Laparoscopic Pelvic Exenteration Research Articles

Intraoperative 'pressure field' haemodynamic monitoring in a patient with severe aortic regurgitation having laparoscopic robot-assisted colorectal surgery.

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, leading to myocardial ischaemia and heart failure. Transoesophageal echocardiography (TOE) assists haemodynamic management intraoperatively but requires subspecialist skills and enables limited inferences to be drawn regarding the impact of afterload on myocardial performance. Minimally invasive haemodynamic monitoring enabling real-time visualisation of a patient's 'pressure field' has been suggested as a potential adjunct or alternative to TOE, with the added advantage of providing continuous quantitative information about both stroke volume and the afterload to ventricular ejection in a single visualisation. We describe an example of successful concurrent use of pressure field haemodynamic monitoring and TOE in a patient with severe aortic regurgitation having a prolonged laparoscopic robot-assisted pelvic exenteration.

Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408mL vs. 2385ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Long-term outcomes of pelvic exenterations for gynecological malignancies: a single-center retrospective cohort study

BackgroundRecently, with the advancement of medical technology, the postoperative morbidity of pelvic exenteration (PE) has gradually decreased, and it has become a curative treatment option for some patients with recurrent gynecological malignancies. However, more evidence is still needed to support its efficacy. This study aimed to explore the safety and long-term survival outcome of PE and the feasibility of umbilical single-port laparoscopic PE for gynecologic malignancies in a single medical center in China.Patients and methodsPE for gynecological cancers except for ovarian cancer conducted by a single surgical team in Sun Yat-sen University Cancer Center between July 2014 and December 2019 were included and the data were retrospectively analyzed.ResultsForty-one cases were included and median age at diagnosis was 53 years. Cervical cancer accounted for 87.8% of all cases, and most of them received prior treatment (95.1%). Sixteen procedures were performed in 2016 and before, and 25 after 2016. Three anterior PE were performed by umbilical single-site laparoscopy. The median operation time was 460 min, and the median estimated blood loss was 600 ml. There was no perioperative death. The years of the operations was significantly associated with the length of the operation time (P = 0.0018). The overall morbidity was 52.4%, while the severe complications rate was 19.0%. The most common complication was pelvic and abdominal infection. The years of surgery was also significantly associated with the occurrence of severe complication (P = 0.040). The median follow-up time was 55.8 months. The median disease-free survival (DFS) was 17.9 months, and the median overall survival (OS) was 25.3 months. The 5-year DFS was 28.5%, and the 5-year OS was 30.8%.ConclusionPE is safe for patient who is selected by a multi-disciplinary treatment, and can be a curative treatment for some patients. PE demands a high level of experience from the surgical team. Umbilical single-port laparoscopy was a technically feasible approach for APE, meriting further investigation.

Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative.

Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients. From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared. A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295min, p = 0.009), blood loss (100 vs. 300ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR1.02, p = 0.002), poor tumor differentiation (HR3.05, p = 0.004), and (y)pT4b stage (HR2.35, p = 0.035) were independent risk factors for disease-free survival. LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.

The impact of staple transection of the dorsal venous complex and urethra on intraoperative blood loss in cooperative laparoscopic and transperineal endoscopic pelvic exenteration.

While laparoscopic pelvic exenteration reduces intraoperative blood loss, dorsal venous complex bleeding during this procedure causes issues. We previously introduced a method to transect the dorsal venous complex and urethra using a linear stapler during cooperative laparoscopic and transperineal endoscopic (two-team) pelvic exenteration. The present study assessed its effectiveness in reducing intraoperative blood loss by comparing it with conventional laparoscopic pelvic exenteration. This retrospective cohort study was conducted at a Japanese tertiary referral center. Eleven cases of two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex (T-PE group) were compared to 25 cases of conventional laparoscopic pelvic exenteration (C-PE group). The primary outcome measure was intraoperative blood loss. There were no significant between-group differences in patient background. The mean intraoperative blood loss was significantly lower in the T-PE group than in the C-PE group (200 vs. 850mL, p = 0.01). The respective mean operation time, postoperative complication rate, and R0 resection rate were similar between the T-PE and C-PE groups (636min vs. 688min, p = 0.36; 36% vs. 44%, p = 0.65; 100% vs. 100%, p = 1.00). Two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex reduced intraoperative blood loss from the dorsal venous complex in a technically safe and oncologically feasible manner.

