Exenteration In Patients Research Articles

Indications for primary and secondary exenterations in patients with cervical cancer

Fifty years after the introduction of exenterative surgery in gynecologic oncology, the indication for primary and secondary exenteration is controversially discussed in cervical cancer patients. In addition, the term "palliative exenteration" is not precisely defined. We evaluate the role of primary exenteration in patients with stage IVA cervical cancer and the role of secondary palliative exenteration. The study retrospectively analyzed surgical and oncologic data of 55 patients who underwent exenterative surgery in the Department of Gynecology at the University of Jena between February 1998 and January 2004. Primary surgery was performed in 20 patients with laparoscopically confirmed stage IVA cervical cancer, while 35 patients with recurrent cervical cancer underwent secondary exenteration. Fifty-one had total, 3 posterior and 1 anterior exenteration. Survival was analyzed in relation to the patient's age, indication (primary versus secondary, curative versus palliative), previous therapy (operation, radiation, chemotherapy, radiochemotherapy), histology, resection margins, pelvic nodal involvement, time interval from primary therapy to recurrence, type of exenteration and adjuvant therapy. Early and late postoperative complications as well as perioperative mortality were reviewed. The overall cumulative survival of all patients after exenteration was 36.8% at 5 years with 52.5% in the primary group and 26.7% in the recurrent one (p=0.0472). Complications were noted in 56.9% of patients, most commonly fistulas or gastrointestinal complications. Operative mortality was 5.5%. Survival correlated significantly with the time interval between primary treatment and recurrence (within 1-2 years 16.8% five-year survival, 2-5 years 28%, >5 years 83.2%, p=0.0105) as well as with curative or palliative intention (2-year survival rate of 60% in patients with curative intent, 10.5% in those with palliative intent, p=0.0001) and with tumor-free resection margins (2-year survival of 10.2% for positive margins, 5-year survival of 55.2% for negatives ones, p=0.0057). The age, the type of exenteration, the histologic type and the metastatic spread to pelvic lymph nodes had no significant influence on long-term survival. In patients with histopathologically confirmed stage IVA cervical cancer primary, exenteration is a valid alternative to primary chemoradiation. In patients with persistent or recurrent tumor limited to the pelvis, secondary exenteration should be offered in the absence of other therapeutic options. Palliative and curative attempts can best be differentiated by the resection margin status.

Indications for Orbital Exenteration in Mucormycosis

To determine whether evidence-based standards exist regarding the indications for orbital exenteration in patients with orbital mucormycosis. A literature review was performed of 113 articles (1943 to 2004). Factors possibly related to patient survival were analyzed. Additionally, a survey was sent to all ASOPRS Fellowship Preceptors to ascertain the frequency, outcome, treatment modalities, and indications for exenteration by these practicing physicians. For published cases, parameter estimates (PE <or= 1.00) indicated that patients with mucormycosis with age >46 years, frontal sinus involvement, and fever were less likely to survive compared with patients without these conditions. Patients treated with amphotericin B (OR, 4.476) and those with diabetes (OR, 4.987) were more likely to survive compared with patients without these conditions. Exenterated patients with fever were more likely to survive compared with nonexenterated patients with fever (P=0.0468). Thirty-four ASOPRS Fellowship Preceptors received surveys; 26 (76%) completed the survey. Responses to specific survey questions showed a varied experience and indication for exenteration throughout the country. : Our study underscores the lack of adequate data regarding the evaluation of treatment of orbital mucormycosis. No standard of care currently exists to guide physicians on when exenteration may benefit a mucormycosis patient. Further study is needed to determine which variables indicate the extent of disease and which variables or analytic scheme might predict the progression of orbital mucormycosis with or without exenteration.

Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients

In 1993, the authors introduced an orthotopic bladder replacement technique in the treatment of gynecological cancer patients. In this series, they report their long-term experience with orthotopic urinary reconstruction in case of primary- and radiotherapy-treated recurrent gynecological malignancies. Between 1993 and 2003, in 29 patients orthotopic ileocecal ascending colon reservoirs (Budapest pouch) were created. Twenty-one of the 29 patients received radiotherapy prior to their operation. In 12 out of these 29 cases, the fecal stream was reconstructed with the use of low rectal anastomosis. Two patients (6.9%) died in the perioperative period. Orthotopic reconstruction of the lower urinary system was successful in 77% of the cases. Success rate was 68% in the irradiated cohort of patients. All orthotopic bladder replacement patients voided voluntarily at the time of their follow-up, without the need of self-catheterization, and 23.5% of them complained of some degree of daytime incontinence and 47% of nighttime incontinence. Low rectal anastomosis reconstruction of the fecal stream was successful in all but one case. Our present experience demonstrated that anterior and total supralevator pelvic exenteration in patients with gynecological malignancies is feasible with orthotopic reconstruction of the lower urinary tract.

