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Total Laparoscopic Posterior Pelvic Exenteration: A Case Report of Low Anterior Resection With En Bloc Partial Vaginectomy With Sphincter Preservation and Handsewn Coloanal Anastomosis for Locoregionally Advanced Carcinoma of Rectum Invading Female Genital Tract
Abstract
Posterior pelvic exenteration (PPE) has been used as modality of treatment for recurrent or primary cancer of rectum that has invaded into the female genital tract. We report a case of PPE performed for locoregionally advanced carcinoma of rectum invading the uterus; which was performed in a totally laparoscopic manner. The handsewn coloanal anastomosis was performed transrectally thus obviating the need for even a minilaparotomy for abdominal access for specimen retrieval or anastomotic stapler application. This is a first reported case in the literature where a total laparoscopic PPE was performed with successful outcome and oncological adequacy and safety.
... Because of these technical difficulties, there are very few case reports of laparoscopic pelvic exenteration for rectal cancer [15,17]. Patel et al. [15] reported two cases of salvage laparoscopic total pelvic exenteration with intraoperative blood loss of 1200 ml and an operation time of 5.5 h. ...
... Patel et al. [15] reported two cases of salvage laparoscopic total pelvic exenteration with intraoperative blood loss of 1200 ml and an operation time of 5.5 h. Puntambekar et al. [17] also reported a case of laparoscopic posterior pelvic exenteration in a female patient with rectal cancer, although en bloc resection of rectal cancer with a female genital organ is likely to be less difficult, even laparoscopically, that when it invades a male genital organ. ...
The aim of this study was to present the feasibility and surgical outcome of robotic en bloc resection of the rectum and with prostate and seminal vesicle invaded by rectal cancer.
The details of three consecutive cases involving male patients in their forties, with locally invasive low rectal cancers are presented. The da Vinci robotic system was used by experienced colorectal and urological surgeons to perform en bloc resection of the rectum, prostate and seminal vesicles.
In the first case, coloanal and vesico-urethral anastomoses were performed, and the second included an end colostomy and vesico-urethral anastomosis. The bladder and bulbar urethra were also removed en bloc in the third case, with robotic intracorporeal ileal conduit formation and end colostomy. There was no major complication postoperatively. In the second patient there was a minor leakage at the vesico-urethral anastomosis. The third was readmitted the following week with a urinary infection which settled with intravenous antibiotics. In the first case, the circumferential resection margin was microscopically positive but the patient is currently free of recurrence after 14 months. In the second and third cases, all margins were clear.
This the first report of the use of the da Vinci robotic system for pelvic exenteration in patients with locally advanced rectal cancer invading the prostate and seminal vesicles. The robot may have a potential role in selected patients requiring exenterative pelvic surgery particularly in men.
... 10 As far as we know there are just a few case reports available of laparoscopies posterior exenteration for carcinoma rectum. 12 Although open posterior exenteration is a known established procedure, it has been rarely performed with the complete minimally invasive approach. Ours is a high volume center where each year >300 rectal cancer surgeries are done with an MIS approach. ...
Background:
Laparoscopic posterior exenteration (total and supralevator) is a complex and rarely done procedure. In this study we describe the surgical technique and short-term perioperative outcomes in 7 female patients of locally advanced carcinoma rectum operated with laparoscopic pelvic exenteration.
Materials and Methods:
We report 7 cases of carcinoma rectum involving either posterior wall of the uterus or vagina, which were operated with a laparoscopic procedure. All perioperative and intraoperative data were collected retrospectively from prospectively maintained electronic data.
Results:
Nine female patients with the diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. In MRI 4 patients had uterus-cervix involvement and 3 patients had a posterior vaginal wall and anal sphincter involvement. Four patients were operated with laparoscopic supralevator posterior exenteration and 3 patients were operated with laparoscopic complete posterior exenteration. Three patients underwent vaginal reconstruction, which was done with bilateral V-Y plasty. All 7 patients received neoadjuvant chemoradiotherapy (NACTRT), 3 patients also received additional chemotherapy (CAPOX regimen) due to poor response to NACTRT. Mean body mass index (BMI) was 23.85 (range 19-27.20). Mean duration for complete posterior exenteration was 9.63 hours (range 7-12 hours). Mean duration for supralevator posterior exenteration was 6.81 hours (range 6.25-7.5 hours). The mean postoperative stay was 10.71 days (range 7-16 days). Mean blood loss was 700 mL (range 200-1800 mL). On postoperative histopathology, all margins were free of tumor in all cases.
Conclusion:
Laparoscopic approach for locally advanced carcinoma rectum in female patients is feasible with less morbidity and safe short-term oncological outcomes. Careful selection of patients based on MRI is a must before undertaking the minimally invasive surgery approach. Long-term outcomes are still unknown and will require long-term follow-up.
