Posterior Pelvic Exenteration Research Articles

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.

PWE-308 Pelvic exenteration for primary advanced and locally recurrent rectal cancer: outcomes and experience at a single institution

<h3>Introduction</h3> Pelvic exenteration is a potential curative treatment for primary advanced rectal cancer (PARC) and locally recurrent rectal cancer (LRRC). The aim of such extensive radical surgery is to achieve clear resection margins. <h3>Method</h3> A retrospective study was performed of pelvic exenteration procedures carried out between 2004 and 2014 in St Thomas’ Hospital for PARC and LRRC. Factors evaluated included age, sex, neo-adjuvant therapy, type of operation, intraoperative blood loss, resection margins, 30day morbidity and mortality and overall survival. <h3>Results</h3> Pelvic exenteration was performed in 71 patients. 51 patients were treated with neoadjuvant chemoradiation. Of the 71 patients, 52 had total, 6 had anterior and 13 had posterior pelvic exenteration; sacrectomy was performed in 4 patients. Thirty nine (39) patients (27males) with median age 61(29–80) years underwent pelvic exenteration for PARC and thirty two (32) patients (10 males) with median age 62(41–80) years had pelvic exenteration for LRRC. The median blood loss was 3700 ml (range 150015000) for PARC and 3750 ml (range 1500–15000) for LRRC. A complete resection (R0) was achieved in 67.6% of all patients; 74.4% for patients with PARC and 59.4% for patients with LRRC. Major complications (Clavien-Dindo, Grade III-IV) were 35.9% and 34.4% respectively. One patient died within 30 days. Overall survival was 32.5 months for PARC and 21.1 months for LRRC. <h3>Conclusion</h3> Pelvic exenteration is associated with considerable morbidity but low mortality and acceptable overall survival, in the absence of other effective treatment modalities. Careful preoperative assessment and a multidisciplinary approach make this extensive surgical technique safe and feasible in an experienced centre. <h3>Disclosure of interest</h3> None Declared.

Complications après exentération pelvienne postérieure modifiée selon Hudson dans le cadre de tumeurs malignes ovariennes

ObjectiveComplication and survival analysis of cytoreduction surgery with modified posterior pelvic exenteration in the surgical treatment of the ovarian malignant tumor. MethodsA retrospective monocentric study between 2000 and 2013 in Rhone-Alpes cancer treatment center. One hundred and fifty-two patients with ovarian cancer and treated by surgery with modified posterior pelvic exenteration were included. Complication in the 30 days after surgery was analysed by the Clavien-Dindo classification. ResultsIn our study, rate of global complication was 62.5% with a morbidity rate of grave complication of 7.9%. Our rate of complete resection was 82.2%. Three fistulas (2.2%) were found. On average, there was 6.6±1.8 (2–11) surgery gesture associated with Hudson resection during surgery. In univariate analysis, there was a statistic significant association between complication from the rank II of Clavien-Dindo classification and supraradical surgery, post-chemotherapy surgery, recurrent surgery, the resection of a diaphragmatic dome, and the partial gastric resection. This association was also observed with the number of surgical gesture associated with Hudson resection. ConclusionsThe main prognostic surgical factor in ovarian cancer is to obtain a no macroscopic residual disease. The modified posterior pelvic exenteration allowed to obtain it. Our study demonstrates a low rate of grave complication further to this type of surgery.

Chemoradiation therapy with S-1 for primary squamous cell carcinoma of the rectum: report of three cases.

PurposeAlthough successful treatment of squamous cell carcinoma (SCC) of the rectum using chemoradiation therapy (CRT) has been reported, a standard protocol has yet to be established. The aim is to ascertain the effectiveness of CRT with S-1 for three patients with SCC of the rectum.Case presentationWe treated three female patients complaining of rectal bleeding. The patients were diagnosed as having primary SCC of the rectum by means of routine examinations; one of them was a very rare case because of the presence of two lesions in the lower rectum. We treated the patients using CRT with S1 at a radiation dose of 1.8 Gy/fraction given five times weekly (Monday to Friday) to a median dose of 59.4 (45 to 59.4) Gy; S-1 (80 mg/m2/day) was administered orally during radiation therapy. One of three patients had an adverse event involving massive hemorrhage from the tumor. All patients exhibited an excellent response to CRT with S-1; two patients had a complete response, and one patient had a partial response and underwent a posterior pelvic exenteration with advancement flap reconstruction as a salvage treatment. Pathological examination of the resected specimen and lymph nodes revealed no tumor cells indicating a pathological complete response. In this series, the response rate was 100%.ConclusionsWe suggest that CRT with S-1 be chosen as the first-line therapy for SCC of the rectum. However, a large study will be required to establish a safe and effective regimen.

Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: A single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010

BackgroundThe benefits in terms of curative resection and survival of pelvic exenterations for specific extraluminal pelvic recurrences from rectal cancer in the era of total mesorectal excision were assessed. MethodsWe conducted a single-center review of patients with extraluminal pelvic recurrence from colorectal cancer between March 2004 and November 2010. Twenty-seven pelvic exenterations (13 posterior and 14 total) were performed. Independent predicative factors such as age, sex, local control on first surgery, pelvic sidewall excision, initial International Union Against Cancer (UICC) staging, sphincter-preserving resection at first surgery, tumor presentation on computed tomography and magnetic resonance imaging (pelvis sidewall involvement, number of fixation sites, ureteral involvement), local disease-free interval, previous symptoms, and postoperative treatment were analyzed. ResultsNo operative mortality was noted in this series. Overall morbidity rate was 74%; 22% of the patients developed severe complications. Complete surgical clearance (R0) was obtained in 63% of the patients. The rate of R0 resections was lower in total pelvic exenteration (57%) than in posterior pelvic exenteration (69%). Three years overall survival and disease-free survival were 76% and 59%, respectively. Curative resection (R0) was the only independent prognostic factor for overall survival (P = .0016) and disease-free survival (P < .0001). ConclusionPelvic exenterations for extraluminal pelvic recurrences from rectal cancer afford a high R0 resection rate with acceptable morbidity.

Current status and outcomes of pelvic exenteration for recurrent cervical cancer: a systematic review

To evaluate the current status and outcomes of pelvic exenteration (PE) for recurrent cervical cancer. The following electronic databases has been searched on recurrent cervical cancer management and treatment:Chinese Biological Medicine Disk (CBM), PubMed and Cochrane library. All retrieved studies had to fulfill the following inclusion criteria: cohort studies of recurrent cervical cancer, containing information of detailed patient and operation characteristics as well as the survival rate. Only publications in the English literature were included. All eligible literatures between Jan. 1990 and Aug. 2013 were assessed for quality. Relevant basic characteristics, complications, survival rate and prognostic factors were reviewed. There were eight trials involving 607 patients with cervical cancer received PE, including 515 cases with recurrent disease and 92 cases with primary disease. Four hundred and ninety patients had received total pelvic exenteration (TPE) operation, 103 underwent anterior pelvic exenteration (APE) and 14 received posterior pelvic exenteration (PPE). The 5-year overall survival rate for recurrent cervical cancer fluctuate from 26.7% to 56.0%. Complication rates were from 34.3% to 83.3% and the mortality rate was 1.2% (7/607). Among the relevant factors affecting survival time, resection margin status seemed to be the most important. Based on this systematic review, PE does help improve the survival of recurrent cervical cancer patients on the basis of strict selection of candidates.

Surgical results of pelvic exenteration in the treatment of gynecologic cancer.

BackgroundOur aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration.MethodsWe performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications.ResultsTwenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367 minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3 days and total hospital stay of 9.4 days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage.ConclusionsPostoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.

Preoperative Radiation Therapy With Concurrent Capecitabine, Bevacizumab, and Erlotinib for Rectal Cancer: A Phase 1 Trial

