Defining Benchmarks for Pelvic Exenteration Surgery: A Multicentre Analysis of Patients with Locally Advanced and Recurrent Rectal Cancer.
Annals of surgery
OBJECTIVE:To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres. BACKGROUND DATA:PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement. METHODS:This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres. RESULTS:763 patients underwent PE, of which 464 patients (61%) had LARC and 299 (39%) had LRRC. 544 patients (71%) who met predefined lower risk criteria formed the benchmark cohort. For LARC patients, the calculated benchmark threshold for major complication rate was ≤44%; comprehensive complication index (CCI): ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For LRRC patients, the calculated benchmark threshold for major complication rate was ≤53%; CCI: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%. CONCLUSIONS:The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.
10.1097/SLA.0000000000006348
Pelvic Exenteration for Advanced Nonrectal Pelvic Malignancy.
Annals of surgery
OBJECTIVE:To determine factors associated with outcomes following pelvic exenteration for advanced nonrectal pelvic malignancy. BACKGROUND:The PelvEx Collaborative provides large volume data from specialist centers to ascertain factors associated with improved outcomes. METHODS:Consecutive patients who underwent pelvic exenteration for nonrectal pelvic malignancy between 2006 and 2017 were identified from 22 tertiary centers. Patient demographics, neoadjuvant therapy, histopathological assessment, length of stay, 30-day major complication/mortality rate were recorded.The primary endpoints were factors associated with survival. The secondary endpoints included the difference in margin rates across the cohorts, impact of neoadjuvant treatment on survival, associated morbidity, and mortality. RESULTS:One thousand two hundred ninety-three patients were identified. 40.4% (n = 523) had gynecological malignancies (endometrial, ovarian, cervical, and vaginal), 35.7% (n = 462) urological (bladder), 18.1% (n = 234) anal, and 5.7% had sarcoma (n = 74).The median age across the cohort was 63 years (range, 23-85). The median 30-day mortality rate was 1.7%, with the highest rates occurring following exenteration for recurrent sarcoma or locally advanced cervical cancer (3.3% each). The median length of hospital stay was 17.5 days. 34.5% of patients experienced a major complication, with highest rate occurring in those having salvage surgery for anal cancer.Multivariable analysis showed R0 resection was the main factor associated with long-term survival. The 3-year overall-survival rate for R0 resection was 48% for endometrial malignancy, 40.6% for ovarian, 49.4% for cervical, 43.8% for vaginal, 59% for bladder, 48.3% for anal, and 48.1% for sarcoma. CONCLUSION:Pelvic exenteration remains an important treatment in selected patients with advanced or recurrent nonrectal pelvic malignancy. The range in 3-year overall survival following R0 resection (40%-59%) reflects the diversity of tumor types.
10.1097/SLA.0000000000003533
Robotic-Assisted Total Laparoscopic Supralevator Pelvic Exenteration: Steps in Excising the Pelvic Viscera.
Behbehani Sadikah,Islam Mohammad,Magtibay Paul
Journal of minimally invasive gynecology
STUDY OBJECTIVE:To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically. DESIGN:Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration. SETTING:Tertiary care academic center. PATIENTS:A patient undergoing pelvic exenteration for uterine leiomyosarcoma. INTERVENTIONS:Robotic total supralevator pelvic exenteration. MEASUREMENTS AND MAIN RESULTS:In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL. CONCLUSION:Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.
10.1016/j.jmig.2019.05.012
Complications and survival after total pelvic exenteration.
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology
BACKGROUND:Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival. METHODS:Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed. RESULTS:The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients. CONCLUSION:The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
10.1016/j.ejso.2021.12.472
Management of Urinary Incontinence before and after Total Pelvic Reconstruction for Advanced Pelvic Organ Prolapse with and without Incontinence.
