Pelvic exenteration: Pre-, intra-, and post-operative considerations

Intraoperative Radiation Therapy (IORT) in Gynecologic Cancers: A Scoping Review

OBJECTIVE

We aimed to analyze the current literature for IORT in gynecological cancers and summarized clinical outcomes regarding patient selection.

METHODS

A systematic search was conducted utilizing PUBMED, Embase, and CINAHL to identify studies following PRISMA-ScR guidelines. A PICOS structure was utilized: population: patients with epithelial gynecological cancers; intervention: IORT; C: a comparator was not required, as we aimed to analyze patient selection; outcome: clinical outcomes and overall survival; and S: experimental and quasi-experimental analytical observational studies and descriptive observational studies, excluding case series published in English and limited to the last 10 years. Data extraction was conducted for patient selection, IORT, oncological outcomes, and morbidity.

RESULTS

A total of 707 results were identified, and 509 studies were uploaded to Covidence for screening after removing duplications. Of the 21 eligible studies, 9 were included in the final review. The total number of patients included was 348. The studies were retrospective single-institution studies, except for one. There was significant heterogeneity in their design and protocols. IORT was exclusively used for recurrent and advanced stage gynecological cancers adjunct to pelvic exenteration or laterally extended endopelvic resections with variable indications across institutions. The mean number of IORT patients per study was 2.8 per year. Survival rates were variable and dependent on the surgical margin. Endometrial cancer had a favorable outcome compared to vulvar and cervical cancers.

CONCLUSIONS

Current clinical practice, as demonstrated by the research, is consistent with NCCN guidelines that endorse the application of IORT in instances of recurrent cervical, vaginal, and vulvar malignancies; however, there are no established recommendations for primary tumors. The analysis shows that there are gaps in our knowledge, mainly regarding the status of the margins, the criteria used to choose patients, and the outcomes that are specific to each histology. The standardization of protocols and prospectively powered studies are needed to refine patient selection criteria.

Gracilis flap and partial colpocleisis of Kahr for pelvic organ prolapse after anterior exenteration: A case report

Anterior exenteration is a radical surgical option for treating locally advanced pelvic malignancies when alternative treatments are deemed ineffective or inappropriate. Due to its nature as an ablative treatment, interference with supportive structures of the pelvic floor can result in pelvic organ prolapse. A 70-year-old woman presented with prolapse after radical cystectomy and following two unsuccessful attempts at Le Fort colpocleisis, the second of which was further complicated by rupture of the vaginal cuff. After exploratory laparotomy to evaluate pelvic adhesions and potential tumor recurrence, the necrotic vaginal apex was excised via the vaginal route, and a musculus gracilis flap was created to cover the levator hiatus in a Z-shaped pattern. The introitus was then narrowed by partial colpocleisis of Kahr. The postoperative course was uneventful and high patient satisfaction and an adequate anatomic result were found at one-year follow-up. There is a scarcity of literature regarding the optimal treatment for pelvic organ prolapse after anterior exenteration, and to our knowledge this is the first published report of the use of a gracilis flap combined with partial colpocleisis of Kahr with a satisfactory outcome in this complicated situation. This case underscores the importance of a multidisciplinary approach in managing prolapse after radical cystectomy, showcasing the successful integration of expertise across gynecology, urology, and reconstructive surgery.

Implementing a physiotherapy-led prehabilitation service and improving inpatient rehabilitation for people with complex colorectal cancer: a service evaluation project

Background/Aims

Prehabilitation improves pre-operative functional status which improves post-operative outcomes. There is limited evidence on the role prehabilitation for people with locally advanced or recurrent colorectal cancer and because of the complex nature of the surgery, patients have particular need for optimisation and specialist rehabilitation. A service evaluation was implemented to evaluate the impact of prehabilitation and increased post-operative rehabilitation in those with locally advanced or recurrent colorectal cancer.

Methods

Exercise-based prehabilitation and an increase in inpatient rehabilitation was implemented for those referred to the complex colorectal cancer clinic (n=59). Hospital length of stay and number of inpatient physiotherapy contacts (therapy sessions) were collected between May 2021 and May 2022 and compared to retrospective data of 44 people who underwent surgery between 2018 and 2019 to help evaluate this project. A range of secondary outcome measures were also collected to assess the impact of prehabilitation, including the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core-30, 30-Second Sit-to-Stand Test, Duke Activity Status Index and a patient questionnaire. Paired sample t-tests were performed to compare the total hospital length of stay for all patients in the retrospective 2018–2019 data group with the prehabilitation data group from 2021–2022.

