Total pelvic exenteration: The Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003)

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Abstract

Objective.

To review the trends, modifications and results of 103 consecutive total pelvic exenterations (TPE) performed at the Montefiore Medical Center and Albert Einstein College of Medicine from 1987 to 2003.

Methods.

All patients who underwent TPE from January 1987 to December 2003 were included. The medical record, complications, follow-up, clinical status and demographic information were entered in a database. The procedure performed, the method of urinary diversion, colonic diversion, pelvic floor support and vaginal reconstruction were documented. Surviving patients were surveyed regarding their satisfaction with the urinary diversion, the vaginal reconstruction and their sexual function since the surgery.

Results.

103 pts were identified. Indications for TPE were recurrent cancers of the cervix (95), endometrium (2), colon and rectum (5), vulva (1). Overall 5-year survival was 47%. 5-year survival for pts with recurrent cervix cancer was 48%. Six pts (6%) recurred >5 years after the TPE. 14 pts (14%) had ureteral anastomotic leaks (no difference between ileal conduit 9/65 (14%) versus 5/38 (13%) continent conduit (P = 0.92). 34 pts (89%) with continent conduits were “continent.” 14 pts (17%) had wound complications. 4 pts (4%) had parastomal hernias. 5/11 (46%) pts who had a low rectal reanastomosis developed recurrence in the pelvis. 21/39 (54%) of pts with continent conduits would choose an ileal conduit if they had the option again. Long-term renal function was similar in pts with ileal and continent conduits. Mesh of any type for pelvic floor reconstruction is associated with infection and bowel/urinary fistulas. VRAM flaps for neovagina fill the pelvic dead space, reduce the risk of fistulas and 20/36 pts (55%) are sexually active.

Conclusions.

Our overall 5-year survival is encouraging, and modifications in surgical technique have improved the reconstructive phase. Low rectal anastomoses at TPE adversely affects survival. Many of our pts with continent urinary diversions would not choose this method again. Mesh of any type is associated with sepsis and bowel/urinary fistulas. VRAM for neovagina reduces fistula rate and are functional in >55% of pts. TPE remains a potentially curative option for these pts.

Introduction

Over 50 years ago, pelvic exenteration was first described by Brunschwig and colleagues from the Memorial Hospital in New York [1]. Initially, pelvic exenteration was utilized for the palliative surgical management of advanced and recurrent gynecologic cancers but, over the next 10–15 years, evolved into a curative intervention for advanced and recurrent gynecologic cancers confined to the central pelvis [2], [3]. The extent of the surgical procedure required has been adapted to the site and location of the recurrent or residual disease. Total pelvic exenteration (TPE) entails the en bloc resection of the pelvic viscera in both the anterior and posterior urogenital compartments and is the only available procedure for extensive tumors of the cervix, uterus, vagina, vulva, colon (usually recto-sigmoid), bladder, urethra and occasionally ovary [4], [5], [6].

Currently, the primary role of TPE is for the treatment of cancers of the cervix that recur in the central pelvis following radiation therapy with or without chemotherapy in patients with no evidence of occult metastatic disease outside the pelvis. Although the incidence of advanced stage cervical cancer appears to be declining in many developed countries, it remains a significant problem for women in developing and third world countries [7], [8], [9], [10], [11]. It is a major health care issue in South America (and other developing and third world countries) where it is still the most common cancer in women [9].

There have been numerous reports describing the surgical procedure, technique and the outcome from numerous prestigious institutions around the world [5], [6], [12], [13], [14], [15], [16], [17], [18], [19]. The patient selection criteria, peri-operative preparation and post-operative care have changed significantly over the past two decades. The surgical procedure has evolved from a purely extirpative/exenterative one to an operation that includes a reconstructive phase which has assumed even greater importance in recent years with refinements in urinary diversion, colon sparing surgery, preservation of the anal sphincter and vaginal and pelvic floor reconstruction.

In keeping with other large academic medical centers, we have made significant modifications to our surgical techniques for both the extirpative and the reconstructive phases of the total pelvic exenteration procedure at the Albert Einstein College of Medicine and Montefiore Medical Center over the past 18 years. We have previously published a series of patients where we described the risk factors for poor prognosis at the time of TPE and those patients who might benefit from intra-operative or post-operative brachytherapy [20]. We have also reported on the modifications, complications and sexual function with regard to vaginal reconstruction using the Vertical Rectus Abdominis Myocutaneous (VRAM) flap at the time of TPE [21]. The majority of the alterations and modifications to the surgical procedures at TPE described in this report were initiated and performed by the primary author (GLG).

Section snippets

Materials and methods

After IRB approval (protocol #04-01-011E), there was a systematic review of in-patient and out-patient medical records from all patients who underwent TPE on the gynecologic oncology service at the Albert Einstein College of Medicine/Montefiore Medical Center from January 1987 to December 2003. Pts who underwent an anterior exenteration only or a posterior exenteration only were excluded from this analysis. A database was developed abstracting the predetermined variables of interest from the

Results

Between 1987 and 2003, TPE was performed on 103 patients. We have follow-up information on all the patients in this group. Additional demographic characteristics are shown in Table 1. The mean age was 52.7 years (range 24–81 years). The race and ethnic distribution was as follows: Caucasian (36%), Hispanic White (34%), African American (26%) and Asian–South Island/Pacific (4%). The majority of the patients (95) underwent the procedure for recurrent cervical cancer, 2 for recurrent endometrial

Comment

We have made a number of significant modifications to the TPE procedure over the past 18 years at the Albert Einstein College of Medicine/Montefiore Medical Center. We do not rely on examination under anesthesia, CT scan or MRI reports to determine whether our patients are eligible candidates for TPE. We offer the patient the option of an exploratory laparotomy to determine whether they are eligible or ineligible for the procedure. We generally do not perform palliative TPE and will usually

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    Presented in part at the annual Society of Gynecologic Oncologists Meeting in Miami in March 2005.

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