Laparoscopic versus open pelvic exenteration for locally advanced rectal cancer: analysis of short- and long-term effects

Objective: To explore the feasibility, safety, and short- and long-term efficacy of laparoscopic pelvic exenteration (LPE) in treating locally advanced rectal cancer. Methods: The clinical data of 173 patients who had undergone pelvic exenteration (PE) for locally advanced rectal cancer that had been shown by preoperative imaging or intraoperative exploration to have invaded beyond the mesorectal excision plane and adjacent organs in the Cancer Hospital, Chinese Academy of Medical Sciences (n=64) and Peking University First Hospital (n=109) from 2010 January to 2021 December were collected retrospectively. Laparoscopic PE (LPE) had been performed on 82 of these patients and open PE (OPE) on 91. Short- and long-term outcomes (1-, 3-, and 5-year overall and disease-free survival and 1- and 3-year cumulative local recurrence rates) were compared between these groups. Results: The only statistically significant difference in baseline data between the two groups (P>0.05) was administration of neoadjuvant therapy. Compared with OPE, LPE had a significantly shorter operative time (319.3±129.3 minutes versus 417.3±155.0 minutes, t=4.531, P<0.001) and less intraoperative blood loss (175 [20-2000] ml vs. 500 [20-4500] ml, U=2206.500, P<0.001). The R0 resection rates were 98.8% and 94.5%, respectively (χ2=2.355, P=0.214). At 18.3% (15/82), and the incidence of perioperative complications was lower in the LPE group than in the OPE group (37.4% [34/91], χ2=7.727, P=0.005). The rates of surgical site infection were 7.3% (6/82) and 23.1% (21/91) in the LPE and OPE group, respectively (χ2=8.134, P=0.004). The rates of abdominal wound infection were 0 and 12.1% (11/91) (χ2=10.585, P=0.001), respectively, and of urinary tract infection 0 and 6.6% (6/91) (χ2=5.601, P=0.030), respectively. Postoperative hospital stay was shorter in the LPE than OPE group (12 [4-60] days vs. 15 [7-87] days, U=2498.000, P<0.001). The median follow-up time was 40 (2-88) months in the LPE group and 59 (1-130) months in the OPE group. The 1-, 3-, and 5-year overall survival rates were 91.3%, 76.0%, and 62.5%, respectively, in the LPE group, and 91.2%, 68.9%, and 57.6%, respectively, in the OPE group. The 1, 3, and 5-year disease-free survival rates were 82.8%, 64.9%, and 59.7%, respectively, in the LPE group and 76.9%, 57.8%, and 52.7%, respectively, in the OPE group. The 1- and 3-year cumulative local recurrence rates were 5.1% and 14.1%, respectively, in the LPE group and 8.0% and 15.1%, respectively, in the OPE group (both P>0.05). Conclusions: In locally advanced rectal cancer patients, LPE is associated with shorter operative time, less intraoperative blood loss, fewer perioperative complications, and shorter hospital stay compared with OPE. It is safe and feasible without compromising oncological effect.

Short- and long-term outcomes of laparoscopic versus open pelvic exenteration for locally advanced rectal cancer: a single-center propensity score matching analysis.

