Quality of life after pelvic exenteration for gynecologic cancer: Findings from a qualitative study.

OBJECTIVE: Pelvic exenteration (PE) in carefully selected gynecologic cancer patients has a 5-year survival rate as high as 60%. Thus, there is a growing number of PE survivors dealing with the effects of this radical surgery. The current study sought to explore women's physical, psychological, and social quality of life (QOL) after PE. METHODS: Fourteen women who had undergone PE for recurrent gynecologic cancer at least 1 year previously completed semistructured qualitative interviews designed to elicit expectations and experiences of QOL following PE. Thematic analysis was used to code transcripts for both a priori and emergent themes. RESULTS: Themes included PE versus palliative care, preparedness, persistent symptoms, the not so normal new normal, new rules of social engagement, support, emotional diversity, and bouncing back through adaptive coping. Key differences with previous studies include the explicit acknowledgement of the need for palliative care, the chronic nature of multiple, seemingly unaddressed physical symptoms in survivorship, and the predominance of positive psychological symptoms. While a minority expressed emotional distress and regret for undergoing PE, most articulated a sense of resilience gained through a variety of adaptive coping strategies. CONCLUSIONS: Findings underscore the persistent physical, psychological, and social effects of PE on QOL and the need for comprehensive, multidisciplinary patient care before and long after surgery. Findings should promote development of a best practice clinical pathway for the care and education of women who undergo PE with curative intent for gynecologic cancer.

Prospective assessment of patient-reported outcomes in gynecologic cancer patients before and after pelvic exenteration.

OBJECTIVE: Pelvic exenteration (PE) is a surgical procedure associated with significant morbidity offered to select women with locally advanced or recurrent gynecologic cancers. This ongoing study examines an array of patient-reported outcomes and satisfaction with PE. METHODS: Since February 2009, prospectively enrolled participants completed questionnaires evaluating body image (BIS), depression (CESD), social support (DUFSS), symptoms (MDASI), sexual function (SAQ), functional status (SF-12), quality of life (The Stoma-QOL), satisfaction with decision (SWD) and an investigator-designed survey at baseline, 6, and 12months after PE. Mann-Whitney and Wilcoxon signed-rank tests were used to evaluate the data. RESULTS: Fifty-four women enrolled. Median age was 56years (31, 85). Median BMI was 30.7kg/m2 (16.8, 54.4). The majority of patients (78%) were white. Cancer diagnoses included 41% cervix, 22% uterus, 19% vagina, 17% vulva and 2% ovary. Most surgeries were total PEs (76%). Patients were satisfied with their decision to undergo PE at 6 and 12months. One year after exenteration, 79% of women stated they would have a PE again. Sexual pleasure decreased from baseline to 12months after PE (p=0.02), while sexual discomfort remained unchanged (p=0.42). Body image worsened over time (p=0.003). Physical functioning (SF-12) declined (p=0.001), while mental functioning remained stable (p=0.46). There were no significant changes in stoma-related QOL, social support, or depression scores. CONCLUSIONS: Despite a decrease in physical functioning, persistent low body image and sexual pleasure, most women were satisfied with their decision and would undergo pelvic exenteration again. This study identifies survivorship issues that should be addressed after PE.

Quality of Life in Women After Pelvic Exenteration for Gynecological Malignancies: A Multicentric Study.

