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PubMed2001

T4 rectal cancer treated with preoperative chemoradiation to the posterior pelvis followed by multivisceral resection: patterns of failure and limitations of treatment.

PURPOSE: To analyze the overall pattern of treatment failure and sites of pelvic disease recurrence relative to the radiation fields used in treating patients with clinically staged T4 rectal cancer with preoperative chemoradiation followed by multivisceral resection. METHODS AND MATERIALS: Between 1990 and 1998, 45 patients with T4 rectal cancer were treated with preoperative chemoradiation. Clinical staging was according to the system of the American Joint Cancer Committee and was based on endoscopic ultrasonography, chemotherapy (CT), and physical examination. A diagnosis of T4 disease required evidence of invasion of a contiguous structure on CT (n = 31) or endorectal ultrasonography (n = 6), vaginal mucosal involvement on pelvic examination (n = 6), or a combination of these findings (n = 2). Chemoradiation was delivered with 18 MV photons using a 3-field belly-board technique. The median total dose was 45 Gy in all patients (range 45-63). Nine patients received a boost with external beam radiotherapy (EBRT) (n = 5, 1.8-18 Gy), intraoperative RT (n = 3, 10-20 Gy), or interstitial brachytherapy (n = 1, 20 Gy). All patients received concurrent chemotherapy consisting of protracted venous infusion 5-fluorouracil (300 mg/m(2), 5 d/wk). Resection was not performed in 13 (29%) of the 45 patients because of metastases detected before resection or patient refusal. Multivisceral resection and pelvic exenteration was required in 21 (66%) and 11 (34%) of 32 patients, respectively. We compared the location of pelvic disease recurrence with the RT simulation films. The Kaplan-Meier method was used to calculate the 4-year actuarial pelvic and distant recurrent rates and the overall survival rate. RESULTS: The median length of follow-up was 31.0 months for all patients and 40.0 months for patients alive at last follow-up. When only the resected cases were considered, the local recurrence rate was 20%. Distant metastases occurred in 44% of cases; the overall survival rate was 69%. When all patients were considered, the local recurrence rate was similar (24%), but the rate of distant recurrence (51%) was higher and the overall survival rate lower (50%). Pelvic disease was controlled in all 8 patients whose disease responded well to chemoradiation (either a histologically complete response or microscopic residual disease). Three of 4 patients with close or positive margins had pelvic recurrences despite intraoperative RT and brachytherapy. Nine of the 10 pelvic recurrences occurred in the radiation field. Elective external iliac nodal irradiation was not used, and nodal metastases were not seen in that region. In 1 case, marginal recurrence occurred in a common iliac node at the superior edge of the treatment field. CONCLUSIONS: Despite aggressive multimodality therapy including multivisceral resection, a high rate of pelvic and distant disease recurrence occurred in patients with clinically staged T4 disease. Regional disease recurred almost exclusively in the radiation field. The intraoperative RT and interstitial brachytherapy doses used did not prevent pelvic disease recurrence in patients with close or positive margins. Novel strategies such as higher preoperative doses of RT with or without altered fractionation or more effective radiosensitizers are needed to improve locoregional control in patients with T4 disease. Future strategies must also include more effective systemic therapy.

Adult↗

PubMed1993

Closure of a perineal sinus connected with the small bowel developing after radical surgery for rectal carcinoma: a report of the operative procedures used in two cases.

A technique for closure of a perineal sinus connected with the small bowel is described herein. One patient who underwent Miles' operation and another who underwent total pelvic exenteration for rectal carcinoma developed a perineal sinus through which a large amount of intestinal fluid was discharged. The pelvic orifice of the sinus was successfully closed in both patients using a right rectus abdominis muscle flap. In one patient, the muscle flap was reflected with the peritoneal surface inside and fixed to the pelvic floor covering the pelvic orifice of the sinus. In the other patient, the flap was isolated without the attached peritoneum and the peritoneal side of the flap covered with omentum.

Fistula↗

PubMed1983

[Treatment of cancer of the vulva].

