Pelvic Exenteration

To describe the technique, feasibility and early complications of "Rome pouch" urinary diversion. Thirty-five consecutive patients affected by advanced or recurrent gynecological cancers who required anterior or total pelvectomy entered the study. Rome pouch technique starts with the transection of terminal ileum about 12 cm from the ileocecal valve; the large colon is transected 15-20 cm distal to the hepatic flexure. The intestinal wall tension and internal pressure are reduced using 5-8 transverse teniamyotomies of the cecum. The efferent segment of the pouch is created either with the appendix or with the distal ileum. Operative data, intra- and early postoperative complications were recorded. Between February 2000 and March 2006, an ileocolonic urinary diversion (Rome pouch) was carried out in 35 patients affected by advanced or recurrent gynecologic malignancies. The average operative time to complete the anterior and total exenteration including reconstruction procedure was 285 (range, 230-350) and 320 (range 280-415) min, respectively. The average time in performing the Rome pouch technique was 60 min (range, 45-90). Overall postoperative complication rate (major and minor complications) was 82% (29 patients). Febrile morbidity occurred in 26 patients (74%). Wound complications and pelvic collection were found in 7 (20%) and 6 (17%) patients, respectively. Our experience demonstrated that Rome pouch technique represents a valid alternative in gynecology oncology for continent urinary diversion. This technique showed low rate of medical and early urologic complications. The simplicity of performing the procedure and the reduced operating time are the best goals reached by Rome pouch technique. Future comparative trials will better define the role that the Rome pouch will have in these patients.

Background and Objectives:Soft tissue sarcomas (STS) of the true pelvis are rare tumors and there is little information in the literature related to pelvic STS. The purposes of this review were to understand the anatomic extension of these tumors to better plan surgical treatment and to determine the outcome of these patients.Soft tissue sarcomas (STS) of the true pelvis are rare tumors and there is little information in the literature related to pelvic STS. The purposes of this review were to understand the anatomic extension of these tumors to better plan surgical treatment and to determine the outcome of these patients.Methods:Eighteen consecutive patients presenting between 1987 and 1995 with soft tissue sarcomas involving the true pelvis were retrospectively reviewed at minimum follow-up of 18 months. Cross-sectional imaging was reviewed for each patient to determine the anatomical location of the lesions.Eighteen consecutive patients presenting between 1987 and 1995 with soft tissue sarcomas involving the true pelvis were retrospectively reviewed at minimum follow-up of 18 months. Cross-sectional imaging was reviewed for each patient to determine the anatomical location of the lesions.Results:The tumors were confined to the true pelvis in 4 patients, extended to the retroperitoneum in three cases, and extended to the thigh in 11 patients. Adjuvant radiation was administered to all but 2 patients who had received radiation to the region in the past and all patients underwent surgical resection (local resection in 13 patients and hindquarter amputation in 5 patients). Surgical resection had a high rate of morbidity and complications including positive resection margins in nine individuals. Of the 18 patients, 11 died at a mean time of 15.5 (2–58) months from surgery, 4 were alive with evidence of disease at a mean time of 44.3 (18–68) months, and 3 were alive with no evidence of disease at a mean time of 57 (43–71) months.The tumors were confined to the true pelvis in 4 patients, extended to the retroperitoneum in three cases, and extended to the thigh in 11 patients. Adjuvant radiation was administered to all but 2 patients who had received radiation to the region in the past and all patients underwent surgical resection (local resection in 13 patients and hindquarter amputation in 5 patients). Surgical resection had a high rate of morbidity and complications including positive resection margins in nine individuals. Of the 18 patients, 11 died at a mean time of 15.5 (2–58) months from surgery, 4 were alive with evidence of disease at a mean time of 44.3 (18–68) months, and 3 were alive with no evidence of disease at a mean time of 57 (43–71) months.Conclusions:Soft tissue sarcoma of the pelvis is fortunately a rare disease with a high risk of local and systemic disease progression despite treatment with irradiation and surgical resection. J. Surg. Oncol. 2001; 77:8–14. © 2001 Wiley-Liss, Inc.Soft tissue sarcoma of the pelvis is fortunately a rare disease with a high risk of local and systemic disease progression despite treatment with irradiation and surgical resection. J. Surg. Oncol. 2001; 77:8–14. © 2001 Wiley-Liss, Inc.