Results

A total of 59 patients entered the service between May 2021 and May 2022. A significant difference between the length of stay in the two groups was found (P<0.05, t=0.731). Improvements in the Sit-to-Stand Test and Duke Activity Status Index were demonstrated (P<0.001). Data from the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core-30 showed small but not significant reductions in the severity of physical, fatigue, pain and appetite functioning scales. For the more complex patients, average weekly inpatient physiotherapy contacts per person increased from three in 2018–2019 to seven in 2021–2022. Patient compliance and satisfaction was high following implementation of the service development project.

Conclusions

Prehabilitation improves pre-operative functional status and combined with effective inpatient rehabilitation, may reduce hospital length of stay for those undergoing complex colorectal cancer surgery.

Implications for practice

Services that offer surgery for locally advanced or recurrent colorectal cancer should consider implementing a prehabilitation programme to improve pre-operative functional status. For those undergoing more complex surgeries, increased post-operative rehabilitation provision should be considered, as combined with prehabilitation, it may reduce hospital length of stay.

Quality of life following pelvic exenteration in neoplasms

BACKGROUND

Pelvic exenteration (PE) is an extensive surgical treatment reserved for advanced or recurrent pelvic neoplasms, with potential impacts on patients' quality of life (QoL) poorly referenced in the literature.

OBJECTIVES

This study aimed to evaluate QoL outcomes among three types of PE.

METHODS

A cross-sectional study assessed 106 patients divided into anterior PE (APE), posterior PE (PPE), or total PE (TPE) groups. QoL was measured using e short form 36 version 2 (SF-36) and the European Organization for Research and Treatment of Cancer QoL Quality of Life Questionnaire Core 30 (QLQ-C30) QoL questionnaires. Descriptive and inferential analyses compared questionnaire scores.

RESULTS

The findings unveiled a balance among the three groups concerning demographic variables and comorbidities, with the exception of a male predominance in the APE and TPE cohorts. Notably, the APE group exhibited elevated scores in overall health (assessed via SF-36) and social functioning and diarrhea domains (assessed via QLQ-C30). Moreover, in terms of the fatigue and nausea/vomiting domains (assessed via QLQ-C30), the APE group demonstrated superior QoL compared to the PPE group. Conversely, the PPE group manifested a notably lower QoL in the constipation domain (assessed via QLQ-C30) compared to the other two groups. Additionally, disease recurrence was significantly associated with diminished QoL across multiple domains.

CONCLUSION

APE patients exhibited better QoL than PPE and TPE groups, with disease recurrence adversely affecting QoL.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

PelvEx Collaborative. Beating the empty pelvis syndrome: the PelvEx Collaborative core outcome set study protocol

INTRODUCTION

The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. 'PelvEx-Beating the empty pelvis syndrome' aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome.

METHODS AND ANALYSIS

A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting.

ETHICS AND DISSEMINATION

The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome.

TRIAL REGISTRATION NUMBER

NCT05683795.

Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence

Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.

Perineal defect reconstruction after surgery for advanced or locally recurrent rectal cancer involving organ resection: Multiple flaps combined with lining repair

AIM

The aim of this study was to investigate the efficacy of multiple perineal perforator flaps in repairing deep perineal defects after pelvic exenteration for locally advanced or recurrent rectal cancer.

METHOD

We investigated the outcomes of eight patients whose repairs involved a novel method of using an internal pudendal artery perforator (IPAP) flap combined with an inferior gluteal artery perforator (IGAP) flap.

RESULTS

There were four male and four female patients with a mean age of 56 years (36-72 years). Bilateral IPAP flaps combined with bilateral IGAP flaps were used in five patients, unilateral IPAP flaps combined with bilateral IGAP flaps were used in two patients and bilateral IPAP flaps were used in one patient. There were no functional limitations in daily activities during the 6-month follow-up period.

CONCLUSION

Our study showed that using multiple perineal perforator flaps combined with lining repair is feasible for repairing deep perineal defects in patients who have undergone rectal cancer surgery that includes pelvic exenteration.

Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration

Background

Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration.

Methods

A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months.

Results

The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications.

Conclusions

A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.