Pelvic Cancer Surgery Research Articles

Near Total Transection of the Obturator Nerve and Primary Repair during Laparoscopic Radical Hysterectomy for Cervical Cancer

Background: Obturator nerve injury is a rare complication and it may occur during pelvic cancer surgery especially during pelvic lymphadenectomy. The injury may cause paraesthesia, sensory loss or pain in the medial thigh which may extend down to the knee. It can also cause weakness in adduction with gait disturbance, medial thigh wasting and possible medico-legal consequences. Case Report: The patient is a 57 year old lady who was found to have an early cervical cancer. MRI abdomen and pelvis was negative for regional lymphadenopathy or distant metastases hence clinically she had a Stage IB1 SCC of cervix. She underwent a Total Laparoscopic Wertheim's Radical Hysterectomy BSO Bilateral Pelvic Lymphadenectomy in February 2015. During the pelvic lymphadenectomy, the left obturator nerve was inadvertently damaged and partially transected by the Harmonic scalpel. The nerve was reconstituted by interrupted 5-O vicryl suture to the epineural layer of the nerve. Post operatively, the patient experienced weakness of the adductor muscles (3/5) but negligible sensory loss. Four months after intensive physiotherapy, the motor deficit was markedly reduced and her gait was normal. There was no sensory loss. Final histology revealed that the surgical margins was clear and 0/41 pelvic lymph nodes were negative. Hence she did not need any adjuvant therapy. Conclusion: Obturator nerve injury is a rare complication with a significant clinical impact if unrecognised. In uncomplicated cases, laparoscopic route of repair is feasible and safe and an immediate repair of the nerve is preferable.

Long-term Outcomes of Augmentation Enterocystoplasty in Patients With End-Stage Bladder Diseases: A Single-Institute Experience Involving 102 Patients.

PurposeAugmentation enterocystoplasty (AE) has been shown to improve clinical symptoms in patients with end-stage bladder disease (ESBD). Herein, we report the long-term outcomes of a series of patients with different etiologies of ESBD who received AE. MethodsWe retrospectively reviewed 102 patients with ESBD who received AE at the Hualien Tzu Chi General Hospital from 1992 to 2014. ESBD in this study was defined as including neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) or myelomeningocele, inflammatory bladder disease (IBD), ESBD occurring after pelvic cancer surgery, and other etiologies. Complications including active lower urinary tract problems and urinary tract infection (UTI), as well as patients’ self-reported satisfaction with the procedure, were evaluated. ResultsA total of 102 patients were included in the study. A majority of patients received AE for NLUTD (n=43), followed by IBD (n=38), ESBD after pelvic cancer surgery (n=15), and the other etiologies (n=6). Patients had a mean age of 39.4±18.7 years and were followed for a mean of 78 months. All patients had significantly increased cystometric bladder capacity and compliance at the time of follow-up. Fifty-four patients (52.9%) reported moderate to excellent satisfaction with the outcome, and there were no significant differences among the groups (P=0.430). The most common reason for dissatisfaction was the need for clean intermittent catheterization (CIC; 41.7%), followed by urinary incontinence (25.0%) and recurrent UTI (16.7%). ConclusionsAE is a safe and effective procedure for patients with ESBD. Postoperative urinary incontinence and UTI as well as the need for CIC may affect quality of life and decrease patient satisfaction.

Postoperative paralytic ileus remains a problem following surgery for advanced pelvic cancers