OBJECTIVES: This retrospective, multicentric study investigates quality-of-life issues and emotional distress in gynecological cancer survivors submitted to pelvic exenteration (PE). METHODS: The Global Health Status scale of European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30; the EORTC QLQ-CX24 (CX24), and EORTC QLQ-OV28 questionnaires were administered at least 12 months from surgery only in women with no evidence of further recurrence after PE. Statistical analysis was performed by the analysis of variance (for repeated measures. RESULTS: Ninety-six subjects affected by gynecological malignancies receiving PE were enrolled in the study. Anterior PE was performed in 47 patients (49%), posterior PE was performed in 29 cases (30.2%), and total PE performed in 20 women (20.8%). In 38 cases (39.6%), a definitive colostomy was performed. Urinary diversion with continent pouch was created in 11 patients. (11.5%), whereas in the remaining cases, a noncontinent pouch was reconstructed. Patients showed a significant discomfort in attitude to disease (71.5 ± 4.7), body image (48.9 ± 6.4), financial difficulties (56.2 ± 5.8), gastrointestinal symptoms (constipation, 47.8 ± 5.1; diarrhea, 62.4 ± 6.6; appetite loss, 43.6 ± 6.7), insomnia (64.5 ± 6.6), Global Health Status (64.6 ± 3.8), physical functioning (65.8 ± 4.6), role functioning (58.8 ± 5.8), and emotional functioning (67.4 ± 4.2). A higher number of ostomies (hazard rate [HR], 7.613; P = 0.012), the creation of a noncontinent bladder (HR, 8.230; P = 0.009), and of definitive colostomy (HR, 8.516; P = 0.008) emerged as independent predictors of poorer Global Health Status scores. Older age (HR, 11.235; P = 0.003), vaginal/vulvar cancer (HR, 7.369; P = 0.013), total/posterior PE (HR, 7.393; P = 0.013), higher number of ostomies (HR, 7.613; P = 0.012), the creation of a noncontinent bladder (HR, 8.230; P = 0.009), and of definitive colostomy (HR, 8.516; P = 0.008) emerged as independent predictors of lower body image levels. CONCLUSIONS: Long-term psycho-oncological support is strongly recommended. The reduction of ostomies seems the most effective way to improve patients' quality of life.

Prospective Assessment of First-Year Quality of Life After Pelvic Exenteration for Gynecologic Malignancy: A French Multicentric Study.

BACKGROUND: Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent. METHODS: A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure. RESULTS: The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration. CONCLUSIONS: Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.

Ansiedad, depresión, percepción y sentimientos de mujeres con cáncer indicadas para cirugía de exenteración pélvica / Anxiety, depression, perceptions and feelings of women with cancer referred for pelvic exenteration surgery

Objetivo: el presente estudio evalúa señales de depresión y ansiedad en mujeres con cáncer indicadas para cirugía de exenteración pélvica (EP), e identifica sus percepciones y sentimientos ante la EP. Método: Participaron en el estudio seis mujeres (37 a 64 años) que recibían tratamiento oncológico en un hospital del sur de Brasil. Las pacientes rellenaron una ficha de datos sociodemográficos y respondieron a la Escala Hospitalaria de Ansiedad y Depresión (HADS). También fueron realizadas entrevistas semiestructuradas. Resultados: En general, los resultados revelan reacciones emocionales a la indicación de EP para las participantes. Se verificó la presencia de ansiedad y depresión (50% y 66,7%, respectivamente) en el periodo preoperatorio. A partir del análisis de las entrevistas fue posible identificar dudas y temores sobre el resultado de la cirugía, así como sobre las expectativas de cura del cáncer. También aparecieron sentimientos de miedo, preocupación y ansiedad ante las ostomías. Conclusión: Estudios longitudinales pueden ampliar la comprensión del impacto de la EP, considerando también el periodo postoperatorio. Se subraya la necesidad de un seguimiento psicológico preoperatorio para mujeres indicadas para este procedimiento altamente especializado e invasivo (AU)

Objective: This study aimed to evaluate depression and anxiety in women with cancer who were referred for pelvic exenteration (PE), and to identify their perceptions and feelings regarding PE. Methods: Six women (aged between 37 and 64 years,) undergoing cancer treatment at a hospital in the city of Porto Alegre, Brazil, took part in the study. Sociodemographic data were collected and a semi-structured interview and the Hospital Anxiety and Depression Scale (HADS) were employed. Results: The overall findings revealed emotional implications related to PE. Anxiety and depression were experienced by the participants (50% and 66.7%, respectively) before the surgery. The interviews showed doubts and fears regarding the surgical outcomes as well as expectations for cancer cure. Anxiety, fear and worries associated with ostomies also emerged. Conclusion: Longitudinal studies may contribute to a broader understanding of the impact of this surgery, including the postoperative period. It is possible to highlight the need to psychological assistance before the surgery to women referred to this highly specialized and invasive medical procedure (AU)

Baseline quality of life predicts pelvic exenteration outcome.