... Posterior pelvic exenteration has also been studied as a surgical modality in females with rectal tumor adherent or invaded to the uterus and vagina. It involves the removal of the rectum, sigmoid colon, internal reproductive organs, draining lymph nodes and pelvic peritoneum in women (189)(190)(191). A supralevator pelvic exenteration is another option which involves the en bloc removal of the compromised organs similar to the TPE, preserving an adequate distal margin in the rectum. ...
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number
of young patients diagnosed with rectal cancer have made it as one of the major health problems in
the world. With regard to the improved access to and use of modern screening tools, a number of
new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs,
management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal
tract or even the colon. In this article, we will review the current updates on rectal cancer
including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods
and latest treatment modalities and approaches will also be discussed in detail.
To describe our results in managing locally advanced primary or recurrent pelvic malignancies.
Investigations included: clinical, laboratory, endoscopic (rectoscopy and colonoscopy) examinations, ultrasound scan, and CT scan or MRI of the abdomen and pelvis, to determine the extent of the pelvic malignancy. A careful explorative laparatomy of abdomen and pelvis was performed, followed by anterior, posterior or total pelvic exenteration.
In the period June 1995-Jan 2002, 7 anterior, 2 posterior and 51 total pelvic exenterations were performed in 60 patients, distributed as follows: 28 for rectal cancer (12 primary, 16 recurrent), 20 for cervical cancer (9 primary, 11 recurrent) and 12 for other pelvic malignancies. The median survival time and overall 5-year survival rates were as follows: primary rectal cancer--50 months and 32%; recurrent rectal cancer--31 months and 17%; primary cervical cancer--46.4 months and 41% and recurrent cervical cancer--23.4 months and 16%. During the same period, 559 of our patients were treated for primary or recurrent rectal cancer by different types of straightforward resection.
Pelvic exenteration is justifiable in cases of locally advanced primary and recurrent malignancies of rectum, cervical cancer and possibly in cases of other pelvic malignancies.
Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity.
To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration.
Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2).
The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66% (n = 1). The overall rate morbidity was 53,3% (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 %), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7%.
In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.
Laparoscopic salvage surgery for colorectal cancer is a novel but technically challenging option for surgeons. The aim of this study was to evaluate the feasibility and safety of laparoscopic surgery in patients with recurrent or metachronous colorectal cancer in comparison with an open approach.
The data used in this study were obtained from databases, the data of which were collected prospectively from January 1996 to February 2010. Data pertaining to patients, operations, and short-term outcomes were analyzed and compared between open and laparoscopic salvage groups.
Among the 3,425 patients studied, colorectal cancer recurred in 565 patients (16.5%) and 41 patients had colorectal salvage operations. Twenty-six patients with recurrence underwent open surgery and 15 cases underwent laparoscopic surgery. The short-term outcomes of the laparoscopic group were comparable with those of the open surgery group or were partly favorable. The five-year disease-free interval and overall survival of recurrent cancer patients were not significantly different from those of the open patients. Metachronous colorectal cancer occurred in 13 patients (0.38%), 5 of whom had open surgery and 6 had laparoscopic salvage. The only significant difference between the groups was a shorter operating time for the laparoscopic group. Late in the study, four patients in the laparoscopic recurrent group and one patient in the metachronous group were converted to open surgery.
Laparoscopic surgery yielded short-term outcomes that were comparable to those of conventional open surgery, in both recurrent and metachronous colorectal cancer patients. Thus, minimally invasive salvage approaches should be considered as a treatment option for the recurrent and the metachronous colorectal cancer patient.
To study the feasibility, morbidity, and oncologic outcome of laparoscopic posterior exenteration in patients with advanced gynecologic malignant diseases.
Retrospective study based on clinical experience (Canadian Task Force classification III).
Private hospital.
The medical records for 10 patients who underwent laparoscopic posterior exenteration because of advanced gynecologic malignant disease were retrospectively reviewed.
Laparoscopic posterior exenteration involving selective resection of the uterus, ovaries, vagina, and rectum was performed using a 6-port technique that included harmonic shears, the LigaSure device, and a circular endostapling instrument.
Histopathologic diagnosis included carcinoma of the cervix in 5 patients, ovary in 4 patients, and vagina in 1 patient. Indication for surgery was primary disease in 7 patients and secondary disease in 3 patients. Complications included delayed bladder recovery in 4 patients, and anastomotic leak, wound infection, and prolonged ileus in 1 patient each. No conversions to open surgery were required. The extent of resection was supralevator in 8 patients and infralevator in 2. Median operative time was 210 minutes. Median length of hospital stay was 9 days. Median blood loss was 360 mL. Disease recurred in 1 patient. After a median follow-up of 26 months, 9 patients were alive, and 8 were free of disease.
Laparoscopic posterior exenteration is feasible in advanced gynecologic malignant disease with rectal involvement. In addition to the known benefits of laparoscopic surgery, carefully selected patients could achieve a survival benefit following R0 resection.