BackgroundParalytic postoperative ileus (POI) is associated with increased morbidity and mortality after abdominal surgery. Despite increased awareness and implementation of various measures, POI remains a problem, perhaps moreso for those patients undergoing extensive oncological surgical treatment. The aim of this study was to describe the extent of POI after advanced cancer surgery in the era of contemporary treatment modalities of POI. MethodsA retrospective analysis of all patients who underwent either abdominoperineal excision with transpelvic vertical rectus abdominal musculocutaneous (VRAM)-flap after anal cancer or pelvic exenteration at single institution from January 2012 to November 2013 was carried out. Patients were identified from operative codes, and data were retrieved from patient records. ResultsEighty-nine patients were included in the study, 21 abdominoperineal excision and 68 pelvic exenteration procedures. Median nasogastric tube duration was 4 days (range: 0-44). Median time to first flatus was 1 day (range 0-15). Median time to defecation was 3 days (range 0-16 days). Twenty-three patients (28%) experienced prolonged ileus. There was a significant longer time to first defecation for patients who received a VRAM flap (P = 0.046). There was also a significant association between longer operative times and first flatus (P = 0.007). ConclusionsThis retrospective study reveals that POI remains as a significant clinical problem in patients undergoing advanced pelvic cancer surgery, despite the increased awareness and implementation of enhanced recovery protocols. New regimens for better prophylaxis are needed, and further research on POI treatment is important.

Forma de presentación, historia natural y evolución de la enfermedad tromboembólica venosa postoperatoria en pacientes operados por cáncer abdominal y pélvico. Análisis del registro RIETE

IntroductionVenous thromboembolism (VTE) represents a serious complication after oncologic surgery. Recent studies have shown that the risk of VTE persists several weeks after surgery. This study assesses the form of presentation and time course of VTE after abdominal and pelvic cancer surgery. MethodsProspective, multicenter, observational study that analyzes data from an international registry (RIETE) that includes consecutive patients with symptomatic VTE. Our study assesses the form and time of presentation of postoperative VTE, as well as main outcomes, in patients operated for abdominopelvic cancer 8 weeks prior to VTE diagnosis. Variables related to the presentation of VTE after hospital discharge are identified. ResultsOut of the 766 analyzed patients with VTE, 395 (52%) presented pulmonary embolism (PE). Most VTE cases (84%) were detected after the first postoperative week, and 38% after one month. Among patients with VTE in the first postoperative week, 70% presented PE. VTE presented after hospital discharge in 54% of cases. Colorectal, urologic, and gynecologic tumors, the use of radiotherapy, and blood hemoglobin levels were independently associated with VTE diagnosis after hospital discharge. Complications (thrombosis recurrence, bleeding, and death) occurred in 34% of patients with VTE detected before hospital discharge, compared to 24% in VTE after hospital discharge (P<0.01). ConclusionsVTE occurs after hospital discharge in most patients, particularly in those operated for colorectal, urologic, and gynecologic cancer. Pulmonary embolism is more frequent in patients who develop early VTE, who also have worse prognosis.

Form of Presentation, Natural History and Course of Postoperative Venous Thromboembolism in Patients Operated on for Pelvic and Abdominal Cancer. Analysis of the RIETE Registry

IntroductionVenous thromboembolism (VTE) represents a serious complication after oncologic surgery. Recent studies have shown that the risk of VTE persists several weeks after surgery. This study assesses the form of presentation and time course of VTE after abdominal and pelvic cancer surgery. MethodsProspective, multicenter, observational study that analyzes data from an international registry (RIETE) that includes consecutive patients with symptomatic VTE. Our study assesses the form and time of presentation of postoperative VTE, as well as main outcomes, in patients operated for abdominopelvic cancer 8 weeks prior to VTE diagnosis. Variables related to the presentation of VTE after hospital discharge are identified. ResultsOut of the 766 analyzed patients with VTE, 395 (52%) presented pulmonary embolism (PE). Most VTE cases (84%) were detected after the first postoperative week, and 38% after one month. Among patients with VTE in the first postoperative week, 70% presented PE. VTE presented after hospital discharge in 54% of cases. Colorectal, urologic, and gynecologic tumors, the use of radiotherapy, and blood hemoglobin levels were independently associated with VTE diagnosis after hospital discharge. Complications (thrombosis recurrence, bleeding, and death) occurred in 34% of patients with VTE detected before hospital discharge, compared to 24% in VTE after hospital discharge (P<0.01). ConclusionsVTE occurs after hospital discharge in most patients, particularly in those operated for colorectal, urologic, and gynecologic cancer. Pulmonary embolism is more frequent in patients who develop early VTE, who also have worse prognosis.