BACKGROUND: Recurrent rectal cancer affects a significant group of patients with no current consensus on management. This study investigated patients' quality of life (QoL) in the 12 months after pelvic exenteration. METHOD: Prospective cohort study with clinical and QoL data collected at baseline and 1, 3, 6, 9 and 12 months. QoL trajectories were modelled over 12 months from date of discharge using linear mixed models. RESULTS: Of 117 patients, 93 underwent pelvic exenteration surgery, 24 did not. Thirty-day mortality was nil for both groups. For patients who had surgery, 15 (16%) died within 12 months of surgery compared with nine (38%) of the non-surgery group. Baseline QoL scores were highly variable. The non-exenteration patients' QoL gradually declined over 12 months while exenteration patients declined then recovered. Patients with high baseline QoL scores remained high, and those with low baseline QoL remained low. Baseline QoL score, gender and bony resection were significant predictors of QoL score at 12 months. CONCLUSION: Baseline QoL is a significant, independent predictor of patients' QoL after pelvic exenteration for recurrent rectal cancer.

Palliative Pelvic Exenteration: Clinical Outcomes and Quality of Life.

BACKGROUND: Locally advanced pelvic malignancy can be associated with disabling symptoms and reduced quality of life. If resectable with clear margins, a pelvic exenteration can offer long-term survival and improved quality of life. Its role in the palliation of symptoms has been described; however, the clinical outcomes and surgical indication are poorly defined. OBJECTIVE: This study describes the clinical and quality-of-life outcomes after palliative pelvic exenteration for advanced pelvic malignancy. DESIGN: Clinical data and patient-reported outcomes were collected for patients undergoing pelvic exenteration for symptom palliation. SETTINGS: This study was conducted at a tertiary referral center for pelvic exenteration. PATIENTS: All of the patients undergoing palliative pelvic exenteration for advanced primary rectal or recurrent cancer were included in our analysis. MAIN OUTCOME MEASURES: Patient-reported quality of life and physical and mental health status were measured. Quality-of-life trajectories were modeled over the 12 months from the date of surgery using linear mixed models. RESULTS: A total of 39 patients underwent pelvic exenteration for symptom palliation. Although there were no in-hospital deaths, 34% experienced significant morbidity. Patient-reported quality of life reduced postoperatively and gradually declined thereafter. Overall median survival was 24 months, with a 1-year mortality rate of 31%. There was a significant survival difference for the 39 patients undergoing pelvic exenteration compared with those patients who only had a debulking/bypass procedure or were closed without definitive treatment (overall median survival = 24 versus 9 months; p = <0.02). LIMITATIONS: Disease and patient heterogeneity limit the interpretation of these results. CONCLUSIONS: Palliative pelvic exenteration is a technically demanding operation that can be performed safely in a dedicated exenteration center. However, no durable palliation of symptoms with associated improved or sustained quality of life was observed, and the role of palliation therefore remains highly controversial in this complex group of patients.

[Quality of life after extensive pelvic surgery]. / Kvalita zivota po extenzivních pánevních operacích.

