Time Of Exenteration Research Articles

Pelvic exenteration for recurrent or persistent gynecologic malignancies: Clinical and histopathologic factors predicting recurrence and survival in a modern cohort

ObjectivesTo explore pre-operative factors and their impact on overall survival (OS) in a modern cohort of patients who underwent pelvic exenteration (PE) for gynecologic malignancies. MethodsA retrospective review was performed for all patients who underwent a PE from 1/1/2010 through 12/31/2018 at our institution. Inclusion criteria were exenteration due to recurrent or progressive carcinoma of the uterus, cervix, vagina or vulva, with histologically confirmed complete surgical resection of the malignancy. Exclusion criteria included PE for palliation of symptoms without recurrence, and for ovarian or rare histologic malignancies. Univariable and multivariable analysis were performed to identify factors predicting prolonged survival. ResultsOverall, 71 patients met the inclusion criteria. Median age at time of exenteration was 62 years (range, 28–86 years). Vulvar cancer was the most common primary diagnosis (32%); 30% had cervical cancer; 23%, uterine cancer; 15%, vaginal cancer. Median OS was 55.1 months (95% confidence interval (CI): 36-not estimable) with a median follow-up time of 40.8 months (95% CI: 1–116.1). On univariable analysis, age > 62 years (hazard ratio (HR) 2.71, 95% CI 1.27–5.79), American Society of Anesthesia (ASA) 3–4 (HR: 3.41 (95% CI 1.03–11.29), and vulvar cancer (HR 4.19 (95% CI 1.17–14.96) predicted worse OS. Tumor size and prior progression-free interval (PFI) did not meet statistical significance in OS analyses. On multivariable analysis, there were no significant factors associated with worse OS. ConclusionsPE performed with curative intent may be considered a treatment option in well-counseled, carefully selected patients, irrespective of tumor size and PFI before exenteration.

Salvage robotic anterior pelvic exenteration for cervical cancer: technique and feasibility

The aim of our study was to explain the technique and evaluate the feasibility and safety of robotic anterior pelvic exenteration in cases of residual/recurrent cervical cancer as a salvage therapy. The study was conducted as a retrospective review of all the cases of central residual/recurrent cervical cancer who underwent anterior pelvic exenteration by robotic approach with curative intent at our centre between January 2013 and December 2019. Information regarding various treatment related parameters like duration of surgery, estimated blood loss, length of hospital stay, early and late complications and recurrence and survival was collected and evaluated. 14 patients underwent anterior pelvic exenteration by robotic approach in this period. The median age of patients at time of exenteration was 52.5years. 13 out of 14 patients had received combined chemoradiation as a part of intial treatment. The median duration of surgery was 305min with a median estimated blood loss of 135ml and median length of hospital stay of 6.5days. Early complications like urosepsis, uretero-ileal anastomotic leak and paralytic ileus occurred in 36% patients and late complications like ureteric stricture and bowel perforation occurred in 28.6% patients. Negative surgical margins could be achieved in all the patients. Over a median follow-up period of 17.5months, five patients developed recurrence and five patients experienced mortality, with four out of five patients dying due to recurrent disease. The 12-month DFS was 68.2% and the 12-month OS was 77.1%. Robotic anterior pelvic exenteration is a safe and feasible option in selected patients with recurrent/residual cervical cancer as a salvage procedure, with acceptable morbidity and mortality.

