First Report: Robot-Assisted Total Pelvic Exenteration for Locally Advanced Prostate Cancer.

Pelvic exenteration is used in the treatment of several pelvic cancers, including those of the rectum, uterus, and bladder. We report the first case of robotic pelvic exenteration for the treatment of symptomatic prostate cancer involving the rectum and bladder. A six-port transperitoneal robotic approach was used. Bilateral extended lymphadenectomy up to the inferior mesenteric artery was performed. The rectum and bladder were removed en bloc, and a double-barrel anastomosis was then performed with both ureters being connected to the lower opening of the colostomy. Operative time was 249 minutes, and estimated blood loss was 600 mL. No intraoperative or postoperative complications were recorded. Biopsy of the rectum and bladder showed prostatic adenocarcinoma with a Gleason score of 9 (5+4), and 1 of 17 nodes was positive for cancer. Postoperative prostate-specific antigen level was 1.24 ng/mL. The patient is already 19 months after surgery with optimal quality of life. Thus pelvic exenteration is a feasible alternative for highly symptomatic prostate cancer involving adjacent pelvic organs.

Surgical results of pelvic exenteration in the treatment of gynecologic cancer.

BACKGROUND: Our aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration. METHODS: We performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications. RESULTS: Twenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367 minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3 days and total hospital stay of 9.4 days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage. CONCLUSIONS: Postoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.

[Post-radiotherapy pelvic exenteration in relapsed cervical cancer: experience of a tertiary health service in the northeast of Brazil]. / Exenteração pélvica para câncer do colo uterino recidivado pós-radioterapia: experiência de um centro terciário do Nordeste brasileiro.

PURPOSE: to analyze complications, morbidity, mortality and survival rate in a group of patients with cervical cancer with central pelvic relapse after primary radiotherapy treatment. METHODS: retrospective study of a series of 16 cases of pelvic exenteration after primary radiotherapy treatment. Descriptive statistics, survival curve through Kaplan-Meier's method, and regression analysis to evaluate prognosis were performed. RESULTS: sixteen patients have undergone pelvic exenteration. Epidermoid carcinoma, IIb stage and undifferentiated grade were the most frequent conditions. Post-operatory tumor relapse occurred in half the cases. Eleven patients presented peri or post-surgical complications, the most frequent being pelvic infection, that of the surgical wound, and urinary fistulae. Global survival rate was 64.3%, with average follow-up of 11 months. Regression analysis did not detect any significant prognosis factor for the patient survival. CONCLUSIONS: the survival rate was 64.3%. No particular factor associated to poor prognosis has been found in the present series of cases.

Exenteração pélvica para câncer do colo uterino recidivado pós-radioterapia: experiência de um centro terciário do Nordeste brasileiro / Post-radiotherapy pelvic exenteration in relapsed cervical cancer: experience of a tertiary health service in the northeast of Brazil

OBJETIVO: analisar complicações, morbidade, mortalidade e sobrevida num grupo de pacientes com câncer de colo uterino com recidiva pélvica central submetidas à exenteração pélvica pós-tratamento primário com radioterapia. MÉTODOS: estudo retrospectivo de uma série de 16 casos de exenteração pélvica pós-tratamento primário com radioterapia. Foi realizada estatística descritiva, curva de sobrevida pelo método de Kaplan-Meier e análise de regressão linear múltipla para avaliar fatores prognósticos. RESULTADOS: dezesseis pacientes foram submetidas à exenteração pélvica. O carcinoma epidermoide, o estádio IIb e o grau indiferenciado foram as condições mais frequentes. A recidiva tumoral pós-operatória ocorreu na metade dos casos. Onze pacientes apresentaram complicações perioperatórias ou pós-operatórias e as mais frequentes foram infecções pélvica e da ferida operatória e fístulas urinárias. A sobrevida global foi de 64,3 por cento, com um seguimento mediano de 11 meses. A análise de regressão linear múltipla não revelou fatores prognósticos significativos na sobrevida das pacientes. CONCLUSÕES: a taxa de sobrevida foi de 64,3 por cento. Nenhum fator associado a pior prognóstico foi encontrado nesta série.

