SLNB is still a matter of debate. METHODS: We evaluated the feasibility and the accuracy of SLNB before NC using a combined procedure (blue dye and radio-labelled detection) before NC. Axillary lymph node dissection (ALND) was performed after completion of NC in a homogeneous cohort study with clinically axillary node-negative breast cancer. RESULTS: Among the 20 women who had metastatic SLNB (65%), 4 (20%) had additional metastatic node on ALND. By contrast, all the 11 women who had no metastatic SLNB had no involved nodes in the ALND. The SLN identification rate before NC was 100% with any false negative. CONCLUSIONS: SLNB before NC is a feasible and an accurate diagnostic tool to predict the pre-therapeutic axilla status. These findings suggest that ALND may be avoided in patients with a negative SLNB performed before NC.

A nomogram predictive of non-sentinel lymph node involvement in breast cancer patients with a sentinel lymph node micrometastasis.

PURPOSE: Predictive factors of non-sentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) have been studied in the case of sentinel node (SN) involvement, with validation of a nomogram. This nomogram is not accurate for SN micrometastasis. The purpose of our study was to determine a nomogram for predicting the likelihood of NSN involvement in breast cancer patients with a SN micrometastasis. METHODS: We collated 909 observations of SN micrometastases with additional ALND. Characteristics of the patients, tumours and SN were analysed. RESULTS: Involvement of SN was diagnosed 490 times (53.9%) with standard staining (HES) and 419 times solely on immunohistochemical analysis (IHC) (46.1%). NSN invasion was observed in 114 patients (12.5%), whereas 62.3% (71) had only one NSN involved and 37.7% (43) two or more NSN involved. In multivariate analysis, significant predictive factors were: tumour size (pT stage < or = 10 mm or >11 and < or = 20 or >20 mm [odds ratio (OR) 2.1 and 3.43], micrometastases detected by HES or IHC [OR 1.64], presence or absence of lymphovascular invasion (LVI) [OR 1.76], tumour histological type mixed or not [OR 2.64]. The rate and probability of NSN involvement with the model are given for 24 groups, with a representation by a nomogram. CONCLUSION: One group, corresponding to 10.1% of the patients, was associated with a risk of NSN involvement of less than 5%, and five groups, corresponding to 29.8% of the patients, were associated with a risk < or = 10%. Omission of ALND could be proposed with minimal risk for a low probability of NSN involvement.

[Margin status in invasive breast cancer]. / Marge d'exérèse dans les cancers infiltrants du sein.

Breast conserving surgery and mastectomy are equivalent for overall survival. However, the rate of local recurrence is higher for breast conserving surgery. Several predictive factors for local recurrence have been identified and some of them such as margins of resection, radiation therapy, chemotherapy, and hormonotherapy can be modified. The aim of this study is to review arguments in the literature to define optimal margins of resection. The orientation of the specimen and the inking of lateral margins are essentials for the histopathological analysis. Lateral margins are the most important since the resection is close to the pectoral muscle. According to the literature, the rate of local recurrence is higher when margins are positive. Moreover, the presence of tumoral cells on specimen after a re-excision is correlated with the positivity of the margins. There are no agreements about the number of millimeters requested to consider a margin sufficient. However, two millimeters seem to show a decrease of local recurrence. The influence of extensive intraductal component on local recurrence risk has been studied. Several factors are correlated and to define independent factors seem to be interesting.

Robot-assisted laparoscopy in gynecologic oncology.