Overall survival after pelvic exenteration for gynecologic malignancy

BackgroundFive-Year survival after pelvic exenteration for gynecologic malignancies has been reported as high as 60%. The objective of this study was to determine overall survival (OS) after pelvic exenteration and evaluate factors impacting outcome. MethodsA retrospective review of all women who underwent pelvic exenteration at our institution between February 1993 and December 2010 was performed. OS was defined as time from exenteration to date of death or last contact. Survival analysis was performed using the Kaplan Meyer method. Multivariate analysis was performed to determine the impact of clinical and pathologic factors on survival outcomes. ResultsOne hundred sixty patients with gynecologic malignancy underwent pelvic exenteration. Five-year recurrence free survival (RFS) was 33% (95%CI 0.25–0.40). Factors which negatively impacted RFS included shorter treatment-free interval (p=.050), vulvar primary (p=.032), positive margins (p<.001), lymphovascular space invasion (LVSI, p<.001), positive lymph nodes (p<.001) and perineural invasion (p=0.030). In multivariate analysis, positive margins (p=.040), positive nodes (p<.001) and lymphovascular space invasion (LVSI, p=.003) retained a significant impact on RFS.Five-year OS was 40% (95% CI 0.32–0.48). Factors which negatively impacted OS included vulvar primary (p=.04), positive margins (p<.001), LVSI (p<.001), positive lymph nodes (p<.001) and perineural invasion (p=.008). In multivariate analysis, positive nodes (p=.001) and LVSI (p=.001) retained a significant impact on OS. ConclusionFive-year OS after pelvic exenteration was 40%. Survival outcomes have not significantly improved despite improvements in technique and patient selection. Multiple non-modifiable factors at the time of exenteration are associated with poor survival.

Évaluation des techniques de reconstruction après exentération orbitaire. À propos de 56 cas

To describe the management of orbital exenterations and the surgical techniques for the reconstruction of orbital exenteration cavities. This retrospective study includes 56 patients who underwent orbital exenteration between 2000 and 2009. Patients' age at the time of exenteration, diagnoses, complications and reconstructive techniques were studied. Fifty-six patients - 31 male and 25 female patients - who underwent orbital exenteration between 2000 to 2009 were included in the study. The mean age was 62.5 years at the time of exenteration. Average follow-up was 23 months. The principal diagnoses were basal cell carcinoma of the eyelids (25%) and conjunctival melanoma (20%). For orbital reconstruction, 18 patients (32%) had a muscle flap, and 24 patients (43%) underwent secondary reconstruction by bone-anchored implants after spontaneous epithelialisation of the orbit. Approximately 50% of the patients received postoperative radiation therapy. Surgical reconstruction using muscle flaps may mask recurrent tumor. Epithelialisation and bone-anchored implants supporting the prosthesis allow for recurrent cancer surveillance while providing better stabilization of the prosthesis. Radiation therapy seems to render the orbit more fragile and thus less stable for implants. Orbital exenteration is a mutilating technique. Rehabilitation techniques have been improved, in particular the bone-anchored implants which allow adaptation of the prosthesis with satisfactory cosmetic results.

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.

Pelvic exenteration with curative intent for recurrent uterine malignancies

ObjectiveTo evaluate the outcomes observed with pelvic exenteration with curative intent for recurrent uterine malignancies in the modern era. MethodsWe reviewed the records of all patients who underwent this procedure at our institution between 1/1997 and 03/2011. Postoperative complications up to 90days after surgery were analyzed and graded as per our institution grading system. Survivals were estimated using the Kaplan–Meier method. ResultsDuring the study period, 21 patients were identified. Median age at the time of exenteration was 57years (range, 36–75). Median tumor size was 6cm (range, microscopic — 14.5). Tumor histology was: endometrioid, 10 cases; mixed, serous, and carcinosarcoma, 7 cases; and sarcomas, 4 cases. The type of exenteration was: total, 14 cases; anterior, 6 cases and posterior, 1 case. There were no intra- or postoperative mortalities. Seven patients (33%) developed at least one grade 2 complication, and 10 patients (48%) developed at least one grade 3 complication. Five (24%) patients had to be re-operated on in the first 90days post surgery. The median follow up time after exenteration was 39months (range, 5–112). The 5-year survival of the entire cohort was 40% (95% CI: 18–63). An improved survival was observed in patients with endometrioid tumors and sarcomas (5-year survival rates of 50% and 66%, respectively). The presence of pelvic sidewall involvement and/or hydronephrosis did not negatively affect survival. ConclusionPelvic exenteration for recurrent uterine malignancies can be associated with long-term survival in properly selected patients. A high rate of postoperative complications remains a hallmark of this procedure and should be discussed carefully with patients facing this decision.