The goal of this phase 1 trial was to determine the maximum tolerated dose (MTD) of concurrent capecitabine, bevacizumab, and erlotinib with preoperative radiation therapy for rectal cancer. Patients with clinical stage II to III rectal adenocarcinoma, within 12 cm from the anal verge, were treated in 4 escalating dose levels, using the continual reassessment method. Patients received preoperative radiation therapy with concurrent bevacizumab (5 mg/kg intravenously every 2 weeks), erlotinib, and capecitabine. Capecitabine dose was increased from 650 mg/m(2) to 825 mg/m(2) orally twice daily on the days of radiation therapy; erlotinib dose was increased from 50 mg orally daily in weeks 1 to 3, to 50 mg daily in weeks 1 to 6, to 100 mg daily in weeks 1 to 6. Patients underwent surgery at least 9 weeks after the last dose of bevacizumab. A total of 19 patients were enrolled, and 18 patients were considered evaluable. No patient had grade 4 acute toxicity, and 1 patient had grade 3 acute toxicity (hypertension). The MTD was not reached. All 18 evaluable patients underwent surgery, with low anterior resection in 7 (39%), proctectomy with coloanal anastomosis in 4 patients (22%), posterior pelvic exenteration in 1 (6%), and abdominoperineal resection in 6 (33%). Of the 18 patients, 8 (44%) had pathologic complete response, and 1 had complete response of the primary tumor with positive nodes. Three patients (17%) had grade 3 postoperative complications (ileus, small bowel obstruction, and infection). With a median follow-up of 34 months, 1 patient developed distant metastasis, and no patient had local recurrence or died. The 3-year disease-free survival was 94%. The combination of preoperative radiation therapy with concurrent capecitabine, bevacizumab, and erlotinib was well tolerated. The pathologic complete response rate appears promising and may warrant further investigation.

Perineal Hernia Following Abdominoperineal Amputation and Myocutaneous Flap

Perineal hernia after infralevator posterior pelvic exenteration due to adenocarcinoma of the lower rectum with genital invasion: a rectus abdominis myocutaneous flap was used to repair the defect and reconstruct the vagina. The donor abdominal fascia area was reinforced with bio-absorbable mesh (BioA-Gore). On CT, ileal loops were observed with elongated mesentery in the pelvis and perineum, and ‘‘donor’’ parietal weakness (without sac) (Fig. 1). The myocutaneous flap itself was not able to prevent the development of a perineal hernia after abdominal-perineal resection, nor did absorbable mesh avoid the parietal defect created by removing the anterior fascia of the rectal muscle. c i r e s p . 2 0 1 3 ; 9 1 ( 8 ) : 5 3 4

Surgical treatment and prognosis analysis of cT4bM0 primary rectal cancer

Objective To investigate the surgical treatment strategies and prognostic factors of cT4bM0 primary rectal cancer.Methods The clinical data of 53 patients with cT4bM0 primary rectal cancer who were admitted to the First Hospital of Peking University from January 2000 to December 2010 were retrospectively analyzed.All the patients received en-bloc multivisceral resection and postoperative chemotherapy.The survival and prognostic factors were analyzed.The patients were followed up via out-patient examination,phone call or mail,and the follow-up was ended till December 2012.The survival curve was drawn using the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Uni-and multivariate analysis were done using chisquare test and COX's proportional hazard model.Results Of all the 53 patients,20 received posterior pelvic exenteration (PPE),20 received total pelvic exenteration (TPE),3 received low anterior resection (LAR) +local resection of ballder,2 received LAR + ovariectomy,2 received LAR + local resection of ureter,1 received LAR + local resection of posterior vaginal wall,1 received LAR + vesiculectomy and vesectomy,3 received abdominoperineal resection (APR) + local resection of posterior vaginal wall,1 received APR + sacrectomy.R0 resection was achieved in all the patients.No intraoperative death was observed,and the incidence of postoperative complication was 9.4％ (5/53).The results of postoperative pathological examination showed that 2 patients were with well-differentiated adenocarcinoma,41 with moderate-differentiated adenocarcinoma,and 10 with poorly differentiated adenocarcinoma.Twenty-four patients were with lymph node metastasis.Four patients were in TNM stage Ⅰ,25 in TNM stage Ⅱ and 24 in TNM stage Ⅲ.Fifty-three patients were followed up postoperatively,and the median time for follow-up was 33 months (range,4-116 months).The overall 5-year survival rates was 57.3％.The 5-year survival rate for patients with or without lymph node metastasis were 77.1％ and 30.4％,respectively,with significant difference between the 2 groups (x2 =7.374,P ＜ 0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion mere 51.0％ and 68.5％,with no significant difference (x2=1.148,P ＞0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion in stage Ⅱ were 74.6％ and 85.7％,with no significant difference between the 2 groups (x2=0.118,P ＞ 0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion in stage Ⅲ were 28.8％ and 37.5％,with no significant difference between the 2 groups (x2 =0.959,P ＞ 0.05).The results of univariate analysis showed that lymph node metastasis and TNM stage were the risk factors influencing the prognosis of patients with cT4bM0 primary rectal cancer (x2=6.468,6.596,P ＜ 0.05).The results of multivariate analysis showed that lymph node metastasis was the independent risk factor (RR =3.797,P ＜ 0.05).Conclusions En-bloc multivisceral resection should be the first surgical treatment choice for patients with cT4bM0 primary rectal cancer,and lymph node metastasis is the independent risk factor.Under the same N stage,the prognosis of patients with malignant infiltration or inflammatory adhesion is similar if R0 resection is achieved. Key words: Rectal neoplasms ; Surgical procedures, operative; Prognosis