Research on short-term outcomes and long-term oncological results of laparoscopic pelvic exenteration (LPE) for locally advanced rectal cancer (LARC) is still limited. The purpose of this study was to compare the outcomes of LPE and open pelvic exenteration (OPE). Between January 2010 and December 2019, consecutive LARC patients who underwent radical pelvic exenteration at Peking University First Hospital were enrolled. Groups were matched at a 1:1 ratio using propensity score matching. The primary endpoints were 3year overall survival (OS) and disease-free survival (DFS). The secondary endpoints were postoperative short-term outcomes. There were 144 patients (68 males and 76 females, median age 58.5 [range 27.0-86.0] years). After matching, patients were stratified into LPE (n = 48) and OPE (n = 48) groups (LPE: 24 males and 24 females, median age 57.0 [range 27.0-81.0] years; OPE: 26 males and 22 females, median age 58.0[range 36.0-80.0] years). There were no significant differences on baseline data between the two groups. Compared with the OPE group, the LPE group had a significantly lower estimated blood loss (200 vs 500ml, p = 0.003), less overall postoperative complications (12/48 vs 25/48, p = 0.006), less surgical site infection (8/48 vs 20/48, p = 0.007), shorter length of stay (12 vs. 15days, p = 0.005), but similar operative time (344 vs. 360min, p = 0.493). The pathological R0 resection rate (98.0% vs. 93.7%, p = 0.610), 3year local recurrence (18.4% vs. 23.5, p = 0.140), 3year OS (74.6% vs. 65.5%, p = 0.290) and 3-year DFS (60.0% vs. 50.3%, p = 0.208) were similar between the two groups. Shorter distance from anal verge (HR = 0.92, p = 0.042), (y) pT4b (HR = 2.45, p = 0.023), (y)pN1-2 (HR = 2.42, p = 0.004) and positive CRM (HR = 6.23, p = 0.004) were independent prognostic risks for 3year DFS. LPE can be performed safely and has certain short-term advantages over OPE, most notably less blood loss and surgical site infection. However, LPE does not improve long-term oncological outcomes.

A mixed-method evaluation of cadaver surgery training for gynecologic oncology.

Traditional surgical training techniques with using patients, and new advances with live animals, artificial models, and simulation methods have several shortcomings. There are a few reports on the usefulness of cadaver surgery training (CST) in gynecology. Herein, we used a mixed-method evaluation to qualitatively and quantitatively explore the educational efficacy of CST by conducting CST programs at the Sapporo Medical University, Japan. In 2020, we conducted two CST programs with 45 participants-13 residents, 8 specialists recognized by Japan Society of Obstetrics and Gynecology, 23 certified endoscopists recognized by Japan Society of Gynecology and Obstetrics Endoscopy and Minimally Invasive Therapy, 15 specialists recognized by Japan Society of Gynecologic Oncology, and 14 certified endoscopists cum oncology. Three participants observed the procedure virtually and 42 were physically present. Laparoscopic radical hysterectomy and pelvic exenteration were performed on five Thiel-embalmed cadavers. Participants were asked to complete pre- and post-training surveys that included qualitative questions, concerning the purpose and cost of CST, and quantitative questions, testing anatomical knowledge. We observed that the rate of score improvement to the quantitative questions increased from 58.6% pre-CST to 75.6% post-CST. Furthermore, oncology specialists and those who performed more surgeries and faced more complications during surgeries recorded high percentage of correct answers. Multiple regression analysis statistically confirmed these results. This study confirmed the educational efficacy of CST.

Laparoscopic posterior pelvic exenteration for clear cell adenocarcinoma arising in an episiotomy scar

Malignant degeneration of endometriosis is a very rare event, especially when it develops in an episiotomy scar. A 53-year-old woman with an enlarged perineal mass presented to the hospital. She had undergone vaginal delivery with episiotomy twice. Imaging analyses showed a mass involving the levator ani muscle apart from the rectum, with lymph node metastases to the right inguinal and internal iliac regions. A biopsy specimen of the right inguinal lymph node revealed poorly differentiated adenocarcinoma. She underwent neoadjuvant chemotherapy according to the treatment strategy of anal fistula cancer. Laparoscopic posterior pelvic exenteration and pelvic lymph node dissection with anterior inguinal node dissection was performed, along with perineal reconstruction. Pathological examination revealed clear cell adenocarcinoma with lymph node metastases, derived from extrapelvic endometriosis in the episiotomy scar. She was treated with adjuvant chemotherapy according to the treatment strategy of vulvar cancer, and showed no evidence of recurrence after 15 months of surgery.

