Robotic Pelvic Exenteration for Gynecologic Malignancies, Anatomic Landmarks, and Surgical Steps: A Systematic Review

Abstract

Pelvic exenteration represents the last resort procedure for patients with advanced primary or recurrent gynecological malignancy. Pelvic exenteration can be divided into different subgroup based on anatomical extension of the procedures. The growing application of the minimally invasive surgical approach unlocked new perspectives for gynecologic oncology surgery. Minimally invasive surgery may offer significant advantages in terms of perioperative outcomes. Since 2009, several Robotic Assisted Laparoscopic Pelvic Exenteration experiences have been described in literature. The advent of robotic surgery resulted in a new spur to the worldwide spread of minimally invasive pelvic exenteration. We present a review of the literature on robotic-assisted pelvic exenteration. The search was conducted using electronic databases from inception of each database through June 2021. 13 articles including 53 patients were included in this review. Anterior exenteration was pursued in 42 patients (79.2%), 2 patients underwent posterior exenteration (3.8%), while 9 patients (17%) were subjected to total exenteration. The most common urinary reconstruction was non-continent urinary diversion (90.2%). Among the 11 women who underwent to total or posterior exenteration, 8 (72.7%) received a terminal colostomy. Conversion to laparotomy was required in two cases due to intraoperative vascular injury. Complications' report was available for 51 patients. Fifteen Dindo Grade 2 complications occurred in 11 patients (21.6%), and 14 grade 3 complications were registered in 13 patients (25.5%). Only grade 4 complications were reported (2%). In 88% of women, the resection margins were negative. Pelvic exenteration represents a salvage procedure in patients with recurrent or persistent gynecological cancers often after radiotherapy. A careful patient selection remains the milestone of such a mutilating surgery. The introduction of the minimally invasive approach has led to advantages in terms of perioperative outcomes compared to classic open surgery. This review shows the feasibility of robotic pelvic exenteration. An important step forward should be to investigate the potential equivalence between robotic approaches and the laparotomic one, in terms of long-term oncological outcomes.

Combination of robotic and transperineal techniques for total pelvic exenteration followed by a posterior–anterior approach to the supralevator space – a video vignette

“…Histopathological analysis revealed complete excision with clear margins. This combination technique may be subject to further developments [1][2][3][4]. We have demonstrated that simultaneous surgery and the sequential procedure can shorten the operating time.…”

Advances in Cytoreductive Surgery and Combination Therapy for Ovarian Cancer

“…European Society for Medical Oncology (ESMO) guidelines recommend that the removal of enlarged lymph nodes is currently part of achieving satisfactory debulking, but total lymphadenectomy should not be considered a standard procedure until clinical trial results are available. The steps of pelvic resection could be performed with different modalities including laparotomy, laparoscopy or robotic [16]. National Comprehensive Cancer Network (NCCN) guidelines recommend that attention be paid to the removal of suspicious or enlarged lymph nodes, and that there is no need to remove clinically diagnosed negative lymph nodes.…”

Robotic or laparoscopic pelvic exenteration for gynecological malignancies: feasible options to open surgery

“…Pelvic exenteration, either curative or palliative, means not only the partial or complete evisceration of the pelvic cavity but also, most often, the creation of stomas [ 1 2 ]. Considered a mutilating procedure, it is strongly associated with high morbidity and psychosocial impacts on patients [ 3 4 ].…”

“…However, in selected cases, it has emerged as the only possibility to increase life expectancy, improve the chances of survival, and relieve symptoms [ 5 6 ]. In the field of gynecology, pelvic exenteration has evolved from a salvage procedure to radical resection [ 1 7 8 ], mainly for the treatment of cervical cancer (CC) [ 7 8 ], either locally advanced stage IVa or centrally recurrent. However, patients with other relapsed gynecological cancers may benefit from this extensive procedure [ 9 ].…”