Clinical outcome of pelvic exenteration in patients with advanced or recurrent uterine cervical cancer

Pelvic exenteration has attained an important role in the treatment of advanced or recurrent cervical cancer for obtaining a complete cure or longer disease-free survival. The purpose of this study was to evaluate patients undergoing pelvic exenteration and to determine the clinical features associated with outcome and survival. We retrospectively analyzed the records of 12 patients who underwent pelvic exenteration for uterine cervical cancer between July 2002 and August 2011. Two patients had primary stage IVA cervical adenocarcinoma and 10 patients had recurrent cervical cancer. Eight patients underwent anterior pelvic exenteration, 3 patients underwent total pelvic exenteration, and 1 patient underwent posterior pelvic exenteration. With a median duration of follow-up of 22 months (range 3-116 months), 5 patients were alive without recurrence. Of 5 patients with no evidence of disease, 4 were recurrent or residual tumor, all of whom had common factors, such as a tumor size ≤ 30 mm, negative surgical margins, complete resection, and no lymph node involvement. The 5-year overall survival rate for 12 patients was 42.2 %. Ileus was the most common complication (42 %) and post-operative intestinal anastomosis leaks developed in 3 patients, but no ureteral anastomosis leaks occurred. Pelvic exenteration is a feasible surgical procedure in advanced and/or recurrent cervical cancer patients with no associated post-operative mortality, and the only therapeutic option for complete cure or long-term survival; however, post-operative complications frequently occur.

Total Laparoscopic Posterior Pelvic Exenteration

Posterior pelvic exenteration (PPE) has been used as modality of treatment for recurrent or primary cancer of rectum that has invaded into the female genital tract. We report a case of PPE performed for locoregionally advanced carcinoma of rectum invading the uterus; which was performed in a totally laparoscopic manner. The handsewn coloanal anastomosis was performed transrectally thus obviating the need for even a minilaparotomy for abdominal access for specimen retrieval or anastomotic stapler application. This is a first reported case in the literature where a total laparoscopic PPE was performed with successful outcome and oncological adequacy and safety.

Phase II trial on neoadjuvant intravenous and trans-uterine arterial chemotherapy for locally advanced bulky cervical adenocarcinoma

ObjectiveA phase II trial on neoadjuvant trans-uterine arterial chemotherapy (TUAC) followed by type III radical hysterectomy (RH) was conducted for patients with bulky cervical adenocarcinoma (AC). MethodsTumors of >4cm were eligible. The neoadjuvant regimen comprised paclitaxel (60mg/m2 intravenously on days 1, 8, and 15) and cisplatin (70mg/m2 TUAC followed by transcatheter embolization with gelatin sponge particles on day 2) repeated every 3weeks for 3cycles. The primary endpoints were clinical and pathological responses. ResultsTwenty-two patients (median age, 51years; range, 33–75years) were enrolled. The International Federation of Gynecology and Obstetrics stages were IB2 (9 patients), IIA–IIB (8), IIIB (3), and IVA (2). The adeno/adenosquamous ratio was 16/6. The overall clinical response rate was 95.4% (95% confidence interval [CI], 86.7–100%). RH was completed in 19 patients (86%), including 2 stage IVA patients who underwent anterior or posterior pelvic exenteration. Of the 19 patients, no residual malignant cells were found pathologically in 4; thus, the pathological complete response rate was 18% (4/22). No patients experienced grade 4 thrombocytopenia or febrile neutropenia or required platelet transfusions. The 5-year progression-free survival and overall survival rates in stages IB2–IIB were 70.0% (95%CI, 48.1–92.1%) and 69.5% (95%CI, 47.0–92.0%), respectively. The 2 patients with stage IVA tumors were alive without recurrence for 72 and 84months after enrollment. ConclusionsTUAC showed high clinical and pathological response rates. TUAC is promising for stage IB2–IIB and IVA bulky AC.