LAPOROSCOPIC PELVIC EXENTERATION FOR TREATMENT OF PRIMARY MULTIPLE CANCER. CASE REPORT

This clinical case represents the experience of surgical treatment of a patient with multiple primary metachronous cancer: 1. Sigmoid cancer рТ4NxM0. Resection of sigmoid colon (16.12.2013). Three courses of adjuvant chemotherapy (XELOX). Recurrence (2015). Laparotomy, Colproctectomy with D3 paraaortic lymph dissection. Ileostomy (2015). One course of chemotherapy (XELOX). 2. Upper tract urothelial carcinoma (right ureter) pT2N0M0R0. Right nephroureterectomy with the resection of the bladder and right testicular cord, cystostomy (19.02.2015). Recurrence. Nephrostomy drainage of the left kidney. Adhesive disease. Rectovesical fistula. Taking into account the history and comorbid status of the patient, it was decided to perform laparoscopic supralevator pelvic exenteration, ureterectomy on the left. The duration of the operation was 280 minutes, intraoperative blood loss was 200 ml. The period of stay in intensive care is 24 hours, the patient was discharged on the 7th day after the operation, the resection margin was negative (R0). After 12 months, there is no data for the disease progressed.

Laparoscopic pelvic exenteration and laterally extended endopelvic resection for postradiation recurrent cervical carcinoma: Technical feasibility and short-term oncologic outcome

ObjectiveSurgery is the only treatment for cervical cancer recurrence in a previously irradiated field. Pelvic exenteration (PE) and laterally extended endopelvic resection (LEER) are indicated for select patients; however, morbidity and mortality rates remain high, and new treatment modalities are required. Laparoscopy optimizes visualization and allows meticulous dissection while also reducing intraoperative blood loss and postoperative complications without worsening the outcomes. We aimed to clarify the feasibility and outcomes of laparoscopic PE and LEER for previously irradiated recurrent cervical cancer. MethodsWe prospectively investigated the outcomes of laparoscopic PE and LEER in 28 patients with recurrent cervical carcinoma after radiotherapy. ResultsSeventeen laparoscopic PEs for central recurrences and 11 laparoscopic LEERs for lateral recurrences were performed. The median operation time and blood loss were 454mins and 285 mL in the PE group, and 562mins and 325 mL in the LEER group, respectively, with no conversions to laparotomy. R0 resection was achieved in all patients in the PE group and 73% in the LEER group. The morbidity and mortality rates were 41% and 0% in PE group, and 55% and 0% in LEER group, respectively. The 2-year disease-free survival and overall survival were 68.9% and 76% in the PE group, and 27.3% and 29.6% in the LEER group, respectively. ConclusionLaparoscopic PE is feasible for previously irradiated central recurrent cervical cancer and has acceptable outcomes. Laparoscopic LEER is also feasible for lateral recurrence, but oncologic outcome may be modest in this limited preliminary study. Further studies using a larger sample size with a longer follow-up period is warranted to determine the indications for laparoscopic LEER.

Surgical outcomes of hybrid hand-assisted laparoscopic pelvic exenteration for locally advanced rectal cancer: Initial experience.

Hybrid hand-assisted laparoscopic surgery (HALS) combines better visualization of laparoscopic surgery with the advantages of open surgery. The aim of this study was to describe important technical considerations of HALS and to assess the feasibility of hybrid HALS pelvic exenteration (PE) for primary advanced rectal cancer. From May 2012 to August 2018, we retrospectively analyzed 11 patients who underwent PE for primary advanced rectal cancer (< 10 cm from the anal verge). Patients were divided into the open PE group (n = 5) and the hybrid HALS PE group (n = 6). There was no significant difference in patient characteristics between the two groups, and all included patients were male. Tumor invasion to adjacent organs was mostly anterior invasion. In addition, four patients (66%) in the hybrid HALS PE group and two (40%) in the open PE group received neoadjuvant therapy (P = .3). Compared to open surgery, hybrid HALS has the advantages of less bleeding and less invasion, and can achieve the same results in the short-term. It was a reasonable procedure which was easy and safe dissection of internal iliac vessels and dorsal vein complex. Thus, hybrid HALS may become a useful approach for PE.