Is it the End for Urologic Pelvic Laparoscopic Surgery?

To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: "pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access" was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.

Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy.

The study investigated the effect of collagen mesh-assisted closure at the donor site in preventing the formation of incisional hernia following construction of a vertical rectus abdominis myocutaneus (VRAM) flap as part of pelvic surgery for recurrent colorectal cancer. The study was a double-blinded randomized controlled superiority trial that was designed and performed according to the Consolidated Standards of Reporting Trials (CONSORT) Statement. Eligible patients undergoing surgery that included a VRAM flap for advanced colorectal pelvic malignancy were prospectively randomized to conventional abdominal wound closure or collagen mesh-assisted closure. The primary end-point was incisional herniation at 1year confirmed by CT. Secondary end-points were CT-verified incisional herniation at 3 and 36months, clinically recognizable incisional herniation, donor-site and reconstructive-site complications, surgical mortality, postoperative morbidity, postoperative recovery and survival. In total, 58 (29 conventional closure; 29 mesh-assisted closure) patients were included. At 1year, incisional herniation on the CT scan was found in 12 (50%) of 24 patients in the conventional closure group, and in 8 (33%) of 24 in the mesh-assisted closure group (P=0.38). No significant difference between the groups was found in surgical mortality, early or late complications or survival. Donor-site morbidity was comparable between the two groups. No preventative effect of collagen mesh-assisted closure was observed following VRAM flap reconstruction.

Incidence of venous thromboembolic events following major pelvic and abdominal surgery for cancer.

478 Background: The recommendation to administer extended-duration (28 days) venous thromboembolic events (VTE) prophylaxis with low molecular weight heparin in patients undergoing abdominal and pelvic surgery for cancer has not been widely implemented mainly because most studies focus on asymptomatic events with unknown clinical significance. The objective of this study was to determine the post-hospital discharge VTE incidence in these patients who do not receive post-hospital discharge prophylaxis. Methods: Prospective cohort study of patients undergoing abdominal and pelvic operations for cancer within the gastrointestinal tract, hepatobiliary (HPB) system or gynecological organs, with surgery lasting &gt; 1 hour, post-operative stay &lt; 28 days, and not undergoing anticoagulant therapy. Patients were evaluated at 1, 3 and 6 months from index operation for the presence of VTE by means of a screening ultrasound at 28 days and a questionnaire at each follow-up. The proportion with 95% confidence interval (CI) of VTE was calculated. Multivariable logistical regression was performed. Results: Of 284 patients, there were 79 (28%) colorectal, 97 (35%) HPB and 100 (35%) gynecology. All patients received pre- and post-operative in-patient prophylaxis. The proportion of VTE at 6 months was 7%, 95% CI 4.4-10.7 (20 events). Most events occurred between 3-6 months, 4.6%, 95% CI 2.46 – 7.7. Only one event occurred at one month after surgery (0.35%, 95% CI 0.06-1.97). 50% of the cohort had screening ultrasound, all of which were negative. Events were evenly distributed according to the type of surgery. The proportion of patients who died was 6.6%, 95% CI 3.5 – 9.4 (17 patients, 2 of which had a VTE-related death). In the multivariable analysis, post-operative chemotherapy was significantly associated with VTE, odds ratio (OR) 2.74, 95% CI 1.07-6.99. Caprini score was also associated with VTE but was not significant when included in the multivariable analysis, OR 1.19, 95% CI 0.99-1.42. Conclusions: Incidence of VTE following abdominal cancer surgery is low. Most events occur between 3-6 months from surgery. Post-operative chemotherapy is significantly associated with post-hospital discharge VTE.

Interiliac-abdominal exarticulation: The history of development and the relevance of use in modern pelvic cancer surgery

Interiliac-abdominal exarticulation: The history of development and the relevance of use in modern pelvic cancer surgery

Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration.