INTRODUCTION: Multiorgan resections in the small pelvis are standard procedures in oncosurgery and some indications have no alternative. In advanced pelvic cancer, pelvic exenteration with en bloc resection of the involved organs and structures, including portions of the bony pelvis, is indicated. The 5-year survival rate is fairly good, around 50%, but little is known about the long-term quality of life. The aim was to describe the quality of life of long-term total pelvic exenteration survivors. METHOD: In total, 63 pelvic exenterations were performed between 2000 to 2015 at the Department of Surgery, Thomayer Hospital, First Faculty of Medicine, Charles University in Prague, mostly for primary or relapsed rectal cancer. In this retrospective cohort study, the quality of life was assessed using the EORTC QLQ-C30 (version 3.0) and the EORTC QLQ-CR29 questionnaires. The completed questionnaires were scored according to EORTC instructions. RESULTS: At the time of this survey, 24 patients after TPE were surviving longer than one year after the surgery. The five-year survival of all patients was 49%, median survival 4.6 years, and median follow-up 15 months. Most of our patients reported a good level of their physical, emotional, cognitive and social functions. Some patients reported a worse body image, and of course a worsening in their sexual life. Regarding symptom-oriented questions, some patients evaluated the necessity of more frequent care of the stomia as slightly problematic; most patients reported impotence (men) or painful sexual intercourse (women). CONCLUSION: Long-term quality of life in survivors of pelvic exenteration for rectal cancer is comparable with reported results following primary rectal cancer resection with the exception of the sexual function. The quality of life gradually improves in the course of weeks to months from the surgery. KEY WORDS: pelvic exenteration quality of life.

Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life.

INTRODUCTION: Radical surgery with pelvic exenteration offers the only potential for cure in patients with locally advanced primary rectal cancer. This study describes the clinical and patient-reported quality of life outcomes over 12 months for patients having pelvic exenteration for locally advanced primary rectal cancer at a specialised centre for pelvic exenteration. METHODS: Clinical data of consecutive patients undergoing pelvic exenteration for locally advanced primary rectal cancer and patient-reported outcomes were collected at baseline, hospital discharge and at 1, 3, 6, 9 and 12 months. Patient-reported outcomes included cancer-specific quality of life (QoL) and physical and mental health status. Quality of life trajectories were modelled over the 12 months from the date of surgery using linear mixed models. RESULTS: 104 patients with locally advanced rectal cancer underwent pelvic exenteration at Royal Prince Alfred Hospital, Sydney, between December 1994 and October 2014. Complete soft tissue exenteration was performed in 38%. A clear margin was obtained in 86% with a 62% overall five-year survival. QoL outcome questionnaires were completed by 62% of patient cohort. The average FACT-C score returned to pre-surgery QoL by 2 months after surgery, and the average QoL continued to increase slowly over the 12 months. CONCLUSION: Our results support an aggressive approach to advanced primary rectal cancer and lend weight to the oncological role of pelvic exenteration for this group of patients. Quality of life improves rapidly after pelvic exenteration for locally advanced primary rectal cancer and continues to improve over the first year.

Transabdominal-pelvic-perineal (TAPP) anterolateral thigh flap: A new reconstructive technique for complex defects following extended abdominoperineal resection.

BACKGROUND: Abdominoperineal resection (APR) following radiotherapy is associated with a high rate of perineal wound complications. The anterolateral thigh (ALT) flap, combined with the vastus lateralis (VL) muscle, can cover complex perineal and pelvic anteroposterior defects. This is used for the first time transabdominally through the pelvis and the perineum (TAPP) in the infero-posterior directions; this technique has been described and illustrated in this study. METHODS: Among over 90 patients who underwent perineal reconstruction between May 2004 and June 2011, six patients presented high-grade tumours invading perineum, pelvis and sacrum, thereby resulting in a continuous anteroposterior defect. ALT + VL TAPP reconstructions were performed after extended APR and, subsequently, sacrectomy. Patients were examined retrospectively to determine demographics, operative time, complications (general and flap-related), time to complete healing and length of hospital stay. Long-term flap coverage, flap volume stability and functional and aesthetic outcomes were assessed. RESULTS: Mean operating time of the reconstruction was 290 min. No deaths occurred. One patient presented partial flap necrosis. Another patient presented a novel wound dehiscence after flap healing, due to secondary skin dissemination of the primary tumour. Following volumetric flap analysis on serial post-operative CT scans, no significant flap atrophy was observed. All flaps fully covered the defects. No late complications such as fistulas or perineal hernias occurred. Donor-site recovery was uneventful with no functional deficits. CONCLUSIONS: The use of the ALT + VL flap transabdominally is an innovative method to reconstruct exceptionally complex perineal and pelvic defects extending up to the lower back. This flap guarantees superior bulk, obliterating all pelvic dead space, with the fascia lata (FL) supporting the pelvic floor.