Supratrochlear Artery Island Paramedian Forehead Flap for Reconstructing the Exenterated Patient

Orbital exenteration may be needed for surgical extirpation of advanced squamous or basal carcinoma of the eye or ocular adnexa. Many surgeons prefer to allow the exenterated socket granulate by secondary intention. This leads to morbidity and can be very disturbing for the patient. Moreover, it delays the delivery of adjunctive radiation often required in these individuals. We suggest a 1-stage operation that can be undertaken at the time of exenteration or as a delayed procedure to reconstruct the orbit and ensure rapid wound healing and patient rehabilitation. There is minimal donor site morbidity. A total of 5 exenterated orbits have been reconstructed by a new technique utilizing islanded median forehead flap based upon ipsilateral supratrochlear vessels. The donor site could be closed primarily in all patients. The healing was uneventful; the median hospital stay was 3 days. Although there is inevitable scarring of the forehead, this improves considerably over a period of time and does not appear to cause undue aesthetic concerns among our patients. Thus an islandised ipsilateral paramedian forehead flap based upon supratrochlear vessels is another option to close an exenteration defect.

Pelvic exenteration in gynecologic oncology: A single institution study over 20 years

Objective The profile of women with gynecologic malignancies treated with pelvic exenteration has changed since the initial description of this procedure. We sought to evaluate our experience with pelvic exenteration over the last 20 years. Methods Patients who underwent anterior, posterior, or total pelvic exenteration for vulvar, vaginal, and cervical cancer at Barnes-Jewish Hospital between January 1, 1990 and August 1, 2009 were identified through hospital databases. Patient characteristics, the indications for the procedure, procedural modifications, and patient outcomes were retrospectively assessed. Categorical variables were analyzed with chi-square method, and survival data was analyzed using the Kaplan–Meier method and log rank test. Results Fifty-four patients were identified who had pelvic exenteration for cervical, vaginal, or vulvar cancer. Recurrent cervical cancer was the most common procedural indication. One year overall survival from pelvic exenteration for the entire cohort was 64%, with 44% of patients still living at 2 years and 34% at 50 months. Younger age was associated with improved overall survival after exenteration ( p = 0.01). Negative margin status was associated with a longer disease-free survival ( p = 0.014). Nodal status at the time of exenteration was not associated with time to recurrence or progression, site of recurrence, type of post-operative treatment, early or late complications, or survival. Conclusions Despite advances in imaging and increased radical techniques, outcomes and complications after total pelvic exenteration in this cohort are similar to those described historically. Pelvic exenteration results in sustained survival in select patients, especially those that are young with recurrent disease and pathologically negative margins.

Orbital exenterations: an 18-year experience from a single head and neck unit

To review the outcomes of the patients who undergo orbital exenteration for malignancy. A retrospective review of patients who underwent orbital exenteration performed at Royal Prince Alfred and Concord Hospitals between 1990 and 2008. A total of 38 patients were identified. The most common malignancies were squamous cell carcinoma (14 cutaneous and five mucosal origin), basal cell carcinoma (12 cutaneous) and melanoma (five patients). Orbital invasion was the main indication for orbital exenteration. Additional procedures were performed in 29 (76%) patients at the time of exenteration, including craniotomies in eight patients and maxillectomy in 15 patients. Flap reconstructions were required in 35 (92%) patients, including 33 free flap repairs and two local flap repairs. Post-operative complications included cerebrospinal fluid leak (16%) and wound-related complications (13%). The disease-specific survival rate was 97% at 1 year and 92% at 5 years. The local control rate was 83% at 1 year and 55% at 5 years. Fifty per cent of patient mortality and 63% of local recurrence occurred within the first post-operative year. In this series, locoregional control and survival were high, suggesting that aggressive surgical measures such as orbital exenteration are not unreasonable in well-selected patients. Free flap reconstruction is a reliable reconstructive technique which may reduce major complications. The first post-operative year is the most important period when monitoring for recurrence.

Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques.

Vaginal reconstruction following pelvic exenteration is an important aspect of the physical and psychological rehabilitation of women after radical surgery for pelvic malignancies. The choice of techniques is vast, and proper patient and surgical selection is important for obtaining satisfactory functional and aesthetic results. The objective of this retrospective study is to review different techniques for vaginal reconstruction and report the complications and patient satisfaction associated with the different procedures. Between January 1988 and April 2001, 104 pelvic exenterations were performed by the division of gynecologic oncology at the University of Miami, School of Medicine. Twenty-five (24%) patients underwent vulvo-vaginal reconstruction at the time of the exenteration. A retrospective chart review of the 25 patients was performed, and 9 patients were available and contacted for an interview. Twenty-four (96%) patients had received prior definitive radiation therapy. Overall, there were 9 complications (6 major and 3 minor) attributed to vaginal reconstruction, accounting for 36% perioperative morbidity. Seven of the nine (78%) patients interviewed reported successful vaginal intercourse at some point after their operation. All 5 surviving patients in the myocutaneous flap group were very satisfied with their sexual function and were sexually active at the time of their interview. Vaginal reconstruction at the time of pelvic exenteration is an important topic that should be discussed with the patient during the preoperative visit. Although the myocutaneous flaps are associated with longer operative times, they appear to be the preferred type due to decreased postoperative fistulae and better patient satisfaction.

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

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

Complications of the Ileocolonic Continent Urinary Reservoir (Miami Pouch)

Urinary diversion via the continent ileocolonic reservoir has been performed at our institution since February 1988. During a 4-year period, 39 patients have received this procedure as an alternative to other forms of cutaneous urinary diversion at the time of exenteration. We analyze our data in terms of early and late (beyond 6 weeks) complications resulting directly from the operation or from this form of urinary diversion. A total of 18 patients (46%) suffered early complications resulting in an operative mortality rate of 7% (3 of 39 patients). One or more late complications occurred in six patients (15%). Only one patient required reoperation for a postoperative complication. With ongoing experience, problem areas have been identified that have led us to make modifications in technique. We review our experience with the incidence of early and late complications in terms of management and ultimate prevention.

Formation of a vagina at the time of exenteration

The formation of an artificial vagina at the time of exenteration has been described. Femoral gluteal flaps forming a tube suspended to the iliopectineal ligament appeared to give the most Satisfactory results.

Use of Autogenous Split-Thickness Dermal Graft for Reconstruction of the Lining of the Exenterated Orbit

A surgical technique using an exposed dermal graft to line the exenterated orbit has been successful in nine patients. Eight of the nine patients had undergone total maxillectomy at the time of exenteration. A split-thickness (epidermal) skin graft is harvested with a dermatome and hinged at one end. A second split-thickness dermal graft is harvested from the dermal bed of the first graft. The hinged epidermal graft is sutured into its donor site, and the deeper free dermal graft is used to line the orbital cavity. The latter graft tends to be more viable than a split-thickness epidermal graft. Also, because the dermal graft can self-epithelialize or be epithelialized by adjacent tissues, it may be placed adjacent to skin or a mucous membrane.

Exenteration of the orbit.

EXENTERATION of the orbit is a surgical procedure that has been carried out for many centuries. Since the original description of the operation by Bartisch,¹a relatively small number of cases have been reported, and it was therefore thought worth while to review the cases of exenteration of the orbit performed at the Wilmer Ophthalmological Institute during the past 25 years. <h3>REPORT OF CASES</h3> During the 25-year period from 1927 to 1953, there have been 48 orbital exenterations performed at the Wilmer Ophthalmological Institute. Thirty-three patients were from the public wards and 15 were private.* Table 1 shows the race and sex of this group of patients. Thirty were males and 18 females. Four were Negroes, and 44 were white. The ages of the patients at the time of exenteration are shown in Table 2. The youngest patient was 9 months old, and the oldest was 75. The pathologic