Comparison of Morbidity and Survival Between Primary and Interval Cytoreductive Surgery in Patients After Modified Posterior Pelvic Exenteration for Advanced Ovarian Cancer

Surgical management of advanced ovarian cancer often requires low modified posterior pelvic exenteration (MPE) to achieved complete resection. The aim of this study was to evaluate the morbidity of MPE at the time of primary cytoreductive surgery (PCS) and interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy. From 2001 to 2009, 63 patients underwent MPE for advanced ovarian cancer. We analyzed and compared surgical characteristics and postoperative courses between PCS and ICS. Modified posterior pelvic exenteration was performed during PCS for 50 patients (79%) and during ICS for 13 patients (21%). Complete cytoreduction was achieved in 80% of patients (84% in the PCS group and 69% in the ICS group; ns). There was no significant difference between the PCS and ICS groups in the type and the rate of standards or radical surgical procedures. Patients with ICS had a shorter length of stay in the intensive care unit (0.9 vs 2.7 days; P = 0.009), but there was no difference in the total length of hospitalization (P = 0.94). The global rate of postoperative complications was 76%. No differences were found between the 2 groups in digestive or extradigestive complications, iterative surgery, or interventional radiology procedures. The median overall survival was 49.4 months in the PCS group and 27.1 months in the ICS group (P = 0.27), and the median progression-free survival time in both groups was 20 months. There was no difference in the occurrence of postoperative complications between PCS and ICS, especially in morbidity related to MPE. The specific morbidity of this surgical procedure remained low compared with the overall morbidity in cases of extensive surgery.

Pelvic exenteration for colorectal cancer: oncologic outcome in 59 patients at a single institution

BackgroundPelvic exenteration (PE) continues to be the only curative option in selected patients with advanced or recurrent pelvic neoplasms. A current debate exists concerning the appropriate selection of patients for PE, with the most important factor being the absence of extrapelvic disease.AimTo evaluate the outcome of patients submitted to exenterative surgery.Patients and methodsA review of the clinical charts of patients with colorectal cancer who underwent PE between January 1994 and June 2010 at the Institute National of Cancerología in Mexico City was performed.ResultsWe selected 59 patients, 53 of whom were females (90%), and six of whom were males (10%). Mean age at the time of diagnosis was 50 years (range, 21–77 years). A total of 51 patients underwent posterior PE (86%), and eight patients underwent total PE (14%). Operative mortality occurred in two cases (3%), and 29 patients developed complications (49%). Overall, 11 patients (19%) experienced local failure with mean disease-free survival time of 10.2 months. After a mean follow-up of 28.3 months, nine patients are still alive without evidence of the disease (15%).ConclusionsPE should be considered in advanced colorectal cancer without extrapelvic metastatic disease. PE is accompanied by considerable morbidity (49%) and mortality (3%), but local control is desirable. Overall survival justifies the use of this procedure in patients with primary or recurrent locally advanced rectal cancer.

Tailoring the Treatment of Locally Advanced Squamous Cell Carcinoma of the Vulva: Neoadjuvant Chemotherapy Followed by Radical Surgery

To determine the feasibility of performing neoadjuvant chemotherapy (NCH) followed by radical surgery in patients with locally advanced squamous cell carcinoma of the vulva. Prospective and multicenter trial. Thirty-five patients with a diagnosis of previously untreated locally advanced squamous cell carcinoma of the vulva were given 4 schemes of cisplatin-based NCH and 1 NCH regimen with single bleomycin. Then, they underwent radical surgery of the vulva if clinical response was 50% or more. Age, NCH schemes used, toxicity, response to treatment, type of radical surgery performed, and clinical outcome were evaluated. Thirty-three patients completed the proposed schemes, and 30 were assessed for radical surgery. Finally, 27 patients underwent radical surgery (radical vulvectomy or radical local excision plus bilateral inguinofemoral lymphadenectomy). In 2 cases of persistent rectal involvement, posterior pelvic exenteration was performed. Moreover, 24 of 27 patients remain with no evidence of disease to date. Toxicity was acceptable. Median age was 62 years (range, 54-72 years). Median follow-up was 49 months (range, 4-155 months). The use of NCH in selected groups may increase surgical feasibility in initially inoperable patients, thus favoring organ preservation and less extensive resections. Adverse reactions were acceptable, and vulvoperineal deleterious effects that may occur after radiotherapy were consequently avoided.