Social deprivation in patients requiring pelvic exenterative surgery.

AIM: Pelvic exenteration is an aggressive operation for locally advanced rectal cancer. Social deprivation has been shown to reduce life expectancy and has been linked to a poorer outcome in patients with colorectal cancer. The aim of this study was to analyse the effect of social deprivation scores on the outcome in these complex patients. METHOD: A retrospective review of all patients undergoing pelvic exenteration for primary rectal cancer between 2006 and 2014 was performed. Deprivation scores were calculated for all patients using the Welsh Index of Multiple Deprivation. Patients were then grouped into quartiles, from Q1 (most deprived) to Q4 (least deprived). The primary outcome measure was 5-year survival. RESULTS: In all, 120 patients were included (65 female) with a median age of 64 (31-90) years. No differences between quartiles were identified for neoadjuvant therapy (P = 0.687) or type of exenteration (P = 0.690). The median length of stay was significantly higher in the most deprived groups (Q1-Q2; P = 0.023). There was a significant difference in survival between the groups, with lowest 5-year survival rates (53%) in the most deprived quartile (Q1) (P = 0.015). CONCLUSION: Social deprivation is significantly associated with postoperative length of stay and survival in patients undergoing pelvic exenteration for primary rectal cancer.

Quality-of-life outcomes following pelvic exenteration for primary rectal cancer.

BACKGROUND: For patients with locally advanced tumours and contiguous organ involvement, pelvic exenteration (PE) can offer cure with relatively low mortality. The literature surrounding quality of life (QoL) in patients undergoing PE is limited. Furthermore, there are no matched comparisons of QoL between abdominoperineal resection (APR) and PE. The aim of this study was to compare differences in long-term QoL for patients with primary rectal cancer undergoing APR versus PE. METHODS: All patients who underwent either APR or PE between January 2011 and December 2012 were identified. Patients were asked to complete the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire before surgery and 2 weeks afterwards. Subsequent questionnaires were requested at 3, 6, 12 and 24 months after operation. RESULTS: A total of 110 patients were included in the study (54 APR, 56 PE). Median length of stay following operation was 11 (range 3-70) days for APR and 15 (7-84) days for PE. Patients undergoing PE experienced lower physical (mean score 42 versus 56; P = 0.010), role (20 versus 33; P = 0.047), emotional (57 versus 73; P = 0.010) and social (34 versus 52; P = 0.005) functional levels 2 weeks after surgery. Long-term dyspnoea and financial worries were experienced only after PE. Patients undergoing PE had a lower overall global health status at 2 weeks after operation (40 versus 53; P = 0.012). Levels were comparable between groups from 3 months after surgery. CONCLUSION: QoL recovery following PE was equivalent to that after APR alone. Patients should not be denied exenterative surgery based on perceived poor QoL.

The Paradox of Pelvic Exenteration: The Interaction of Clinical and Psychological Variables.

OBJECTIVES: To text the feasibility of a psychological intervention package administered to 49 pelvic exenteration candidates, aimed at evaluating the preoperative prevalence of psychological distress and assessing the presence of any correlation between preoperative psychological distress and clinical variables such as pain and hospitalization length. METHODS: Patients were referred to the psychology unit from the very beginning of their clinical pathway and were administered the Psychological Distress Inventory (PDI) and the Mini-Mental Adjustment to Cancer (Mini-MAC) questionnaire at prehospital admission. Patients presenting with a significant level of distress received nonstandardized psychological support. Statistical analyses were performed to detect the presence of any correlation between psychological variables at prehospital admission and clinical outcomes. RESULTS: The 40% of patients had significant levels of distress at prehospital admission (PDI ≥ 30). As regards Mini-MAC, the mean value of fighting spirit attitude and fatalism was higher in our sample than in the normative sample of the Mini-MAC validation study in the Italian cancer population. Their anxious preoccupation attitude was lower. There were no correlations between clinical and psychological variables: level of postsurgery pain was higher (3.7) in the subgroup of patients with presurgery PDI < 30 compared with those with PDI ≥ 30 (3.5). However, this difference was not statistically significant (P = 1.00). Considering hospitalization length, the above described trend was similar. CONCLUSIONS: Although highly distressed, pelvic exenteration candidates show an adaptive range of coping mechanisms. This calls for a greater effort in studying the complexity of their psychoemotional status to provide them with the best multidisciplinary care. Extensive study of the real effectiveness of psychological intervention is warranted: randomized clinical trials could help in detecting the presence of any correlation between clinical and psychological variables in a multidisciplinary approach.