Song Yu,Wang Xiao-Juan,Chen Yi-Song,Hua Ke-Qin
Chinese medical journal
BACKGROUND:The effectiveness of an anti-incontinence procedure concomitant with prolapse reconstruction for pelvic organ prolapse (POP) in preventing urinary incontinence (UI) after surgery remains controversial. Our study aimed to describe the incidence of pre- and postoperative UI for pelvic reconstructive surgery and evaluate the management of POP associated with UI. METHODS:A total of 329 patients who underwent total pelvic reconstruction between June 2009 and February 2015 at a single institution were identified. These patients were divided into two groups (Group A [Prolift reconstruction]: n = 190 and Group B [modified total pelvic reconstruction]: n = 139). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student's t-tests were used for two independent samples. RESULTS:A total of 115 patients presented with UI preoperatively. The average follow-up time was 46.5 months, with 20 patients lost to follow-up (6.1%). The cure rates of stress UI (SUI), urgency UI (UUI), and mixed UI (MUI) were 51% (30/59), 80% (16/20), and 48% (14/29), respectively. The cure rate of UUI after total pelvic reconstruction (80% [16/20]) was higher than that of SUI (50.8% [30/59], χ = 5.219, P = 0.03), and the cure rate of MUI (48%, 14/29) was the lowest. The cure rate of patients with UI symptoms postoperatively was lower than that of those with symptoms preoperatively (9.1% [28/309] vs. 16.2% [50/309], χ = 7.101, P = 0.01). There was no difference in the incidence of UI postoperatively between Groups A and B (P > 0.05). The cure rate of SUI in patients undergoing tension-free vaginal tape-obturator was not higher than that in those who did not undergo the procedure (42.9% [6/14] vs. 53.3% [24/45], χ = 0.469, P = 0.49). There were no differences in the cure rate for POP or UI between these two types of reconstructions (P > 0.05). CONCLUSIONS:No correlation between the incidence of UI and POP was identified. The results suggest that UI treatment should be performed after POP surgery for patients with both conditions.
10.4103/0366-6999.226057
Pain and quality of life after treatment in patients with locally recurrent rectal cancer.
Esnaola Nestor F,Cantor Scott B,Johnson Margo L,Mirza Attiqa N,Miller Alexander R,Curley Steven A,Crane Christopher H,Cleeland Charles S,Janjan Nora A,Skibber John M
Journal of clinical oncology : official journal of the American Society of Clinical Oncology
PURPOSE:Because survival in patients with locally recurrent rectal cancer (LRRC) is limited, pain control and quality of life (QOL) are important parameters. The purpose of this study was to assess the prevalence of posttreatment pain and QOL of patients with LRRC treated with nonsurgical palliation or resection and identify predictors of poor outcome. PATIENTS AND METHODS:Posttreatment pain severity and QOL were prospectively assessed in 45 patients with LRRC using the Brief Pain Inventory and Functional Assessment of Cancer Therapy-Colorectal questionnaire. RESULTS:Fifteen patients received nonsurgical palliation, and 30 patients underwent resection of their pelvic tumors. There was a significant association between higher posttreatment pain scores and worse QOL (P <.001). Patients treated with nonsurgical palliation reported moderate to severe pain beyond the third month of treatment. Resected patients reported comparable levels of pain during the first 3 postoperative years, particularly after bony resections; long-term survivors (beyond 3 years), however, reported minimal pain and good QOL. Female sex, pelvic/sciatic pain at presentation, total pelvic exenteration, and bony resection were associated with higher rates of moderate to severe posttreatment pain (P =.04, P <.001, P =.04, and P =.02, respectively). Pain at presentation was an independent predictor of posttreatment pain (odds ratio, 7.4 [95% confidence interval, 1.8 to 30.3]; P =.006). CONCLUSION:Patients with LRRC treated with nonsurgical palliation or resection experience significant levels of pain after treatment. Close posttreatment pain monitoring is warranted in patients presenting with pelvic pain, and more aggressive pain management strategies may improve posttreatment QOL.
10.1200/JCO.2002.02.121