A Modified Posterior Pelvic Exenteration Technique in a Woman: (A Simplified Method With Using Transvaginal Way)

We represent a simplified surgical method for posterior pelvic exenteration in a woman by using the transvaginal way in addition to classic abdominal approach. A modified posterior pelvic exenteration technique was performed in a patient with bulky pelvic tumor. The transvaginal way was used for the deep perineal dissection when the abdominal dissection was arrested. An ultralow coloanal anastomosis was completed by using the transvaginal way. After the recovery period, the patient was discharged from hospital without any complication. The transvaginal access should be reminded in the circumstances of the abdominal dissection arrested in posterior pelvic exenteration operations in women.

Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: An analysis of surgical outcomes

ObjectiveTo examine the early and late flap related morbidity and associated risk factors in patients with modified vertical rectus abdominis myocutaneous (VRAM) flap neovaginal reconstruction at the time of pelvic exenteration for gynecologic malignancy. MethodsFrom January 1993 to January 2011, all patients were identified who underwent anterior, posterior, or total pelvic exenteration with VRAM flap neovaginal reconstruction. Patient records were systematically reviewed and demographic, clinicopathologic, operative details, flap related complications, and risk factors for wound healing were recorded and statistical analysis performed. Results46 patients were identified who underwent exenteration with VRAM flap vaginal reconstruction. A risk factor for poor healing including obesity, diabetes, smoking, prior radiation, previous abdominal surgery, or poor nutritional status was present in 38 (82.6%) patients, and 24 (52.2%) had two or more risk factors. Flap complications occurred in 9 (19.6%) patients, one with complete flap necrosis that required re-operation, two with superficial flap necrosis, and three with superficial flap separation. Three patients (6.5%) suffered from vaginal stenosis, one of which was complete. Anterior abdominal wound separation occurred in 22 (47.8%) patients and pelvic abscess occurred in 14 (30.4%) patients. No individual risk factor was significantly associated with VRAM flap related morbidity; however obesity, prior radiation, and prior abdominal incision were present in nearly all the patients with flap complications. ConclusionsThis series confirms that modified VRAM flaps can be used successfully at the time of exenteration, even in an increasingly high risk patient population with an acceptable risk for flap complications.

Single Port Access (SPA) Robot Assisted Laparoscopic Surgery for Posterior Pelvic Exenteration in Patients with Advanced Ovarian Cancer: Farghaly's Technique

Single Port Access (SPA) Robot Assisted Laparoscopic Surgery for Posterior Pelvic Exenteration in Patients with Advanced Ovarian Cancer: Farghaly's Technique

Surgical outcomes for 187 patients with locally recurrent rectal cancer and analysis of prognostic factors

To evaluate the surgical outcomes for patients with locally recurrent rectal cancer (LRRC) and to analyze the prognostic factors. Clinical data of 187 patients with LRRC undergoing surgery at the First Hospital of peking University from January 1985 to December 2009 were retrospectively reviewed. Procedures performed included local resection(n=34), abdominoperineal resection (n=35), posterior pelvic exenteration (n=17), total pelvic exenteration(TPE, n=98), TPE with sacrectomy (n=2), and TPE with internal hemipelvectomy (n=1). The operation was R0 in 87 patients, R1 in 60, and R2 in 40. The degree of radical resection was associated with the initial surgery and the degree of pelvic fixation (P<0.05). The pelvic recurrence rate was 44.4%(64/144). The operative morbidity and mortality were 47.5%(89/187) and 2.7%(5/187), respectively. The overall 3- and 5-year survival rates were 42.2% and 30.7%, respectively. The degree of radical resection and lymph node metastasis were independent risk factors associated with prognosis. The 5-year survival rates of R0, R1 and R2 were 42.6%, 17.2% and 0, respectively(P<0.01). The 5-year survival rates of patients with and without lymph node metastasis were 5.6% and 40.5%(P<0.01) respectively. Accurate evaluation of extent of pelvic fixation and achievement of R0 resection are critical to improve the surgical outcomes for LRRC.