A prospective study of quality of life in patients undergoing pelvic exenteration: interim results.

OBJECTIVE: Little prospective data exist on quality of life (QOL) after pelvic exenteration (PE). This ongoing study prospectively examines the QOL changes following this radical procedure using a comprehensive battery of psychological instruments. METHODS: Since 2005, enrolled patients were interviewed (EORTC QLQ-C30, EORTC QLQ-CR38, EORTC QLQ-BLM30, BFI, BPI-SF, IADL, CES-D, IES-R) preoperatively and at 3, 6, and 12 months after PE for physical/psychological symptoms. Data were examined using repeated measure ANOVA. RESULTS: Sixteen women (3 anterior, 1 posterior, and 12 total PEs), with more than 1 year of follow-up, completed all scheduled interviews. Median age was 58 years (range, 28-76 years). Overall QOL (F = 6.3, p < 0.02), ability to perform instrumental daily activities (F = 6.8, p < 0.02), body image (F = 11.9, p < 0.00), and sexual function (F = 8.0, p < 0.01) all declined at 3 months but were near baseline by 12 months after PE. Although, overall, physical function followed a similar trend (F = 14.8, p < 0.00), it did not return to baseline. At the 12-month interview, patients reported increased gastrointestinal symptoms (F = 8.9, p < 0.01) but significantly less stress-related ideation (F = 6.1, p < 0.03) compared to baseline. Pain levels did not change significantly during the study period (F = 0.4, p < 0.74). CONCLUSIONS: Although patients report lingering gastrointestinal symptoms and some persistent decline in physical function after PE, most adjust well, returning to almost baseline functioning within a year. Providers can counsel patients that many, though not all, symptoms in the first 3 months following exenteration are likely to improve as they adapt to their changed health status. These preliminary results await confirmation of a larger analysis.

Transposed right colon segment for vaginal reconstruction after pelvic exenteration.

Vaginal reconstruction following pelvic exenteration surgery for malignant disease is an important step in the physical and psychological rehabilitation of such patients. Planning of such procedures must include a strategy for reconstruction of the vagina and the oncological surgical team must be aware of the surgical techniques available in order to optimally plan and execute such procedures. We described a procedure which involves supralevator exenteration of the pelvis along with primary colorectal anastomosis. A transposed right colon segment is used to reconstruct the vagina and an omental flap is interpositioned between the reconstructed vagina and the colorectal anastomosis. The procedure is described in the text and in a didactic video.

The impact of treatment for genital cancer on quality of life and body image--results of a prospective longitudinal 10-year study.