The authors suggest a therapeutic scheme for carcinomata (intra-epithelial, micro-invasive and invasive) of the vulva after reviewing the literature and in the light of their own experience. It seems to them that treatment of these cancers can be carried out in the following way: Intra-epithelial cancers: partial vulvectomy for localised lesions or when treatment should be as conservative as possible. Total vulvectomy, or better still, superficial vulvectomy in other cases. Micro-invasive carcinomata: where the invasion is less than 2 mm: only total vulvectomy. Where the invasion is more than 2 mm: total vulvectomy with bilateral superficial lymphadenectomy. This is carried out as a complete lymphadenectomy when the lymph glands are found to be affected in the operating theatre. Invasive carcinomata: we exclude metastatic cancers where the local treatment is only carried out to give some palliation to the patient and sometimes can be combined with chemotherapy when that is possible. Patients that are operable: total vulvectomy with of course bilateral lymphadenectomy. This can be extended to iliac chains when Cloquet's gland is invaded. Radiotherapy after operation is to be discussed seeing that there are important sequelae from this. Lymph gland involvement can be unilateral in cases of N- stage I unilateral patients. Pelvic exenteration is only to be considered for young women who are in good general health and who have no pelvic metastases.

Combined Modality Therapy↗

PubMed1992

Extensive en bloc resection of regionally recurrent carcinoma of the rectum.

To remove regionally recurrent cancer of the rectum completely, more radical extensive resections were attempted than the conventional ones in 35 patients. Twenty-two patients underwent total pelvic exenteration. In 23, sacral resection was done, combined with other procedures including excision of the entire circumference of the lower pelvic ring. There were two hospital deaths. Delayed wound healing was seen in ten. Preoperative severe pain was alleviated in 18. Also, perineal ulcer, vaginal bleeding, bloody stools, and tenesmus disappeared. Of the four 5-year survivors (estimated rate, 23%), only one was disease-free. A second recurrence was seen in 27 patients, of whom 23 had regional failure. It was concluded that so-called local recurrence is a lesion more widespread than indicated by imaging and biopsy. Therefore, even the most radical resection rarely can cure this disease. However, such a surgical procedure can afford more effective palliation than other treatments and may prolong life in selected patients significantly.

Adenocarcinoma↗

PubMed1990

Invasive carcinoma of the vulva. Changing trends in surgical management.

Four hundred fifteen patients who had invasive carcinoma of the vulva were treated with primary surgery from July 1, 1955, through June 30, 1989. Three hundred seventy-six (90%) of the patients had squamous carcinoma. Two hundred fourteen patients (52%) had radical vulvectomy with inguinofemoral lymphadenectomy. Twenty-four patients (6%) underwent radical vulvectomy with pelvic exenteration for advanced disease, and 55 patients (13%) had nonradical operations. The remaining 122 patients (29%) underwent radical vulvectomy, inguinofemoral lymphadenectomy, and pelvic lymphadenectomy. The primary morbidity was associated with lymphedema (8.6%) and groin wound breakdown (54%). No intraoperative deaths occurred among the 415 patients treated surgically, but there were 17 deaths (4%) within 28 days of operation. The absolute 5-year survival rate was 85% in patients with negative inguinofemoral lymph nodes and 39% when these lymph nodes were positive for metastatic carcinoma. The overall absolute 5-year survival rate was 67%.

Adult↗

PubMed1995

Preoperative infusional chemoradiation and surgery with or without an electron beam intraoperative boost for advanced primary rectal cancer.

PURPOSE: To compare the multimodality treatment results of surgical resection plus preoperative radiotherapy with concomitant protracted infusion chemotherapy (preop-chemoXRT), with or without an electron beam intraoperative radiotherapy (EB-IORT) boost, in 37 patients having advanced primary rectal cancer, with the results of a protocol using only preoperative radiotherapy (preop-XRT) plus surgical resection in a historic control group of 36 patients. METHODS AND MATERIALS: Thirty-eight patients with tethered T3 or T4 primary rectal cancer were treated with 45 Gy delivered in 25 fractions over 5 weeks plus infusional chemotherapy. Thirty-seven patients underwent surgical resection: 13 (35%) had restorative operations, and the remainder had either abdomino-perineal resection (APR) or pelvic exenteration (PE). Electron beam intraoperative radiotherapy (EB-IORT) was used in doses of 10-20 Gy for 11 patients with adherent pelvic tumor. In the 36 historic control patients, the preop-XRT dose was 45 Gy, and 93% of them had APR or PE. RESULTS: The local recurrence rate was 3% for the preop-chemoXRT group and 33% for the historic control group. The 3-year survival rate for patients treated with preop-chemoXRT plus resection was 82% compared with 62% for the historic control group. Distant metastases occurred more frequently in patients treated with an EB-IORT boost than in patients who were not (64% vs. 19%, p < 0.05), and the overall 3-year survival rate was lower for the former (67% vs. 96%, p < 0.05). Acute and late toxicities were acceptable. CONCLUSIONS: Preop-chemoXRT for advanced primary rectal cancer results in better control of pelvic disease and better overall survival rates than does preop-XRT alone. With preop-chemoXRT, acute chemoradiation toxicity is increased whereas late morbidity is unchanged compared with preop-XRT alone. Local control in patients with areas of residual or clinically adherent disease is improved by the use of EB-IORT; however, patients treated with EB-IORT had poorer survival rates than those treated without EB-IORT.

