A modern day experience with Brunschwig's operation: advancements in pelvic exenteration

Abstract

<h3>Objectives:</h3> To evaluate the perioperative outcomes and oncologic outcomes of patients undergoing pelvic exenteration, first described by Alexander Brunschwig in 1948, for non-ovarian gynecologic malignancies at a comprehensive cancer center. <h3>Methods:</h3> All patients who underwent exenteration at our institution from 1/2010-12/2019 were identified. Patients with non-ovarian gynecologic malignancies were included. Patients undergoing palliative exenteration were included for perioperative outcomes but excluded from the survival analysis. Post-operative complications were defined as early (≤30 days) and delayed (31-180 days). Complications were graded using a validated institutional secondary surgical events system. Major complications were defined as Grade 3 or above which would, at minimum, require surgical, endoscopic, or radiological intervention. Appropriate statistical analyses were performed. <h3>Results:</h3> One-hundred patients were identified. Eighty-nine (89%) received treatment for recurrent disease, 5 (5%) for primary disease, 1 (1%) for persistent disease, and 5 (5%) received palliative treatment. The most common cancer type was cervical (n=30, 30%), followed by vulvar (n=27, 27%), uterine (n=24, 24%), and vaginal (n=19, 19%). The most common histologies were squamous cell carcinoma (n=61, 61%), endometrioid carcinoma (n=18, 18%), and adenocarcinoma (n=13, 13%). Sixty-two (62%) patients had total exenteration, 30 (30%) anterior exenteration, 8 (8%) posterior exenteration. The median age at time of surgery was 61.3 years (range, 28-86 years). There were no intraoperative deaths or deaths within 30 days of surgery. Six patients expired within the delayed time frame, including 1 (16.7%) from respiratory failure and 5 (83.3%) from aggressive progression of disease. Ninety-seven (97%) patients experienced a perioperative complication: 49 (50%) early, 1 (1%) delayed, 47 (48%) both early and delayed. Fifty/100 patients (50%) had a major complication: 22/50 (44%) early, 19/50 (38%) delayed, 9/50 (18%) both early and delayed. We did not identify any variables statistically associated with the development of a complication, including exenteration type, initial malignancy type, conduit type, operative time, estimated blood loss, or tumor volume. The median follow-up time for the entire cohort was 27.6 months (range, 1.0-117.5). The median follow-up time for survivors was 38.0 months (range, 1.0-117.5). The 3-year PFS was 61.0%, and the 3-year OS was 61.6%. There are 58 total survivors (58%), of whom 16 (28%) and 4 (7%) remain alive after 5 and 10 years, respectively. <h3>Conclusions:</h3> The complication rate for pelvic exenteration remains high, although we identified no variables showing association with the development of a complication. However, the lack of perioperative mortality, and improved oncologic outcomes, exemplify the advancements of this surgical approach since its inception.