Laterally Extended Endopelvic Resection Research Articles

An Easy Learning Approach to a Complex Surgical Technique: A Step-by-Step Site-Relapse Lateral Extended Endopelvic Resection (LEER)

Lateral pelvic sidewall involvement by gynecological tumors has been considered traditionally an absolute contraindication to curative resection.1 Moreover, the involvement of the pelvic sidewall at the time of relapse in cervical cancer after primary or adjuvant pelvic radiation occurs in 8.3% of patients.2,3 Laterally extended endopelvic resection (LEER), based on the ontogenetic compartment theory, provides a potential surgical option for patients for whom palliative therapy is the only alternative.4 This complex and ultraradical, surgical technique allows a high rate of complete resection in more than 70% of patients with gynecological cancers and lateral pelvic sidewall involvement. An adequate selection of patients and a deep knowledge of pelvic anatomy are crucial to obtain acceptable morbimortality rates and improved overall survival in this population.5 To deconstruct this complex procedure, we show a detailed step-by-step technique to facilitate the easy learning curve of this surgical technique. We review the Höckel original technique with different site-relapse adapted steps. We provide a pedagogical high-quality video (Video 1) and anatomical outline drawings (Fig. 1) to understand lateral pelvic wall anatomy and standardize this surgical technique. Our purpose is to bring this knowledge to gynecologists and pelvic surgeons in which pelvic lateral approach may be useful beyond gynecological oncologic surgery (Table 1).

Laterally extended endopelvic resection for advanced or recurrent gynecological malignancies: clinicopathological analysis

To explore the feasibility and safety of laterally extended endopelvic resection (LEER) for advanced and recurrent gynecological malignancies with pelvic sidewall involvement and to evaluate this therapeutic potential of this novel salvage treatment. The clinicopathological data of 5 patients with gynecological malignancies who received laparoscopic LEER treatment in Obstetrics and Gynecology Hospital of Fudan University from January 2019 to September 2021 were retrospectively analyzed, including 3 cases of recurrent cervical cancer, 1 case of primary advanced endometrial cancer and 1 case of pelvic aggressive angiomyxoma. Among them, four patients achieved complete resection (R0) with a negative resection margin; the other patient with recurrent cervical cancer did not complete surgery because of the extreme risk of continuing surgery. The median operation time was 345 (225-482) minutes and the median blood loss was approximately 300 (200-600) ml. Complications occurred in three patients, including lymphocysts, urinary tract infections, and deep venous thrombosis of the lower extremities. Within a median follow-up time of 283 (128-715) days, 4 patients survived tumor-free, and 1 patient died. The high rate of complete resection (R0) and the encouraging oncological outcomes suggest that LEER may be an alternative treatment option for patients with advanced and recurrent gynecological malignancies involving the pelvic sidewall.

Safety and feasibility of laterally extended endopelvic resection for sarcoma in the female genital tract: a prospective cohort study.

ObjectiveThis study aims to evaluate the safety and feasibility of laterally extended endopelvic resection (LEER) for sarcoma in the female genital tract.MethodsWe prospectively recruited gynecologic cancer patients with sarcoma arising from female genital tract who underwent LEER at Seoul National University Hospital from December 2016 to March 2021. Clinicopathologic characteristics, surgical outcomes including postoperative complications and pain control, and survival outcomes of the patients were investigated.ResultsA total of nine patients were registered for this study. The median age was 56 years. Carcinosarcoma (n=2, 22%), leiomyosarcoma (n=2, 22%), and undifferentiated uterine sarcoma (n=2, 22%) were common histology types. Complete resection was achieved in 88.9%. The most common location of pelvic sidewall tumors was infra-iliac acetabulum (66.7%). The pathologic outcome showed a median tumor size of 9.0 cm and internal iliac vessel resection with pelvic sidewall muscle was performed in all patients. The median estimated blood loss was 1,600 mL (range, 300–22,300), and the patients were postoperatively admitted to the intensive care unit for median 1 day (range, 0–8). Complete response was observed in 44.4% (4/9) in radiologic studies after LEER, and median progression-free survival, treatment-related survival, and overall survival were 3.3, 19.6, and 98.9 months, respectively.ConclusionLEER was feasible and safe in treating recurrent sarcoma presenting pelvic sidewall invasion with acceptable survival outcomes and manageable postoperative complications.