OBJECTIVES: The aim of this prospective study was to evaluate the feasibility and the outcome of gynaecological cancer surgery with the Da Vinci S surgical system (Intuitive Surgical). METHODS: From February 2007 to September 2007, 28 patients underwent 32 gynaecological procedures in a single centre. Surgical procedures consisted of total hysterectomy, bilateral oophorectomy, and pelvic and/or lombo-aortic lymphadenectomy. In all cases, surgery was performed using both laparoscopic and robot-assisted laparoscopic techniques. In this heterogeneous series, a subgroup of 12 patients treated for advanced cervical cancer was compared with a retrospective series of 20 patients who underwent the same surgical procedure by laparotomy. RESULTS: Mean age of the entire population was 52.5 years (range 25-72 years) and mean body mass index (BMI) was 25 kg/m(2) (range 18-40 kg/m(2)). Indications for surgery were cervical cancer in 21 cases, endometrial cancer in 7 cases, ovarian cancer in 1 case and cervical dysplasia in 3 cases. Median operating time was 180 min (mean 175.25 min, range 80-360 min) and median estimated blood loss was 110 cc (range 0-400 cc); no transfusions were necessary. No perioperative complications were observed and median time of hospitalisation was 3 days (mean 3.9 days, range 2-8 days). In the subgroup of 12 advanced cervical cancer a significant difference was observed in terms of hospital stay compared with laparotomy; no difference was observed concerning operative time. Fewer complications were observed with laparotomy (33% versus 25%) but more serious complications than with robot-assisted laparoscopy. CONCLUSION: As suggested in the literature, the use of robot-assisted laparoscopy leads to less intraoperative blood loss, less post operative pain and shorter hospital stays compared with those treated by more traditional surgical approaches. Despite the need for more extensive studies, robot-assisted surgery seems to represent a similar technological evolution as the laparoscopic approach 50 years ago.

Equivalent survival in patients with advanced stage IB-II and III-IVA cervical cancer treated by adjuvant surgery following chemoradiotherapy.

OBJECTIVES: To evaluate survival in patients with advanced cervical cancer who underwent surgery after concurrent chemoradiotherapy. METHODS: One hundred and forty-four patients with biopsy-proven stage IB-IVA cervical cancer underwent adjuvant surgery after concurrent chemoradiotherapy. Surgical resection was classified as curative (no evidence of remaining disease after surgery) or palliative (remaining disease after surgery). Endpoints were pelvic control, overall survival (OS) and disease-free survival (DFS) at 5 and 10 years. Analysis included tumour FIGO stage, type of surgery (curative versus palliative), pelvic control, response to chemoradiotherapy and lymphatic status. RESULTS: Tumour FIGO stages were IB-II in 91 cases and III-IVA in 53 cases. Surgery was curative in 127 cases. Pelvic control was achieved in 114 patients and was equivalent in stage IB-II and III-IVA patients. So far, 60 patients have died. The 5-year OS and DFS rates were, respectively, 57.6% [95% CI: 49.1-67.5] and 65% [95% CI: 56.2-75]. OS was significantly affected by the type of surgery (p<2.10(-16)), the presence of tumoural residue (p=0.002) and the pelvic lymphatic status (p<0.001). DFS was affected by the pelvic (p=0.02) and para-aortic lymphatic status (p=0.009). No significant difference was observed between OS and DFS in stage IB-II and III-IVA patients, whereas a macroscopic tumoural residue was observed in, respectively, 30.9 and 52.2% of cases (p=0.022). CONCLUSION: Survival rates were equivalent between patients with IB-II and III-IVA cervical cancer, suggesting that adjuvant surgery following chemoradiotherapy may improve local control.

Female psychopathologic profile during menopausal transition: a preliminary study.

OBJECTIVES: To evaluate the psychopathological profile and the incidence of major depressive disorders in consecutive women attending a Menopause Clinic. METHODS: Women attending outpatient menopause clinic at Filippo del Ponte Hospital in Varese (Italy), referring to the centre from 1 March to 30 April 2005, were invited to fill up a specific questionnaire while waiting for the visit. The questionnaire included demographics and history (e.g. current or past use of antidepressant drugs); symptoms check list (SCL-90-R); Beck depression inventory (BDI). RESULTS: Sixty-four women were enrolled to the study. On the SCL-90-R, "somatic" symptoms cluster was the most frequent. Patients diagnosed as depressed using the Beck depression inventory (BDI) were 18 (28.1%). Thirteen (70%) of currently depressed women presented a positive history of depressive disorders. The analysis of depressed women according to previous depressive disorders revealed higher scores for women with positive history in both scales. Depressed patients have a significantly lower mean age compared to non-depressed patients (53.3+/-6.2 years versus 57.33+/-4.9 years, p=0.023). CONCLUSIONS: Our preliminary data show a high correlation between a history of depressive disorder and recurrence of depression in the menopausal period. Perimenopause seems to be a higher risk period for the development of a depressive disease compared to menopausal status. The somatization cluster warrants further investigation.

Contribution of surgery in patients with bulky residual disease after chemoradiation for advanced cervical carcinoma.