To perform more radical surgery for complex pelvic malignancies and recurrent colorectal cancer, the surgeon must increasingly operate outside the conventional anatomical planes. Published in 1963 the 'Triangle of Marcille' (lumbosacral triangle) remained primarily of intellectual interest being found lateral to the traditional operating field. However, with the advancement of complex colorectal and gynaecological surgery it now provides a schema to assist surgeons in becoming acquainted with a complex and poorly understood anatomical region. Additionally, it prepares the surgeon for the extent of lateral dissection required to achieve the 'holy grail' for oncological surgery in pelvic malignancy, the complete resection (R0). To prosect a preserved cadaver in order to demonstrate, in vivo, the contents and borders of the Triangle of Marcille for the purposes of teaching surgeons and future surgeons. The Triangle of Marcille is both described and demonstrated in vivo, illustrated with diagrams and photographs. The importance of this region to the surgical management of complex colorectal and gynaecological surgery is discussed. The Triangle of Marcille is a vital anatomical region for advanced pelvic surgery, particularly in the current era of pelvic exenteration, and especially for those that include the lateral pelvic compartment.

Venous thromboembolism prophylaxis in patients undergoing abdominal and pelvic cancer surgery: adherence and compliance to ACCP guidelines in DIONYS registry.

BackgroundVenous thromboembolism (VTE) is a major health care problem resulting in significant mortality, morbidity and increase in medical expenses. Patients with malignant diseases represent a high risk population for VTE. The American College of Chest Physicians (ACCP) proposed, since 1986, prophylaxis guidelines that are unequally respected in surgical practice.MethodsDIONYS is a multinational, longitudinal and non-interventional registry including patients having undergone abdominal or pelvic surgery for cancer in Latin America, Africa and the Middle East. Patients were evaluated with regard to VTE prophylaxis, during three consecutive visits, for their adherence to ACCP 2008 guidelines. Data were collected on type and duration of VTE prophylaxis, adherence to guidelines, and compliance with prescriptions, complications and possible reasons for omission of prophylaxis.ResultsBetween 2011 and June 2012, 921 adult patients were included and divided into abdominal (435), pelvic (390) and combined abdominal and pelvic surgery (96), 65.4 % being females. VTE prophylaxis was prescribed to 90 % of patients during hospitalization and to 28.3 % after hospital discharge. Prescriptions adhered to ACCP guidelines in 73.9 % of patients during hospitalization and 18.9 % after discharge. The reason of non-adherence was mainly the clinical judgment by the physician that the patient did not need a prophylaxis. The most commonly prescribed type of prophylaxis was pharmacological (low molecular weight heparin).ConclusionA wide gap exists between VTE prophylaxis in daily practice and the ACCP 2008 guidelines, in abdominal and pelvic cancer surgery. A better awareness of surgeons is probably the best guarantee for improvement of VTE prophylaxis in surgical wards.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-3057-9) contains supplementary material, which is available to authorized users.

Skilled care utilization after abdominal and pelvic cancer surgery in older patients

Background and objectivesOlder cancer patients are less likely to return home after surgery. Utilization of post acute skilled services in this setting is associated with increased mortality. Medicare payments for post acute care continue to grow. This study aims to identify factors associated with the utilization of post acute services at hospital discharge after abdominopelvic cancer surgery. MethodsThis is a retrospective analysis of older cancer patients (age>75) who presented to the Geriatrics clinic at Memorial Sloan Kettering Cancer Center for preoperative evaluation between October 2010 and December 2012. Sociodemographic features, pre-operative geriatric assessment, hospitalization characteristics and discharge disposition data were collected and analyzed. ResultsOut of 592 patients (age>75), 291 (49.2%) were discharged home without services and 301 (50.8%) were discharged home with skilled services or to a skilled nursing facility. Older age (OR 1.058, P=0.010), preoperative ADL dependency (OR 2.242, P=0.001), longer operation time (OR 1.004, P<0.001) and postoperative delirium (OR 2.213, P=0.004) were independently associated with skilled care utilization. ConclusionsOptimizing preoperative status, implementing delirium prevention protocols and streamlining the hospital stay may impact the discharge disposition, helping control healthcare costs and achieving a better outcome for the older surgical cancer patient.