OBJECTIVE: To evaluate the impact of treatment for genital cancer on quality of life and body image to determine patients' therapy-related needs for quality improvement of medical care before and after surgery. METHODS: We started to evaluate women with cervical cancer planned for pelvic exenteration in 1993 and integrated women planned for a Wertheim-Meigs surgery in 1995 before surgery, 4 and 12 months after surgery. Thanks to funding since 1999, more than 400 patients with a diagnosis of genital (n = 185) or breast (n = 217) cancer participated in this prospective study until July 2003. In this paper, we will focus on n = 129 women with cervical cancer. The assessment protocol included objective questionnaires for quality of life and body image (CARES; EORTC; Body image by Strauss and Appelt). The evaluation of quality of life incorporated five dimensions: physical and psychosocial health, marital and sexual status, and medical interaction. RESULTS: Before surgery, women with a Wertheim's procedure indicated significantly less problems concerning the quality of life global score (P = 0.002) and several subscales compared to women with a pelvic exenteration. After surgery, both groups indicated their sexual problems to be the greatest restriction in terms of quality of life, especially in women with non-reconstructive surgery as well as in women with adjuvant radio and/or chemotherapy. Concerning body image, attractiveness or self-confidence was significantly reduced postoperatively compared to the preoperative status for both groups (P = 0.000), and also worsened with the extent of treatment. Worries about the patient's family persisted over time and represented the most important item about all questions concerning quality of life as well as the fear of recurrence. CONCLUSION: This on-going study demonstrates the interferences between the treatment modality and the patient's quality of life, especially about sexuality and body image. Our results suggest not only to provide reconstructive surgery if possible, but also to integrate psychosocial information aspects on future quality of life outcome before surgery as well as to offer psychosocial support related to the extent of treatment modality after surgery.

Quality of life after pelvic exenteration.

OBJECTIVES: Pelvic exenteration, for gynecological and urological cancer, is an extensive and mutilating procedure. The 5-year survival rate is fairly good (40-60%), but little is known about the long-term quality of life. METHODS: In this retrospective cohort study, the quality of life was assessed using the EORTC QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires. RESULTS: Healthy females and those who underwent pelvic exenteration for a gynecological or urological malignancy reported comparable levels of emotional functioning and general quality of life. More physical, sexual, and social problems were, however, noted after exenteration. Younger patients and patients who underwent total pelvic exenteration had the most difficulty in adapting to daily life, disease, and treatment. They also had a worse body image, and the influence of the operation on their sex life was greater compared to other patient groups of this study. CONCLUSION: Despite the immense effect of pelvic exenteration on physical, sexual, and social functioning, women who underwent this procedure reported similar levels of emotional functioning and general quality of life compared to healthy women. Adaptation and the mechanism of response shift presumably play an important role.

Brief report: total pelvic exenteration--A retrospective clinical needs assessment.

This clinical needs assessment retrospectively identified 11 women with a history of gynecologic cancer who had undergone pelvic exenteration within the last 4 years, of whom six were available for interview. All patients agreed to telephone interviews, which lasted approximately 45-60 min and addressed their surgical experience. Seven themes emerged from the interviews: concerns about recovery, complications, ostomies, social support, sexuality, disclosure, and fear. The findings of our needs assessment concur with the existing literature noting decreased sexual interest/activity and difficulties with body image. An improvement in mood and an increase in activities over time postoperatively were noted. We also found reluctance by participants to disclose information about their exenterative procedure.

Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques.

OBJECTIVES: Vaginal reconstruction following pelvic exenteration is an important aspect of the physical and psychological rehabilitation of women after radical surgery for pelvic malignancies. The choice of techniques is vast, and proper patient and surgical selection is important for obtaining satisfactory functional and aesthetic results. The objective of this retrospective study is to review different techniques for vaginal reconstruction and report the complications and patient satisfaction associated with the different procedures. METHODS: Between January 1988 and April 2001, 104 pelvic exenterations were performed by the division of gynecologic oncology at the University of Miami, School of Medicine. Twenty-five (24%) patients underwent vulvo-vaginal reconstruction at the time of the exenteration. A retrospective chart review of the 25 patients was performed, and 9 patients were available and contacted for an interview. RESULTS: Twenty-four (96%) patients had received prior definitive radiation therapy. Overall, there were 9 complications (6 major and 3 minor) attributed to vaginal reconstruction, accounting for 36% perioperative morbidity. Seven of the nine (78%) patients interviewed reported successful vaginal intercourse at some point after their operation. All 5 surviving patients in the myocutaneous flap group were very satisfied with their sexual function and were sexually active at the time of their interview. CONCLUSIONS: Vaginal reconstruction at the time of pelvic exenteration is an important topic that should be discussed with the patient during the preoperative visit. Although the myocutaneous flaps are associated with longer operative times, they appear to be the preferred type due to decreased postoperative fistulae and better patient satisfaction.