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.

Robotically Assisted Laterally Extended Endopelvic Resection (LEER) of an Isolated Ovarian Cancer Recurrence

A 64-year-old woman with recurrent ovarian cancer isolated to the left pelvic sidewall underwent robotic resection of a tumor adherent to the external iliac vein and encasing the ureter and internal iliac vessels. A narrated video-clip of the case is included.

Efficacy and safety of laterally extended endopelvic resection for the pelvic side wall gynecologic tumors: A four-year prospective cohort study with historical comparison.

6092 Background: Although laterally extended endopelvic resection (LEER) has been introduced to control the pelvic sidewall tumors, there is a lack of evidence about its efficacy and safety despite high skillful procedure, compared with the other treatments. Thus, we performed a prospective cohort study with historical comparison for four years. Methods: One gynecologic oncologist performed LEER consecutively for patients with the pelvic sidewall tumors between March 2014 and July 2018. We compared clinicopathologic characteristics and survival between patients who received primary LEER and with those treated with other treatments. Results: We enrolled 37 patients treated with LEER. Among them, 22 (59.5%) and 15 (40.5%) had recurrent and primary disease. Among perioperative outcomes, there was more estimated blood loss, and hospitalization was longer in recurrent disease and previous surgery (p < 0.05). In recurrent disease, previous progression-free survival < 8 months was related to poor recurrence-free survival after LEER (median, 5.4 vs. 10.2 months; p < 0.05). When LEER was applied for the first recurrence of cervical cancer, recurrence-free survival and overall survival after treatment seemed to be longer in LEER (n = 9) than in palliative chemotherapy (n = 27) without statistical significance (median, 12.2 vs. 4.7 months and 23.2 vs. 12.4 months; p = 0.13 and p = 0.63). In 15 patients with primary locally advanced cervical cancer, LEER after partial response to neoadjuvant chemotherapy showed longer progression-free survival than LEER after stable or progressive disease to neoadjuvant chemotherapy and primary radiotherapy (p = 0.012). After LEER, grade 3 and 4 complications developed in 15 (23.1%) and 2 (3.1%) patients. Conclusions: Compared with palliative chemotherapy, LEER followed by palliative chemotherapy may improve progression-free survival in patients with recurrent cervical cancer located in the pelvic sidewall. If possible, it is more effective to apply LEER without preceding palliative chemotherapy for recurrent cervical cancer located in the pelvic sidewall.

Laparoscopic laterally extended endopelvic resection procedure for gynecological malignancies

ObjectivesPelvic side wall infiltration by gynecological malignancies has been considered for a long time an absolute contraindication to curative resection. The development of the laterally extended endopelvic resection (LEER) has...

Laterally Extended Endopelvic Resection as a Salvage Procedure for Locally Advanced And Recurrent Cervical Cancers: A Single-Institution Experience