Role of Extended Thromboprophylaxis After Abdominal and Pelvic Surgery in Cancer Patients: A Systematic Review and Meta-Analysis.

Abdominopelvic cancer surgery increases the risk of postoperative venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) thromboprophylaxis is recommended, and the role of extended thromboprophylaxis (ETP) is controversial. We performed a systematic review to determine the effect of ETP on deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic cancer surgery. A search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was undertaken, and studies were included if they compared extended duration (2-6weeks) with conventional duration of thromboprophylaxis (2weeks or less) after cancer surgery. Pooled relative risk (RR) was estimated using a random effects model. Seven randomized and prospective studies were included, comprising 4807 adult patients. ETP was associated with a significantly reduced incidence of all VTEs [2.6 vs. 5.6%; RR 0.44, 95% confidence interval (CI) 0.28-0.70, number needed to treat (NNT)=39] and proximal DVT (1.4 vs. 2.8%; RR0.46, 95% CI 0.23-0.91, NNT=71). There was no statistically significant difference in the incidence of symptomatic PE (0.8 vs. 1.3%; RR0.56, 95% CI 0.23-1.40), major bleeding (1.8 vs. 1.0%; RR1.19, 95% CI 0.47-2.97), and all-cause mortality (4.2 vs. 3.6%; RR0.79, 95% CI 0.47-1.33). None of the outcomes differed if randomized trials were analyzed independently. ETP after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTEs and proximal DVTs, but had no impact on symptomatic PE, major bleeding, or 3-month mortality. ETP should be routinely considered in the setting of abdominal and pelvic surgery for cancer patients.

Male urinary and sexual function after robotic pelvic autonomic nerve-preserving surgery for rectal cancer.

Urinary and sexual dysfunction is the potential complication of rectal cancer surgery. The aim of this study was to evaluate the urinary and sexual function in male patients with robotic surgery for rectal cancer. This prospective study included 137 of the 336 male patients who underwent surgery for rectal cancer. Urinary and male sexual function was studied by means of a questionnaire based on the International Prostatic Symptom Score and International Index of Erectile Function. All data were collected before surgery and 12 months after surgery. Patients who underwent robotic surgery had significantly decreased incidence of partial or complete erectile dysfunction and sexual dysfunction than patients with laparoscopic surgery. The pre- and post-operative total IPSS scores in patients with robotic surgery were significantly less than that with laparoscopic surgeries. Robotic surgery shows distinct advantages in protecting the pelvic autonomic nerves and relieving post-operative sexual dysfunction.

Role of Extended Thromboprophylaxis after Abdominal and Pelvic Surgery in Cancer Patients: A Systematic Review and Meta-Analysis