LAPAROSCOPIC PELVIC EVISCERATION IN MALE AND FEMALE PATIENTS

Abstract: treatment of patients with primary and recurrent locally advanced pelvic tumors represents an extremely complex problem of surgical oncology.Aim: to evaluate perioperative and long-term postoperative results of laparoscopic pelvic exenteration technique.Material and methods: in the period from 2011 to 2018, 21 pelvic exenteration was performed with laparoscopic access, (mean age 59.79 ± 8.5), sex distribution: 17 women and 4 men. Nosology distribution: in 6 patients cervical cancer was verified, 7 patients had bladder cancer, 4 patients had rectal cancer, 1 patient had vaginal cancer, 2 patients had recurrence of vaginal cancers after previous uterine extirpation and 1 patient with ovarian neoplasm.Results: the volume of the exenteration was as follows: 9 total, 7 anterior and 5 posterior. In all cases, it was possible to achieve a negative margin of resection line (R0). The duration of the operation, the volume of blood loss, the frequency and nature of intra- and postoperative complications were evaluated.Conclusion: laparoscopic access is accompanied by a smaller amount of blood loss, decrease of frequency of early postoperative complications, contributes to more comfortable postoperative period with early activation, less severe pain syndrome and leads to a reduction in the duration of inpatient treatment.

Low rectal gastrointestinal stromal tumor-multimodality therapy: Reports and Review

Gastrointestinal stromal tumor (GIST) is one among the most common mesenchymal tumors of the gastrointestinal tract. Common in the stomach, these are also found in other segments, and there has recently been a spate of reports about rectal and colonic GIST. This article highlights two rectal GISTs that were encountered and underwent laparoscopic abdominoperineal resection (APR) and laparoscopic APR plus Total laparoscopic hystrectomy (TLH) (laparoscopic posterior pelvic exenteration) for the involvement of the posterior vaginal wall. The patients both had smooth postoperative periods and are on tyrosine kinase inhibitors, refusing local external radiotherapy. This article highlights the issues surrounding the management of low rectal GIST, a rare but potentially deadly disease.

Laparoscopic Posterior Pelvic Exenteration (Complete and Supralevator) for Locally Advanced Adenocarcinoma of the Rectum in Females: Surgical Technique and Short-Term Outcomes.

Background: Laparoscopic posterior exenteration (total and supralevator) is a complex and rarely done procedure. In this study we describe the surgical technique and short-term perioperative outcomes in 7 female patients of locally advanced carcinoma rectum operated with laparoscopic pelvic exenteration. Materials and Methods: We report 7 cases of carcinoma rectum involving either posterior wall of the uterus or vagina, which were operated with a laparoscopic procedure. All perioperative and intraoperative data were collected retrospectively from prospectively maintained electronic data. Results: Nine female patients with the diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. In MRI 4 patients had uterus-cervix involvement and 3 patients had a posterior vaginal wall and anal sphincter involvement. Four patients were operated with laparoscopic supralevator posterior exenteration and 3 patients were operated with laparoscopic complete posterior exenteration. Three patients underwent vaginal reconstruction, which was done with bilateral V-Y plasty. All 7 patients received neoadjuvant chemoradiotherapy (NACTRT), 3 patients also received additional chemotherapy (CAPOX regimen) due to poor response to NACTRT. Mean body mass index (BMI) was 23.85 (range 19-27.20). Mean duration for complete posterior exenteration was 9.63 hours (range 7-12 hours). Mean duration for supralevator posterior exenteration was 6.81 hours (range 6.25-7.5 hours). The mean postoperative stay was 10.71 days (range 7-16 days). Mean blood loss was 700 mL (range 200-1800 mL). On postoperative histopathology, all margins were free of tumor in all cases. Conclusion: Laparoscopic approach for locally advanced carcinoma rectum in female patients is feasible with less morbidity and safe short-term oncological outcomes. Careful selection of patients based on MRI is a must before undertaking the minimally invasive surgery approach. Long-term outcomes are still unknown and will require long-term follow-up.