Locally advanced and recurrent cervical cancer involving up to sidewall where the complete negative margin was not achieved usually had a low cure rate and a poor 2-year survival. Laterally extended endopelvic resection (LEER) described by Hockel et al. is a novel approach in these cases in which complete negative margin (R0) can be achieved with adequate local control and better survival. In this study, we analyzed our 5-year experience and outcome after LEER for locally advanced and recurrent cervical cancer. This is a retrospective study of patients who underwent Laterally Extended Endo-pelvic Resection for locally advanced and recurrent carcinoma of cervix during the period from 2012–2017. The following details were recorded from the records: initial stage, histopathology, grade of the tumor, initial treatment modality, methods of urinary and fecal diversion, duration of follow-up, disease-free survival, pattern of recurrence, postoperative histopathology, postoperative morbidity and mortality and survival pattern post-LEER procedure. Totally, 15 patients were operated; among them, 13 cases were recurrent, progressive or residual disease and two cases were primary (stage IVA) cases. Among 13 cases, an initial stage was IIB in six cases and stage IIIB in seven cases. Among 15 patients, five patients received definitive chemo-radiation; eight out of 15 patients received only external beam radiation without brachytherapy. All but one case was done via laparotomy. All margins were negative in all cases. Early (30 days) postoperative mortality was seen in two patients due to urosepsis. Postoperative complications were perineal wound dehiscence (60%), surgical site infections (33%) and electrolyte abnormalities (33%). After 30 days, recurrent urosepsis and chronic renal failure were seen in 46% of patients. No significant differences between two types of diversion techniques were found. Four patients had recurrence in the pelvis and were started on palliative chemotherapy. Two of these patients died within 2 years. Distant metastasis was seen in three patients and all died within 2 years. Average follow-up was 2.9 years (range 15 months–5 years). Two-year overall survival was 53%. Two-year disease-free survival was 40%. LEER as a salvage surgery is indicated for primary and recurrent cervical cancer with disease up to pelvic side wall for improving disease-free survival. Though the operating time and blood loss are high in this mega procedure with increased perioperative mortality and morbidity, negative margin (R0) can be achieved with adequate local control and better survival.

Extended mesometrial resection (EMMR): Surgical approach to the treatment of locally advanced cervical cancer based on the theory of ontogenetic cancer fields

BackgroundBased on ontogenetic-anatomic considerations, we have introduced total mesometrial resection (TMMR) and laterally extended endopelvic resection (LEER) as surgical treatments for patients with cancer of the uterine cervix FIGO stages I B1 - IV A. For a subset of patients with locally advanced disease we have sought to develop an operative strategy characterized by the resection of additional tissue at risk for tumor infiltration as compared to TMMR, but less than in LEER, preserving the urinary bladder function. MethodsWe conducted a prospective single center study to evaluate the feasibility of extended mesometrial resection (EMMR) and therapeutic lymph node dissection as a surgical treatment approach for patients with cervical cancer fixed to the urinary bladder and/or its mesenteries as determined by intraoperative evaluation. None of the patients received postoperative adjuvant radiotherapy. Results48 consecutive patients were accrued into the trial. Median tumor size was 5cm, and 85% of all patients were found to have lymph node metastases. Complete tumor resection (R0) was achieved in all cases. Recurrence free survival at 5years was 54.1% (95% CI 38.3–69.9). The overall survival rate was 62.6% (95% CI 45.6–79.6) at 5years. Perioperative morbidity represented by grade II and III complications (determined by the Franco-Italian glossary) occurred in 25% and 15% of patients, respectively. ConclusionWe demonstrate in this study the feasibility of EMMR as a surgical treatment approach for patients with locally advanced cervical cancer and regional lymph node invasion without the necessity for postoperative adjuvant radiation.

Surgical treatment and histopathological assessment of advanced cervicovaginal carcinoma: A prospective study and retrospective analysis

BackgroundStandard treatment of advanced cervicovaginal cancer [international federation of gynecology and obstetrics (FIGO) stages II(B), III(A, B), IVA] is (chemo-)radiation excluding the possibility of systematic histopathological assessment of locoregional tumour spread. Laterally extended endopelvic resection (LEER) and therapeutic lymph node dissection (tLND) are novel surgical treatment options for advanced cervicovaginal cancer. MethodsThe therapeutic efficacy of LEER for locally advanced primary and recurrent cervicovaginal cancer was reassessed by an update of the prospective observational trial at the University of Leipzig. LEER specimens were histopathologically analysed for patterns of locoregional tumour spread with particular consideration of morphogenetic cancer fields. Histopathological features associated with malignant ureteral obstruction were evaluated. Clinical (FIGO), pathological (pT) and ontogenetic (oT) tumour staging were compared. ResultsEighty-eight patients with locally advanced primary and recurrent cervicovaginal cancer were treated with LEER and tLND. LEER removed all but one tumour with microscopically clear margins (R0). After median follow-up of 40 months (7–191) five-year overall survival rate was 50% (95% confidence interval [CI]: 40–62) for the whole cohort and 46% (95% CI: 34–62) for 51 patients without a curative option from current treatment. The tissue domains of cervicovaginal cancer spread mirrored the derivatives of the morphogenetic fields instrumental for the formation of the lower genital ducts. Periureteral fibrosis accompanying mesometrial invasion, tumour infiltration of the mesureter and infiltration of the ureter itself were identified as histopathological correlates of ureteral obstruction associated with an increasingly worse prognosis. Ontogenetic tumour staging based on morphogenetic cancer fields predicted outcome better than pT and FIGO staging. InterpretationLEER and tLND expand the curative treatment options for advanced cervicovaginal cancer. Histopathological assessment of advanced disease supports the concept of tumour spread within morphogenetic cancer fields, provides insights into the pathomechanism of ureteral obstruction and allows precise tumour staging.