During the initial 6 yr (1972-1978) of the Intergroup Rhabdomyosarcoma Study (IRS), 27 patients with rhabdomyosarcoma of the female urogenital tract were treated, and the results of therapy were evaluated on the basis of 3-7 yr of observation. By primary site these tumors were: bladder, 14; vagina, 9; vulva, 2; and cervix uterus, 2. Twenty-three presented with localized tumors; the four remaining patients (1 bladder, 1 vagina, and 2 cervix) had distant metastases at diagnosis. Two patients with bladder tumors underwent pelvic exenteration, local irradiation, and chemotherapy (2 yr), and were without relapse. Ten patients were treated by partial cystectomy and postoperative chemotherapy (with or without local irradiation) and fatal recurrence occurred in three. The remaining seven patients are disease-free for 36-74 mo (mean, 51.8 mo). Six of the eight patients with nondisseminated vaginal tumors were treated by initial pelvic exenteration (2), hysterectomy-vaginectomy (2), or hemivaginectomy (2). All received postoperative chemotherapy and three received local irradiation. Delayed hysterectomy-vaginectomy after primary chemotherapy was performed in the two additional patients with vaginal tumors. Relapse has occurred in one of these eight patients with localized vaginal disease. The remaining seven have been observed for 3-5.5 yr (mean, less than 4 yr). Two patients with vulval lesions treated by a combined therapy regimen are without recurrence. Our conclusion is that chemotherapy has significantly increased survival in females with urogenital tract rhabdomyosarcomas.

A 70-year-old female was admitted to our hospital with a complaint of gross hematuria for two months. She had a 5 years history of eczematous vulvar skin eruption. With the diagnosis of T3N0M0 bladder cancer and anogenital Paget's disease, she underwent pelvic exenteration, vulvectomy and reconstruction of the vulva. Histopathological examinations and mucin stains revealed anogenital Paget's disease and invasive bladder cancer which extended to the clitoral skin and formed Pagetoid skin lesion. CEA and cyokeratin staining demonstrated identical expression pattern in bladder cancer cells and Paget's cells, which suggested both neoplastic cells originated from one progenitor cell.

Pelvic exenteration is an option in the treatment of persistent or recurrent cervical carcinomas confined to the central pelvis. The improvement of laparoscopic techniques and equipment in combination with broader experience of surgeons in laparoscopy made laparoscopic pelvic exenteration possible. This article reviews present experience with pelvic exenteration and analyses the advantages and disadvantages of the method compared to classical method (Tab. 2, Ref. 10).

Laparoscopy classically reduces morbidity and invasiveness. To decrease the operative morbidity associated with exenteration, we considered the possibility of performing a total pelvic exenteration by the laparoscopic approach. A 34-year-old woman presented with a cervical cancer relapse. The bladder, uterus, vagina, ovaries, and rectum were mobilized en bloc from the pelvic sidewall. We used vascular endoscopic staplers for the control of sigmoid vessels and anterior branches of internal iliac vessels. The specimen was removed through the vulva. A colo-anal anastomosis and an ileal-loop conduit for urinary tract diversion were made. The operative time was 9 h. The postoperative course was uneventful. Specimen margins were free of disease. With laparoscopic surgical knowledge and new endoscopic staplers, laparoscopic pelvic exenteration procedure is feasible.

Ureteroarterial fistulas are rare, with less than 20 well documented cases reported. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who underwent a previous operation for bladder cancer. The diagnostic and therapeutic approaches in these rare but high risk patients are discussed.

Reconstructive procedures are being performed with increasing frequency in conjunction with pelvic exenterations and other radical gynecologic surgeries. The most common reconstructive procedures include continent urinary diversion, rectosigmoid ...

Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. IV, therapeutic.

Purpose To evaluate the results of palliative pelvic exenteration in patients with gynecologic tumors. Methods A retrospective analysis was carried out in 13 patients from January 2000 to December 2007. The procedure was considered palliative because of distant metastatic disease or unresectable pelvic wall disease. Patients presented with bleeding, fistula, malodorous discharge or untreatable pain. Result Overall complication rate was 38.4%. Mean follow-up time was 8 months. Actuarial 2 years overall survival was 15.4%. Six patients survived more than 5 months and three more than 12 months. All achieved symptoms control and favorable impact in quality of life. Two patients are with stable disease after 26 and 28 months. Conclusions Palliative exenteration is a procedure with high morbidity and mortality rates and should only be offered to highly selected patients. The role of exenterative surgery in relieving severe symptoms in patients with incurable disease is yet to be established.