IntroductionAbdominal or pelvic surgery for cancer increases the risk of postoperative venous thromboembolism (VTE) by 2- to 3-fold. The use of low-molecular weight heparin (LMWH) to prevent post-operative thrombotic events is recommended in high VTE-risk patients; however, the role of extended thromboprophylaxis in this setting is controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective observational studies to determine the effect of extended LMWH thromboprophylaxis on all VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic surgery for cancer.MethodsWe searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, conference abstracts, and trial registries with no language restriction. Studies were included if they compared extended duration (i.e., administration of prophylactic doses of LMWH for more than 2 weeks, up to 6 weeks) versus conventional duration of thromboprophylaxis (i.e., administration of LMWH for two weeks or less) after cancer surgery. Two reviewers independently performed study selection, data extraction, and quality assessment. Studies were evaluated according to a priori inclusion criteria and critically appraised using the Newcastle-Ottawa Quality Assessment Scale (NOQA). Pooled relative risk was estimated using a random effects model.ResultsThree RCTs and 4 observational studies were included, comprising 4807 adult patients who underwent open or laparoscopic abdominal or pelvic surgery for gastrointestinal, gynecological or urological cancers. The 3 RCTs employed screening for asymptomatic DVT using bilateral lower limb compression ultrasound or venography after 4 weeks of surgery. Most of studies were of good quality (NOQA higher or equal to 6). The extended thromboprophylaxis regimen was associated with a significantly reduced incidence of all VTE (2.6% [59/2292] vs 5.6% [124/2209]; RR=0.44 [95% CI 0.28-0.70]) and proximal DVT (1.4% [14/966] vs 2.8% [24/862]; RR=0.33 [95% CI 0.15-0.73]). No data were available for symptomatic DVT. There was no statistically significant difference in the incidence of symptomatic PE between the two groups (0.8% [8/966] vs 1.3% [11/862]; RR= 0.56 [95% CI 0.23-1.40]). We found no significant difference in major bleeding at 1.8% (14/787) in the extended thromboprophylaxis group vs 1.0% (7/713) in the short thromboprophylaxis group (RR=1.19 [95% CI 0.47-2.97]). There was no significant difference in all-cause mortality at 3 months (4.2% [30/720] vs 3.6% [23/643], respectively; RR= 0.79 [95% CI 0.47-1.33]). There was minor heterogeneity between the studies in all extracted outcomes.ConclusionExtended thromboprophylaxis with LMWH after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTE and proximal DVT, but had no impact on symptomatic PE, major bleeding or 3-month mortality. [Display omitted] DisclosuresLee:Pfizer: Consultancy, Honoraria; LEO Pharma: Consultancy, Honoraria; BMS: Research Funding; Bayer: Consultancy. Wu:Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Post-operative use of Low Molecular Weight Heparin: Are patients doing their bit?

Introduction: Current National Institute for Health and Care Excellence (NICE) guidelines recommend the use of Low Molecular Weight Heparin (LMWH) for one month post-operatively in abdominal and pelvic cancer surgery to reduce risk of venous thromboembolism. We audited the prescription of LMWH at discharge and the compliance of patients with LMWH post-operatively and instigated measures to improve compliance. Materials and Methods: All patients undergoing major urological surgery from November 2011 to April 2012 were audited, with data collected on evidence of post-operative prescription (from discharge summaries). Patients within this 3-month period were questioned regarding compliance following discharge. Following this, changes were instigated to improve compliance (earlier discussion of post-operative LMWH administration in clinic, improved patient and junior doctor education). All patients undergoing surgery from November 2012 to June 2013 were identified and a re-audit completed. Results: Post-operative prescription of LMWH improved overall from 73% to 88%. Patient compliance to complete LMWH course improved from 23% to 88%. At re-audit, 97% of patients felt that training was adequate, and 94% of patients understood the rationale for taking LMWH at re-audit. Conclusion: Education of junior doctors improved prescription of LMWH at discharge. Improved patient education improves community LMWH use compliance post-discharge.

The feasibility of laparoscopic extended pelvic surgery for rectal cancer.

The present study aimed to assess the safety and feasibility of laparoscopic extended pelvic surgery for primary or recurrent rectal cancer. The data on 77 patients, who underwent extended pelvic surgery between February 2008 and June 2014, were retrospectively analyzed. The patients were divided, based on their treatment history, into an open surgery (OS) group (n=41) and a laparoscopic surgery (LS) group (n=36). The operative time in the LS group was significantly longer than that in the OS group (766 vs. 561min; p<0.001). In contrast, the LS group was associated with a significantly lower volume of intraoperative blood loss (195 vs. 923ml; p<0.001), fluid balance (5.38 vs. 8.23ml/kg/h; p<0.001) and rate of complications (40.0 vs. 68.3%; p=0.035), and a significantly shorter postoperative hospital stay. The postoperative levels of colloid osmotic pressure and albumin were significantly higher in the LS group. The operative time of the LS group was longer than that of the OS group; however, the LS group experienced less blood loss and fewer complications. Moreover, LS was associated with a reduction in intraoperative infusions and a reduced fluid balance, which maintained homeostasis.