Laterally Extended Endopelvic Resection (Leer) and Reconstructive Techniques for Treatment of Locally Advanced Cervix Cancer: A Case Report

The aim of this report is to describe the surgical procedure done in a 24-year-old woman who presents a locally advanced squamous cervix carcinoma and is proposed to laterally extended endopelvic resection (LEER), intraoperative radiation therapy with electrons (IORT) and urinary and colon diversion with vaginal reconstruction. A year after surgery the patient is alive, without disease and with and acceptable quality of life.

Long-term experience with (laterally) extended endopelvic resection (LEER) in relapsed pelvic malignancies.

Gynecologic cancers recurring in the pelvis are generally advanced in malignant progression limiting curative treatment approaches. The cancer field theory links cancer progression to reversed morphogenesis and allows the exact anatomical delineation of the cancer field, i.e., the tissue compartment of potential tumor infiltration related to the tumor's ontogenetic stage. Cancer surgery is redefined with the resection of ontogenetic stage-related cancer fields instead of the mere removal of the malignant tumor with an uninvolved tissue margin. Most gynecologic pelvic malignancies recurring in the pelvis represent ontogenetic stages 3 and 4. (Laterally) extended endopelvic resection ((L)EER) has been designed to resect the cancer fields of gynecologic tumors in these advanced ontogenetic stages. This paper reports long-term experience with (L)EER for relapsed pelvic malignancies strongly supporting the cancer field theory and the principle and practice of cancer field resection.

Does intra-operative radiation at the time of pelvic exenteration improve survival for patients with recurrent, previously irradiated cervical, vaginal, or vulvar cancer?

ObjectiveTo determine whether intra-operative radiation therapy (IORT) at the time of pelvic exenteration (PE) or laterally extended endopelvic resection (LEER) improves progression-free survival (PFS) in patients with recurrent, previously irradiated gynecologic cancers. MethodsWe conducted a single institution retrospective review of patients who had undergone a complete PE for locally recurrent gynecologic cancer. Demographic and clinicopathologic data were collected. Results32 patients were identified (2000–2012); 21 (66%) cervical cancer, 8 (25%) vaginal, and 3 (9%) vulvar cancer. All patients were previously irradiated. Twenty-one (66%) received IORT. Mean age was 51. Eight patients had a LEER, all with IORT. Median PFS and OS, respectively, for those with PE alone was 33 and 41 vs. 10 and 10months for PE+IORT compared to 9 and 17months for LEER+IORT (P=.04). Increasing tumor size negatively impacted PFS (hazard ratio 1.3; 95%CI 1.12–1.52). Margin status was not associated with survival. No patients undergoing LEER+IORT recurred only locally whereas 62% recurred with a distant component (+/− local). Patients with PE alone had mainly local (36%) and few (9%) distant recurrences compared to 31% local and 38% distant (+/− local) recurrences for those with PE+IORT. ConclusionsWe failed to demonstrate that IORT changes survival and recurrence outcomes. However, patients with clinical indications for IORT at the time of PE have worse prognosis compared to those who do not require IORT. If the need for IORT is anticipated, the surgeon may consider performing a LEER to decrease local recurrence if cure is the goal or consider palliative treatment options.

