The Role of Exenterative Surgery and Urinary Diversion in Persistent or Locally Recurrent Gynecological Malignancy: Complications and Survival

Abstract

Objective: Treatment options in patients with persistent or locally recurrent cervical cancer are limited. The aim of this study was to determine the chance of cure and associated morbidity following pelvic exenteration. Patients and Methods: Consecutive patients who underwent pelvic exenteration between January 1992 and December 2006 at the University Hospital of Bern or the Karlsruhe Medical Center were evaluated. Time to recurrence, type of exenteration and urinary diversion, pathological stage, postoperative complications and survival were assessed. Results: Initial therapy prior to diagnosis of persistent or locally recurrent disease included radiation therapy in 51%. Anterior exenteration was performed in 37 (86%) and total exenteration in 6 (14%). Half of the women underwent additional procedures. A continent urinary diversion was constructed in 16 and an ileal conduit in 27 patients. Early postoperative complications were generally minor and only 2 patients required surgical intervention. Four intestinal fistulas were successfully treated conservatively. Late complications were mainly tumor-related. Complication rates associated with the urinary diversion were low and there was no difference in complications between continent and incontinent diversions. The overall disease-specific 5-year survival rate after exenteration was 36.5%. Survival correlated significantly with surgical margin status. Conclusion: In patients with persistent or locally recurrent gynecological malignancy of the pelvis, exenteration is a viable option with long-term survival in over one third of patients. Continent urinary diversion did not show higher complication rates than an ileal conduit and should be considered even in irradiated patients. This may be of greater significance in younger patients in whom an intact body image can play an important role in quality of life.

Salvage Stereotactic Body Radiosurgery in the Management of Recurrent Gynecological Cancer

“…12 The complication rates for radical exenterative surgery can be as high as 75% for early and83% for late complications. [13][14][15] Systemic salvage chemotherapyis mainly considered palliative due to low response rates and negligible impact on long term survival. In a literature review by Pectasides et al 16 , the response rates to single agent chemotherapy ranged between 7-68% with the highest rates reported with cisplatinum.…”

Impact of palliative urinary diversion by percutaneous nephrostomy drainage and ureteral stenting among patients with advanced cervical cancer and obstructive uropathy: A prospective cohort

“…This may be particularly, but not exclusively, so in developing countries where radiotherapy or chemotherapy may be unavailable or prohibitively expensive for many patients. Radical, exenterative surgery has the potential to control both malignancy and urinary obstruction definitively 17 . Where exenterative surgery is the chosen approach, addressing uremia caused by obstructive uropathy by diversion can optimize the condition of the patient in preparation for the performance of such surgery.…”

Opportunities and Limitations of Pelvic Exenteration Surgery

“…Numerous procedures were outlined in this regard. The spectrum ranges from, e.g., the creation of a continent urostoma with a catheterizable umbilical pouch [ 36 , 57 , 58 , 59 ] ( Figure 3 ), the creation of a neovagina with a colon vaginoplasty [ 59 ] ( Figure 3 ), the creation of a deep coloanal anastomosis with coloplasty/pouch [ 40 , 60 ], to the use of musculocutaneous flaps (e.g., Vertical Rectus Abdominis Myocutaneous (VRAM) flap or free flaps) to cover up defects. To prevent the problem of the so-called “empty pelvis” [ 61 , 62 ], omentoplasty has established itself as an excellent method, i.e., “omentum plug” [ 63 , 64 ].…”