PURPOSE: to analyze complications, morbidity, mortality and survival rate in a group of patients with cervical cancer with central pelvic relapse after primary radiotherapy treatment. METHODS: retrospective study of a series of 16 cases of pelvic exenteration after primary radiotherapy treatment. Descriptive statistics, survival curve through Kaplan-Meier's method, and regression analysis to evaluate prognosis were performed. RESULTS: sixteen patients have undergone pelvic exenteration. Epidermoid carcinoma, IIb stage and undifferentiated grade were the most frequent conditions. Post-operatory tumor relapse occurred in half the cases. Eleven patients presented peri or post-surgical complications, the most frequent being pelvic infection, that of the surgical wound, and urinary fistulae. Global survival rate was 64.3 percent, with average follow-up of 11 months. Regression analysis did not detect any significant prognosis factor for the patient survival. CONCLUSIONS: the survival rate was 64.3 percent. No particular factor associated to poor prognosis has been found in the present series of cases.

A exenteração pélvica no tratamento do câncer de reto estádio T4: experiência de 15 casos operados / Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases

RACIONAL: A exenteração pélvica tem sido a melhor opção terapêutica radical para o tratamento dos tumores de reto T4. No entanto, essa operação ainda permanece com mortalidade significante e alta morbidade. OBJETIVO: Relatar série de 15 casos de exenteração pélvica para tumores de reto T4, analisando a morbidade, mortalidade e sobrevida dos pacientes. MÉTODOS: Foram estudados 15 pacientes com câncer de reto T4 no Serviço de Cirurgia Geral - Oncocirurgia do Hospital do Servidor Publico Estadual de São Paulo, SP, submetidos a exenteração pélvica no período de 1998 e 2006. Sete eram do sexo masculino enquanto oito eram do sexo feminino, com média de idade de 65 anos. Todos apresentavam sintomas incapacitantes. As operações foram: exenteração infra-elevadora (n = 6), exenteração supra-elevadora (n = 4), exenteração posterior (n = 3) e exenteração posterior com cistectomia e ureterectomia parciais (n = 2). RESULTADOS: A média de tempo cirúrgico foi de 403 minutos (280-485). A média de sangramento foi de 1620 mL (300-4800). A mortalidade pós-operatória foi de 6,66 por cento (n = 1). A morbidade pós-operatória foi de 53,3 por cento (n = 8). Os exames histológicos evidenciaram que todas as ressecções foram R0. Envolvimento linfonodal foi observado em quatro pacientes (26,66 por cento) sendo que todos faleceram em decorrência da neoplasia. A sobrevida global em cinco anos foi de 35,7 por cento. CONCLUSÃO: A exenteração pélvica ainda apresenta alta morbidade, no entanto permanece justificada, pois pode conferir maior controle do câncer de reto T4 em longo prazo.

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66 percent (n = 1). The overall rate morbidity was 53,3 percent (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 percent), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7 percent. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.

[Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases]. / A exenteração pélvica no tratamento do câncer de reto estádio T4: experiência de 15 casos operados.

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66% (n = 1). The overall rate morbidity was 53,3% (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 %), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7%. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.

Pelvic exenteration for recurrent or persistent cervical cancer: experience of five years at the National Cancer Institute in Mexico.

Cervical cancer constitutes a major health problem in Mexico and other developing countries. The purpose of our study was to assess the experience of a comprehensive national oncological reference center on pelvic exenteration for post-radiotherapy recurrent or persistent cervical cancer, describing the prognostic value of time to recurrence, procedure complications, and survival. Medical records from 42 patients with post-radiotherapy recurrent or persistent cervical cancer who underwent a pelvic exenteration with curative purposes from 1984 to 1989 were retrospectively reviewed. Histological diagnoses were squamous cell carcinoma (32 patients), adenosquamous carcinoma (9 patients), and adenocarcinoma (1 patient). Average follow up was of 56.3 mo after the procedure and global survival at 5 yr was 65.8%. Survival for patients with early recurrence was 56.9% vs 78% for patients with late recurrence (p = 0.05). Complications were observed in 65.3% of the cases with a surgical mortality of 4.8%. Pelvic exenteration is a surgical procedure with high morbidity in spite of the recent medical advances. Pelvic exenteration should not be indicated with palliative purposes owing to the high rate of complications. Patients with tumor persistence or early recurrence have a worse prognosis. In well-selected cases, exenteration may provide a survival benefit.