Orbit Exenteration in Patients with Malignancy Involving Skull Base

Orbit Exenteration in Patients with Malignancy Involving Skull Base

Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year experience at UCLA

Objective. To retrospectively assess the outcome of patients undergoing pelvic exenteration for recurrent or persistence gynecologic malignancy and the clinical features associated with outcome and survival. Methods. A review was conducted of patients who underwent pelvic exenteration over a 45-year period (1956–2001) at the UCLA Medical Center. Numerous clinical variables were analyzed, including time to relapse, type of exenteration and reconstructive operation, early (<60 days) and late (>60 days) morbidity, and survival. Variables were analyzed by chi-square and life-table analysis. Results. Seventy-five patients (ages 26–74 years) had persistent cervical and vaginal (67) and uterine (8) cancer. Forty-six patients underwent total exenteration, 23 anterior, and 6 posterior. Sixty-nine (92%) patients underwent urinary diversion or neocystoplasty, 54 (72%) patients had a simultaneous neovagina created, and 43 of 52 (83%) patients who had a low colon resection had a primary reanastomosis. Twenty-nine patients died from recurrent malignancy, 28 were alive without disease, 11 were alive with disease, and 7 died from other causes at last follow-up. Survival for patients with cervical and vaginal cancer was 73% at 1 year, 57% at 3 years, and 54% at 5 years. Survival for patients with uterine cancer was 86% at 1 year, 62% at 3 and 5 years. The most frequent early morbidity was urinary tract infection, wound infection, and intestinal fistula; the most frequent late morbidity was urinary tract infection and intestinal obstruction. Conclusion. Pelvic exenteration in patients with recurrent cervical and vaginal malignancy is associated with a durable > 50% 5-year survival. Simultaneously performed pelvic reconstructive operations with a continent urinary diversion, the creation of a neovagina, and the reanastomosis of the colon with the formation of a J-pouch is now our standard; and these operations tend to improve the outcome of patients. Based on our initial experience, recurrent uterine corpus cancer in young women (< 55 years) should be included as an indication for the surgery.

Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies

Objective.Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. Methods.Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). Results.After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9–21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. Conclusion.By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.

Surgical pelvic packing as a means of controlling massive intraoperative bleeding during pelvic posterior exenteration – a case report and review of the literature

This is a report of a case of gynecological hemorrhage after a posterior pelvic exenteration in patients with vulvar cancer treated by temporary pelvic packing at the Department of Gynecology of the Medical University in Gdańsk. The packing was successful and the sponges were removed after 24 h. Twenty-eight days after the operation, the patient was transferred to the Department of Radiotherapy for supplementary treatment. In patients with severe intraoperative hemorrhage, intra-abdominal packing has been successful as a mode of treatment.

Orbital Exenteration: Results of an Individualized Approach

The authors report and evaluate their experience with an individualized approach to orbital exenteration. Retrospective chart review was performed on a consecutive series of 25 orbital exenteration patients at a tertiary care center. The cases were classified into two groups for the retrospective analysis: Total exenteration procedures involved the removal of the entire orbital contents including the periorbita (13 cases), and subtotal procedures preserved at least a quadrant of the orbit or the orbital tissues posterior to the globe (12 cases). The total exenteration group had a lower rate of clear surgical margins and a higher rate of systemic metastasis, whereas patients in the subtotal exenteration group had fewer surgical complications and better functional and aesthetic results. The surgical planning for orbital exenteration should take into account the location, extent, and biological behavior of the orbital disease process and the reconstructive and prosthetic options for the exenterated socket. When an individualized approach to orbital exenteration is used, subtotal procedures can offer improved functional and aesthetic results while still maximizing the chances for a surgical cure.

Continent Urinary Diversion and Low-Rectal Anastomosis in Patients Undergoing Exenterative Procedures for Recurrent Gynecologic Malignancies

Objective. The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies.Methods. We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center.Results. Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catherization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients).Conclusions. Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.

Surgery for gynecologic malignancies

Surgery continues to play a primary role in the investigation and treatment of gynecologic neoplasia. Cold-knife conization is still preferable for diagnosis and treatment of more problematic preinvasive cervical lesions. Newer reconstructive techniques can improve quality of life in exenteration patients. Efforts continue to reduce morbidity associated with vulvar surgery and groin node dissection. Accurate staging and maximum cytoreduction remain essential goals in primary surgery for ovarian cancers. The utility of secondary surgery for disease assessment or further treatment is controversial. Laparoscopy at present has a limited role in gynecologic oncology but may be useful for prophylactic oophorectomy in selected individuals.

Operative Laparoscopy prior to a Pelvic Exenteration in Patients with Recurrent Cervical Cancer

Introduction.Selecting out the true candidates for a pelvic exenteration frequently poses a difficult clinical dilemma in patients with recurrent cervical cancer after radiation therapy. Despite very thorough preoperative investigation, inoperable disease is discovered at the time of laparotomy in up to 60% of cases.Subjects and methods.In this retrospective analysis, we report the use of operative laparoscopy in 13 patients with eitherbiopsy provenlocally recurrent cervical cancer (N= 9) or withclinically suspectedtumor recurrence (N= 4). All have previously received radical radiation therapy.Results.Patients’ ages ranged from 36 to 79 years (median, 43). The median duration of the procedure was 150 min (range,50–200) and median blood loss was 50 cc (range, 50–200). The procedure was well tolerated in all patients. There was no intraoperative complication. One deep thrombophlebitis occurred postoperatively. The laparoscopic evaluation could not be completed in one case because of a large nonmobile uterine fibroid filling the whole pelvis. At laparoscopy, metastatic tumor was identified in 9 of 12 patients (75%). An unnecessary laparotomy was avoided in 8 of those 9 cases (one had a palliative exenteration). The most common site of metastasis was in the previously radiated pelvis (7/9). Three patients had a negative laparoscopy. Two had an exenteration and one had a transureteroureterostomy. At the time of laparotomy, none were found to have disease that would have been missed at laparoscopy.Conclusion.We conclude that operative laparoscopy may be a valuable additional step in the work-up and management of patients with locally recurrent cervical cancer. With experience in retroperitoneal surgery, the procedure can be carried out safely in previously radiated patients. We believe this approach can lower the number of unnecessary laparotomies, reduce the morbidity, and shorten the length of the postoperative recovery.

Maximum cytoreduction with posterior exenteration in patients with advanced ovarian cancer

Maximum cytoreduction with posterior exenteration in patients with advanced ovarian cancer