Incidence and risk factors of venous thromboembolism after pelvic uro-oncologic surgery--a single center experience.

To determine the incidence and assess risk factors for the development of VTE among patients undergoing major pelvic surgery for prostate and bladder cancer in an Australian tertiary referral center. Consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a five-year period (2009-2013) were identified. Patient variables and types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors. The overall incidence of VTE was 1.8%. Patients undergoing radical cystectomy were more likely to suffer a VTE event compared to patients having radical prostatectomy. In this cohort, the risk factors for VTE include, prolonged operative time of greater than 4hours (h), lymph node dissection (LND) and patients requiring blood transfusions. Patients undergoing major pelvic uro-oncologic surgery have an approximately 1.8% risk of developing VTE. Risk factors identified in this study should be used to guide the use of early and prolonged thromboprophylaxis.

Determinants of survival following pelvic exenteration for primary rectal cancer.

Pelvic exenteration is a potentially curative treatment for locally advanced primary rectal cancer. Previous studies have been limited by small sample sizes and heterogeneous data. A consecutive series of patients was studied to identify the clinicopathological determinants of survival. All patients undergoing pelvic exenterative surgery for primary rectal cancer (1992-2014) at this hospital were analysed. The primary outcome measure was 5-year overall survival. Secondary endpoints included length of hospital stay, complication rate, 30-day mortality and disease recurrence rate. Statistical analysis was performed using Kaplan-Meier and Cox regression analysis. A total of 174 patients with a median age of 65 (range 31-90) years were included. Ninety-six patients underwent posterior pelvic exenteration and 78 had total pelvic exenteration. Median follow-up was 48 (range 1-229) months. Two patients (1.1 per cent) died within 30 days of surgery and 16.1 per cent returned to the operating theatre. The 5-year survival rate following complete resection (R0) was 59.3 per cent. In univariable analysis, adverse survival was associated with advanced age (P = 0.003), metastatic disease (P = 0.001), pathological node status (P = 0.001), circumferential resection margin (P = 0.001), local recurrence (P = 0.015) and the need for neoadjuvant therapy (P = 0.039). Pelvic exenteration is an aggressive treatment option with a high morbidity rate that provides favourable long-term outcomes in patients with locally advanced primary rectal cancer.

Improving adherence rate of extended prophylaxis for venous thromboembolic disease after abdominal and pelvic oncologic surgery: a pilot educational study.

Venous thromboembolic disease (VTE) is higher among patients with cancer. For those undergoing abdominal or pelvic surgery for cancer, it is suggested to extend thromboprophylaxis during 4 weeks with low-molecular-weight heparin over limited-duration of 7 days. There is no published local data from our country about compliance with recommended guidelines of extended prophylaxis (EP) in patients with cancer undergoing surgical procedures. Our aim was to evaluate the adherence rate to extended pharmacological thromboprophylaxis after abdominal-pelvic surgery for cancer, before and after an educational intervention program (EIP) geared toward surgeons. Prospective cross-sectional study before and after an EIP aimed for surgeons. All consecutive patients older than 65 years who underwent surgery for abdominal-pelvic neoplasm, at the Hospital Italiano de Buenos Aires, Argentina, between September 2013 and May 2014, were evaluated for inclusion. A total of 120 patients were included, 60 before and 60 after the EIP aimed for surgeons. None of the initial 60 patients received EP, while 13 (21.6%) of 60 patients received prophylaxis for 28 days (all with colon or rectal cancer) after the intervention. There were no bleeding or death during 90 days of follow-up, and there were 7 of 120 VTE events, none in the group receiving extended thromboprophylaxis. The EIP for the surgical team significantly improved their adherence but only in the colon-rectal surgeries. The adherence to the recommended guidelines is still low. Reasons could be the subjective perception of elevated bleeding risk and the variable grade of recommendation in different guidelines.