Exenteración pélvica en el Instituto Nacional de Cancerología / Pelvic exenteration in the Instituto Nacional de Cancerologia

Introducción. Desde 1948, la exenteración pélvica ha sido la alternativa de tratamiento en el rescate para pacientes con recurrencia por cáncer en la pelvis, sobre todo de tipo ginecológico. El procedimiento original ha sido modificado infinidad de ocasiones en un intento por mejorar el estado general y la calidad de vida de las pacientes sometidas a esta intervención. Objetivo. Efectuamos una revisión de la literatura y transmitimos la evaluación sobre el abordaje integral de las pacientes con recurrencia por cáncer ginecológico, con especial énfasis en el manejo perioperatorio estándar de las pacientes candidatas a esta intervención. Material y métodos. Revisión de la literatura, y análisis crítico de los departamentos involucrados, en el manejo perioperatorio de estas pacientes. Se describen con detalle desde el proceso de selección de las mujeres candidatas, rutas de manejo, monitoreo, evaluaciones preoperatorias, técnica quirúrgica más comúnmente empleada en el Instituto Nacional de Cancerología, hasta los cuidados posoperatorios y seguimiento de las pacientes. Resultados. Resultados. La selección meticulosa de las pacientes candidatas al procedimiento se inicia desde la primera entrevista con evaluación del entorno de la pacientes, soporte familiar, factibilidad económica y decision final por parte de la paciente. Participación de un equipo quirúrgico y de enfermería, multidisplinario, familiarizado con el procedimiento y colaborando sincrónicamente en las fases exenterativa y de reconstrucción. Apego y compromiso en la vigilancia estrecha del posoperatorio y evolución a corto, mediano y largo plazo de las pacientes. Conclusiones. El éxito de este tipo de procedimiento requiere pacientes bien seleccionadas, en centro oncológicos de experiencia, participación multidisciplinaria durante la resección quirúrgica, pero sobre todo del compromiso real por parte del equipo quirúrgico y de enfermería durante el manejo posoperatorio

[Current status of frequency and complications of pelvic exenterations for recurrent cervico-uterine cancer after radiation]. / Estado actual de frecuencia y complicaciones de exenteraciones pélvicas por cáncer cervico-uterino recurrente a radiación.

Frequency and morbimortality in pelvic exenterations for cervical cancer recurrent after radiation therapy at The Oncology Service, Hospital General de México, SSA., are presented here. Between 1990 to 1994, seventy six patients with this diagnosis, were subjected to surgical exploration with the next findings: forty seven cases, (61.5%) had unresectable tumors; 29, (38.1%) were treated by exenterative procedures: Anterior exenterations, 14, (48.2%); Total exenterations, 13 (44.8%) and Posterior exenteration, 2 (6.8%). Tumor beyond pelvis was the common cause of unresectability in 34 cases, (72.2%) and periaortic lymph node metastases were related with this finding in 29 patients, (61.7%). Thirteen patients with pelvic exenterations, (44.8%) developed postoperative complications between 1 day and seven months after surgery. In seven cases, (24.1%) these complications were considered as minor complications and in six (20.6%) as major complications: Dehiscence of ureteral anastomosis, two cases, (-6.8%); ureterovaginal fistula, two (6.8%); small bowel obstruction, one (3.4%) and Chronic renal failure, one (3.4%). There were no postoperative deaths related to radical surgery in this series. It is concluded that the rate of laparotomies for cervical cancer recurrent after radiation therapy, have decreased in our Service, as compared to previous analysis as well as the rate of postoperative deaths from pelvic exenterations.

Pelvic exenteration for carcinoma of the cervix: analysis of 252 cases.

We present the results of 252 pelvic exenterations for primary and recurrent carcinoma of the cervix at the Hospital General de Mexico, a tertiary-care institution for the indigent. Emphasis is placed on the morbidity and mortality of the procedure in relation to patient selection. In underdeveloped countries, where early detection of cervical cancer is a rare event, pelvic exenteration must continue in the armamentarium of physicians; it can be associated with gains in the quality of life, with long-term survival, with effective rehabilitation, and possibly with cures.