AIM: To report the outcome of 30 patients who underwent surgery after concomitant chemoradiation for locally advanced cervical cancer with residual disease > or = 2 cm. METHODS: From 1988 to 2004, 143 patients with FIGO stage IB2-IVA cervical cancer underwent surgery after concurrent chemoradiotherapy. Among them, 30 had a residual cervical tumour > or = 2 cm prior to surgery. Surgery consisted in a simple or radical hysterectomy (n=15) or in a pelvic exenteration (n=15). Endpoints were recurrence and distant metastasis rates, overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. Analysis included FIGO stage, response to chemoradiation, para-aortic lymphatic status or type of surgery: palliative (remaining disease after surgery) or curative (no evidence of remaining disease after surgery). RESULTS: Surgery has been only palliative in 11 cases. Pelvic recurrences occurred in 8 patients after a median interval of 8.8 months. Distant metastases occurred in 8 patients after a median interval of 13 months. So far, 16 patients have died (53.3%). The 3-year and 5-year OS rates are 64.9% and 55.6%, respectively, for the 19 patients who had a curative surgery. The DFS rate is 50.8% at 3 and 5 years in this latter group. Overall 12 patients (40%) are alive and free of disease after a median follow-up of 32.5 months. CONCLUSIONS: Adjuvant surgery may improve the outcome of patients with bulky residual tumour after chemoradiation for locally advanced cervical cancer, allowing a 5-year OS of 55.6% after curative intervention.

[Surgical resection after chemotherapy for advanced cervical carcinoma]. / Place de la chirurgie après chimioradiothérapie des cancers du col localement évolués.

Standard treatment of locally advanced cervical carcinoma is actually represented by concomitant chemoradiotherapy followed by brachytherapy since several randomised study results in 1999. Surgical resection after concomitant chemoradiotherapy for locally advanced cervical carcinoma is discussed without evidence of benefice on survival and because morbidity. The aim of this study is to discuss surgery after chemoradiotherapy in terms of rate of morbidity and residual tumor, rate of pelvic disease control, overall survival and disease-free survival.

[Pelvic posterior exenteration with immediate colo-rectal anastomosis: is it justified and feasible in advanced stage ovarian carcinoma?]. / Une exentération pelvienne postérieure avec anastomose est-elle faisable et justifiée dans le traitement des cancers de l'ovaire à un stade évolué?

PURPOSE: The aim of this study is to show that the removal of the rectum is not an obstacle to implement an optimal surgery in advanced epithelial cancer of the ovary. MATERIAL AND METHODS: Retrospective study on a population of 44 women with advanced epithelial cancer of the ovary. The surgery was realized between January 95 and July 03, and all surgeries required a posterior exenteration. This treatment was completed by chemotherapy for 36 of them. RESULTS: The median survival of this population is 36.6 months. 6/44 patients (13.6%) had post-operative complications. The completion of chemotherapy started after an average of 5.2 weeks after surgery. All the assessable patients (43/44) have an anal satisfactory continence. CONCLUSION: The posterior exenteration, when it's necessary, for advanced epithelial cancer of the ovary must not be an obstacle to obtain an optimal surgery. Anal continence is respected and there are no more complications. This surgical act is safe for the management of this pathology without delaying the others therapeutics and allowing a satisfactory quality of life.

Rectus abdominis myocutaneous flap in radical oncopelvic surgery: a safe and useful procedure.

AIMS: The aim of this retrospective study was to evaluate the usefulness of rectus abdominis myocutaneous (RAM) flaps to treat locally advanced pelvic gynaecological or digestive tumours. METHODS: We reviewed 46 patients, who received RAM flaps after radical oncopelvic surgery, including: (a) total vaginal reconstruction (TVR); (b) partial vaginal reconstruction (PVR); (c) perineal reconstruction (PR). RESULTS: Between 1989 and 1998, 46 patients underwent pelvi-perineal reconstruction with RAM flaps after radical pelvic surgery for carcinoma of the cervix (n=22), anal carcinoma (n=11), rectal carcinoma (n=7), or other pelvic tumours types (n=6). There were two post-operative deaths. Overall surgical morbidity was 45, 6% (n=21). Specific morbidity of the RAM flap was 21, 7% (n=10). Global re-intervention rate was 13% (n=6). CONCLUSION: Rectus abdominis myocutaneous flap in radical oncopelvic surgery is useful for vaginal or perineal reconstruction and prevention of pelvic collections after extended resections with a low rate of associated morbidity.