Onkologische Beckenchirurgie unter gynäkologischen Gesichtspunkten

The established gynecological cancer operations are based on functional anatomy derived from the mature organism and on a model of radial progressive tumor permeation. Surgical treatment aims to resect the tumor with a metrically defined radial margin of tissue microscopically free of neoplastic or dysplastic disease. However, despite adequate surgical performance local tumor relapses still occur. In the presence of histopathological risk factors adjuvant radiation is therefore recommended which increases treatment-related morbidity. The Leipzig School of Radical Pelvic Surgery has developed new gynecological cancer operations from a different perspective on anatomy and local tumor spread. Tissue mapping is deduced by following the organism's development from the stage of tissue deposition to maturity (ontogenetic anatomy) to define permissive compartments for cancer permeation. The variants of mesometrial resection (TMMR, PMMR) and vulva field resection (VFR) achieve very high (>95%) local control rates in stages I and II cancer of the lower and middle female genital tract without adjuvant radiation. Laterally extended endopelvic resection (LEER) provides sustained tumor control even in locally advanced and recurrent disease as well as cancer of the distal vagina.

Laterally extended endopelvic resection (LEER)—Principles and practice

Exenteration has been used for the last 6 decades, mainly to treat cancers of the lower and middle female genital tract in the irradiated pelvis. New ablative techniques based on developmentally derived surgical anatomy termed laterally extended endopelvic resection ( LEER) aim to increase the curative resection rate, even of tumors extending to and fixed to the pelvic side wall. LEER is performed as a combination of at least two of the following procedures: total mesorectal excision, total mesometrial resection, and total mesovesical resection. In cases of lateral tumor fixation, the inclusion of pelvic side wall and floor muscles, such as the obturator internus muscle and pubococcygeus, iliococcygeus and coccygeus muscles, and eventually of the internal iliac vessel system assures the completeness of the multicompartmental resection. One hundred patients with locally advanced ( n = 25) and recurrent ( n = 75) gynecologic tumors have been treated with these new procedures. In 76 patients, the tumors were fixed to the pelvic side wall. Two patients with advanced age and extensive comorbidity died during the early postoperative period. Moderate and severe treatment-related morbidity was 70%, mainly due to compromised healing of irradiated tissue and the performance of complex reconstructions. At a median follow-up period of 30 months (range, 1–136 months), 5-year recurrence-free and disease-specific overall survival probabilities are 62% (95% CI, 52–72%) and 55% (95% CI, 43–67%), respectively. LEER has significant potential to salvage selected patients with locally advanced and recurrent gynecologic malignancies, including those with pelvic side wall disease, traditionally not considered for surgical therapy.

Laterally extended endopelvic resection: Novel surgical treatment of locally recurrent cervical carcinoma involving the pelvic side wall

Objectives To demonstrate the therapeutic potential of the laterally extended endopelvic resection (LEER) especially for patients with recurrent cervical carcinomas involving the side wall of an irradiated pelvis. These patients, suffering from the most common situation of local failure, have so far no longer been considered for curative therapy. Methods Extending the lateral resection plane of pelvic exenteration to the medial aspects of the lumbosacral plexus, sacrospinous ligament, acetabulum, and obturator membrane enables the complete removal of a subset of locally advanced and recurrent tumors of the lower female genital tract fixed to the pelvic wall with free margins (R0). Patients selected for LEER were accrued to a prospective outcome trial. Results Thirty-six patients with recurrent ( n = 29) or primary advanced ( n = 7) gynecologic malignancies involving the side wall of the lesser pelvis underwent LEER from July 1996 until October 2002. The majority of the patients suffered from cervical carcinoma ( n = 29) and had received previous pelvic irradiation ( n = 24). Tumor-free (R0) lateral margins were obtained in 34 patients. Severe postoperative complications occurred in 14 patients with one treatment-related death. Five-year survival probability is 49% for the whole group and 46% for those patients considered only for palliation with current treatment options. Most patients without evidence of disease at least 1 year after LEER achieved good quality of life. Conclusion LEER can be offered as novel surgical salvage therapy to a selected subset of patients with locally advanced and recurrent cervical carcinoma involving the pelvic wall.