Technique of the laparoscopic pelvic exenteration

Background: Laparoscopic surgery has proved itself to be a “golden standard” for treatment of most abdominal and retroperitoneal cancers. Such a serious procedure as pelvic exenteration continues to be a complex surgical intervention usually performed through a conventional laparotomic access. However, studies on minimally invasive approach for this intervention have becoming increasingly published in the world literature.Aim: To describe the laparoscopic pelvic exenteration technique of pelvic exenteration, as well as to assess short- and long-term results of these interventions.Materials and methods: From 2011 to 2018, 21 procedures of laparoscopic pelvic exenteration have been performed in 6 surgical centers (Moscow, Russia). Six (6) patients had previously confirmed cervical cancer, 7 patients had bladder cancer, 4 patients had rectal cancer, 1 patient had vaginal cancer, 2 patients had relapsing vaginal cancers after previous uterine extirpation, and 1 patient had an ovarian neoplasm.Results: The laparoscopic pelvic exenteration volumes were as follows: 9 total, 7 anterior and 5 posterior procedures. In 19 out of 21 cases, negative resection margin (R0) was possible. Median duration of the procedure was 254 minutes, median blood loss was 515 ml, and median postoperative hospital stay was 13 days. Postoperative complications were registered in 6 (28.6%) patients. The 3-year overall survival was 85.71%.Сonclusion: The choice of laparoscopic access can reduce blood loss, decrease the rates of early postoperative complications, contributes to a more comfortable postoperative period with early activation and less severe pain syndrome, and leads to a reduction in the duration of hospital stay. These results of the laparoscopic technique are comparable with those of laparoscopic and open pelvic exenteration published by other authors.

Laparoscopic posterior pelvic exenteration for primary adenocarcinoma of the rectovaginal septum without associated endometriosis: A case report

The present report describes a case of laparoscopic posterior pelvic exenteration of a primary adenocarcinoma of the rectovaginal septum (PARS) without associated endometriosis. A 49-year-old woman was admitted to hospital for rectal bleeding. Imaging studies showed a 7-cm solid tumor located in the rectovaginal septum, presenting with invasion to the posterior aspect of the uterine cervix and the anterior rectal wall. The patient received laparoscopic posterior exenteration and rectosigmoid anastomosis followed by chemotherapy. There were no intra- or post-operative complications. Histopathological examination of the neoplastic tissue revealed moderate to severe cytological atypia with bizarre multinucleated cells and prominent mitotic figures. Histopathologically, R0 resection was achieved. No endometriotic lesions were confirmed in the primary tumor or other removed tissues. Immunohistochemistry showed positive staining for cytokeratin (CK)7, cancer antigen 125, vimentin, estrogen receptor and p53, but negative staining for CK20, progesterone receptor, p40 and thyroid transcription factor 1. Based on these findings and on the location of the tumor, the neoplasm was diagnosed as PARS without associated endometriosis, which may have arisen from metaplasia of the embryological Müllerian-duct remnants.

Laparoscopic Pelvic Exenteration for Locally Advanced Rectal Cancer, Technique and Short-Term Outcomes.