[Interest of sentinel lymph node biopsy for the staging of ductal carcinoma in situ]. / Prélèvement de ganglions sentinelles dans les carcinomes intracanalaires du sein (+/- micro-invasion).

PURPOSE: The aim of this study was to define the interest of sentinel lymph node biopsy (SLNB) for the staging of ductal carcinoma in situ (DCIS) and DCIS with micro-invasion (DCISM) in patients with breast carcinoma. MATERIAL AND METHODS: From June 1999 to December 2002 we listed, in a retrospective study, 52 patients treated surgically for a DCIS or a DCISM. All except one had an histology before surgery, and all had SLNB. Intraoperative imprint cytology of the sentinel lymph node (SLN) was performed then there were analysed by staining with hematoxylin-eosin. Patients with positive SLN underwent complete axillary dissection. RESULTS: It was removed an average of three SLNs by patient (extreme 1 to 6). Metastases in the SLN were detected in four (7,7%) of the 52 patients, including three cases had only micrometastases in the SLN. In the four patients treated with complete axillary dissection, the SLN were the only positives nodes. CONCLUSION: The SLNB for DCIS and DCISM increases the involvement rate of lymph node. Because of the widespread for early detection of breast cancer, it is noted a regular increase in the rate of DCIS. Even if the attitude to be had towards the lymph node metastases in these cases is not yet well defined, and so only 2% of the patients approximately die of this pathology, it is interesting because of increase in absolute value of mortality, to try to improve the prognosis criteria to modify the treatment of this pathology.

Two-trocar adnexal surgery: a "quasi" scarless operation.

BACKGROUND: This study aimed to explore the feasibility and safety of two-port abdominal cavity entry for adnexal surgery. METHODS: A series of patients undergoing laparoscopy for benign adnexal diseases requiring adnexectomy, ovariectomy, or salpingectomy were enrolled in the study. A 10-mm 0 degree umbilical operative laparoscope and one 3- or 5-mm suprapubic trocar were used. A grasping forceps was inserted through the ancillary trocar to displace medially and cranially the adnexa or the salpinx. The operation then was performed through the operative channel of the operative laparoscope. RESULTS: A total of 53 patients were enrolled. Bilateral salpingo-oophorectomy was performed in 10 cases. The median operative time was 39 min (range, 21-85 min). The median blood loss was 50 ml (range, 0-300 ml). The median size of the adnexal mass was 6 cm (range, 3-12 cm). No intraoperative complication occurred. At the 3-month follow-up visit, no extraumbilical abdominal scar was visible. CONCLUSIONS: The use of a two-trocar technique is safe and highly appreciated by the patients it leaves no visible abdominal scars.

Major complications of urinary diversion after pelvic exenteration for gynecologic malignancies: a 23-year mono-institutional experience in 124 patients.

OBJECTIVE: The objective of this study was to analyze the postoperative outcome of patients undergoing urinary diversion at the time of pelvic exenteration. METHODS: Between January 1980 and December 2002, 232 pelvic exenterations for gynecologic malignancies were performed in our hospital. One hundred and twenty-four included a urinary diversion. There were locally advanced or recurrent cancers including 101 cervical, 11 endometrial, 5 vagina, 2 ovarian malignancies and 5 pelvic sarcoma. RESULTS: Ninety patients (72.5%) had a history of previous irradiation. Exenterations were 69 anterior and 55 total. Urinary diversion included 14 bilateral ureterostomies, 62 trans-intestinal diversion and 48 continent diversion using distal ileum and right colon. Pelvic filling was performed in 56 patients (45%). Low colorectal anastomosis was performed in 42 of 48 supralevator pelvic exenteration (87.5%). Postoperative mortality rate was 8% (10/124). Overall 12-week postoperative morbidity rate was 52% (65/124) and appears to be significantly higher in irradiated patients and after total exenteration. In trans-intestinal noncontinent group, eight patients were reoperated for a complication directly related to urinary diversion procedure. No reoperation for such a complication was performed in the continent urinary diversion group. CONCLUSIONS: Ileocolic continent pouch seems to be the safer urinary diversion procedure after exenteration for gynecological malignancies especially in irradiated patients and after total exenteration.