The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases.
Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis.
The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins.
NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.
Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m(2)) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.
Since its first description in 1948, total pelvic exenteration has been a surgical option for the treatment of locally advanced rectal cancer in selected patients. During these 50 years, it has remained a formidable procedure with high mortality and substantial morbidity. This report describes the results of total pelvic exenteration for rectal cancer in terms of post-operative mortality, morbidity, and longterm survival in patients with locally advanced primary and recurrent rectal cancer.
A study of the patient records revealed that 24 patients underwent total pelvic exenteration as the treatment for locally advanced primary or recurrent cancer of the rectum from 1983 to 1998. The charts of the patients were reviewed, and morbidity and mortality were documented. The survival of the patients was also analyzed.
Fifteen patients had primary tumor and 9 had locally recurrent cancer. The mean age was 62 years old. There were no postoperative deaths, and the complication rate was 54%. In the treatment of primary tumor, bowel continuity was possible in 60% of the patients. Previous radiation or operation for recurrent disease was not associated with increased morbidity. The overall 5-year survival was 44%. The 5-year survival of patients with primary cancer was 64% and was significantly better than the rate for those with recurrent disease. Only one patient with recurrent disease survived more than 24 months.
Total pelvic exenteration now can be performed with low mortality rates, but the morbidity remains high. In the treatment of primary rectal cancer, good survival (64%) can be achieved, but results are dismal for the treatment of recurrent disease. We suggest better selection of patients for this procedure, especially as a treatment for recurrent rectal cancer.
Indications for and the prognosis of posterior pelvic exenteration (PPE) in rectal cancer patients are not clearly defined. The aim of this study was to analyse the indications, complications and long-term results of PPE in patients with primary rectal cancer.
A retrospective review included patient demographics, tumour and treatment variables, and morbidity, recurrence, and survival statistics. These results were compared with a group of female patients who underwent standard resection for primary rectal cancer in the same period (non PPE group).
The series included 30 women with an average age of 56.7 years (range 22-78). Tumour location was recorded in three cases in the upper rectum, 13 cases in the medium rectum and 14 cases in the lower rectum. A sphincter-preserving procedure was performed in 70% of the patients. Mean operative time was 4.2 h (range 2-7.5 h). Overall major morbidity rate in this series was 50% and mean hospital stay was 19.7 days (range 9-60 days). There was no hospital mortality. Pathological reports showed direct invasion of uterus, vagina or rectovaginal septum in 19 cases, involvement of perirectal tissue in 25 cases and positive lymph nodes in 18 cases. Comparison between PPE and non PPE groups showed no differences in mean tumour diameter, histological grade and tumour stage, but patients in the first group were younger. Although low tumours were seen more frequently in the PPE group (P = 0.003), the rate of sphincter-preserving procedure was comparable in both groups. Operative time was longer (P = 0.04) and morbidity was higher (P = 0.0058) in the PPE group. Local recurrence with or without distant metastases for the whole series was 30%. Five-year survival rate for patients who underwent curative resections (TNM I-III) was 48% in the PPE group vs 62% in the non PPE group (P = 0.09).
In the present series, PPE prolonged operative time, increased postoperative complications and showed a trend toward poor prognosis in recurrence and survival. However, PPE offers the only hope for cure to patients with a primary rectal cancer that is adherent or invades reproductive organs.
To investigate the feasibility of the laparoscopic salvage surgery for locally recurrent rectal cancer.
Seven cases with recurrent rectal carcinoma treated by laparoscopic salvage surgery from February 2004 to July 2005 were retrospectively analyzed. Among them, four were males and 3 females, and the median age was 60 years (range 37-74). Three cases of recurrence were after conventional anterior resection, 2 after laparoscopic-assist anterior resection, 1 after laparoscopic-assist Parks' procedure, and 1 with pars sacral fistula after per-sacral-local resection for three times. Image examination (CT scanning) was taken preoperatively to evaluate the locally recurrence and exclude the distant metastases. The laparoscopic-assist procedure with or without a hand-assist technique was used in this study.
Six cases with the recurrent lesion of central type were treated by salvage surgical procedure as follows: 3 laparoscopic-assist anterior resection, 1 laparoscopic-assist abdominoperineal resection, 1 laparoscopic-assist posterior exenteration, and 1 laparoscopic-assist proctocolectomy with a terminal ileum stoma. All of them were R0 resection confirmed by postoperative pathological examination. The other one with the lesion of combination type was treated with the procedure of laparoscopic-assist sigmoid colostomy. A hand-assist technique was used in 2 cases. The mean operation time, bleeding and hospital day was (211 +/- 13) min, (200 +/- 91) ml, and (15 +/- 10) d, respectively. No conversion and complication occurred.
Laparoscopic salvage surgery for locally recurrent rectal cancer is safe and feasible when taken by experienced laparoscopic colorectal surgeon to the cases with the recurrent lesion of central type.