Background: Since last two decades minimally invasive techniques have revolutionized surgical field. In 2003 Pomel first described laparoscopic pelvic exenteration, since then very few reports have described minimally invasive approaches for total pelvic exenteration. Methods: We report the 10 cases of locally advanced rectal adenocarcinoma which were operated between the periods from March 1, 2017 to November 11, 2017 at the Tata Memorial Hospital, Mumbai. All male patients had lower rectal cancer with prostate involvement on magnetic resonance imaging (MRI). One female patient had uterine and fornix involvement. All perioperative and intraoperative parameters were collected retrospectively from prospectively maintained electronic data. Results: Nine male patients with diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. All patients were operated with minimally invasive approach. All patients underwent abdominoperineal resection with permanent sigmoid stoma. Ileal conduit was constructed with Bricker's procedure through small infraumbilical incision (4-5 cm). Lateral pelvic lymph node dissection was done only when postchemoradiotherapy MRI showed enlarged pelvic nodes. All 10 patients received neoadjuvant chemo radiotherapy, whereas 8 patients received additional neoadjuvant chemotherapy. Mean body mass index was 21.73 (range 19.5-26.3). Mean blood loss was 1000 mL (range 300-2000 mL). Mean duration of surgery was 9.13 hours (range 7-13 hours). One patient developed paralytic ileus, which was managed conservatively. One patient developed intestinal obstruction due to herniation of small intestine behind the left ureter and ileal conduit. The same patient developed acute pylonephritis, which was managed with antibiotics. Mean postoperative stay was 14.6 days (range 9-25 days). On postoperative histopathology, all margins were free of tumor in all cases. Conclusion: Minimally invasive approaches can be used safely for total pelvic exenteration in locally advanced lower rectal adenocarcinoma. All patients had fast recovery with less blood loss. In all patients R0 resection was achieved with adequate margins. Long-term oncological outcomes are still uncertain and will require further follow-up.

Total laparoscopic pelvic exenteration for a laterally recurrent cervical carcinoma with a vesicovaginal fistula that developed after concurrent chemoradiotherapy

ObjectiveFor locally advanced cervical carcinoma, concurrent chemoradiotherapy (CCRT) is the standard treatment, however, CCRT can lead to development of a vesicovaginal or rectovaginal fistula [1]. Treatment options are limited for patients with laterally recurrent cervical carcinoma and fistula formation after CCRT. Chemotherapy with bevacizumab is now used for recurrent or advanced cervical carcinoma, but this treatment is associated with fistula formation [2]. When the recurrent mass is confined to the pelvic cavity, complete surgical resection with negative margins offers the most promise; however, the resectability rate is low in cases of laterally recurrent tumor [3], which may include bony structures, and survival outcomes seem to be poor in cases of a laterally recurrent vs. centrally recurrent tumor, even when the primary tumor has been resected in full [4]. Because analyses have shown that laparoscopy optimizes visualization and thus provides for meticulous dissection and that laparoscopic pelvic exenteration, in comparison to open pelvic exenteration results in minimal intraoperative blood loss and complications, fewer postoperative complications, and a shorter hospital stay [5], we perform laparoscopic pelvic exenteration in cases of laterally recurrent cervical carcinoma. MethodsA 52-year-old woman underwent CCRT for a 10-cm stage IVA cervical carcinoma. That involved the bladder and right ureter, causing right hydronephrosis. Seven months after the CCRT, a recurrent mass at the right pelvic sidewall and vesicovaginal fistula were detected. The mass involved the right ureter and bladder and was attached to the rectum. The patient's right renal function was lost. ResultsTotal pelvic exenteration and right nephroureterectomy were performed laparoscopically. Operation time was 566min, and the blood loss volume was 250mL. Complete tumor clearance was achieved without any complication. No adjuvant treatment has been performed, and follow-up positron emission tomography-computed tomography has revealed no sign of recurrence during the 5months that have passed since the surgery. ConclusionTotal laparoscopic pelvic exenteration is technically feasible for a laterally recurrent cervical carcinoma and vesicovaginal fistula that develop after CCRT.

Safety of Laparoscopic Pelvic Exenteration with Urinary Diversion for Colorectal Malignancies

Safety of Laparoscopic Pelvic Exenteration with Urinary Diversion for Colorectal Malignancies