Adult↗

PubMed1991

Anterior pelvic reconstruction with ileum after cancer treatment.

Ileum has been used to reconstruct the lower urinary tract in 15 patients (10 women, five men) after treatment for bladder or gynaecological cancer. Seven patients had previously received radical pelvic irradiation. Four methods were used: group 1 (five patients): bladder patch after partial cystectomy or bladder augmentation after clam cystotomy for bladder contracture; group 2 (four patients): bladder replacement after subtotal (supratrigonal) cystectomy; group 3 (two patients): ureteric replacement for lower ureteric obstruction or fistula, and group 4 (four patients): complete replacement of bladder and lower ureters after anterior pelvic exenteration, with creation of neovagina from caecum in the two female patients. Review of the results indicates that ileum provides a versatile and safe material for anterior pelvic reconstruction in cancer patients even after previous pelvic irradiation.

Adult↗

PubMed1998

Management of early and late complications of ileocolonic continent urinary reservoir (Miami pouch).

PURPOSE: The object of this study is to review our experience and formulate a plan for early recognition and effective management of early and late complications seen in patients who have undergone construction of the ileocolonic continent urinary reservoir. METHOD: Charts of patients who underwent continent urinary diversion at the Division of Gynecologic Oncology, University of Miami School of Medicine, from 1988 to 1996 were reviewed. We analyzed our data in terms of early and late (beyond 6 weeks) complications resulting directly from the operation or from this form of urinary diversion. RESULTS: Urinary diversion via the continent ileocolonic reservoir has been performed at our institution since February 1988. Sixty-six women have undergone construction of the Miami pouch over the past 81 years. Sixty-three of 66 patients needed a reservoir as a part of total pelvic exenteration for persistent or recurrent gynecologic malignancy. Three patients underwent reservoir construction for repair of vesicovaginal fistula. Sixty-two of 66 patients (95%) have a history of prior pelvic radiation. A total of 35 patients (53%) suffered early complications resulting in an operative mortality rate of 9% (6 of 66 patients). Early complications related to the construction of the reservoir included ureteral stricture/obstruction [10], anastomotic leak [4], reservoir-cutaneous fistula [4], difficulty in catheterization [5], pyelonephritis [10], sepsis [6], DIC [2], and ARDS [1]. Nonsurgical management strategies used for reservoir-related complications in these cases included percutaneous nephrostomy, peripheral hyperalimentation, intravenous antibiotics, and ultrasound-guided catheter placement. Eighty-four percent (16/19) of functional complications of the reservoir resolved with conservative management, whereas 3/19 patients needed surgical revision. One or more late complications (beyond 6 weeks) occurred in 25 patients (37%). Late complications seen included ureteral stricture/obstructions [6], incontinence [8], difficulty in catheterization [7], and urinary stones [4]. Nonsurgical management strategies used included percutaneous nephrostomy, balloon dilation, scheduled catheterization, ultrasound-guided catheter placement, and endoscopic/percutaneous lithotripsy. Four of 25 patients needed reoperation, whereas in 84% (21/25) of patients problems resolved with initial conservative management. CONCLUSION: Successful conservative therapy constitutes establishment of drainage, adequate nutrition, avoidance of sepsis, close observation, and patience. This article reviews the complications of the continent ileocolonic form of urinary diversion and formulates a treatment outline emphasizing an initial conservative approach that offers optimal management of early and late complications seen in this patient group.

Adult↗

PubMed1994

Management of extended radionecrosis in the pelvic area with repeated surgical debridement and omental transposition.

Extended radionecrosis in the pelvic area is a disaster occurring in a minority of patients treated with radiotherapy. Extensive excisional procedures, including pelvic exenteration, have been recommended, but carry high morbidity and mortality rates. Alternative treatment strategies are needed to improve survival and increase the quality of life in these patients. We retrospectively analysed the charts of eight patients treated for radionecrosis in the pelvic area between 1985 and 1991. During this period deviatory procedures, repeated but limited debridement and the early incorporation of an omental flap in the ischemic area were used in an attempt to avoid exenteration, but effectively stop further progression of infection and necrosis. The patients underwent a median of five surgical interventions (range: 2 to 21) for 10 sites of radionecrosis. The total of 61 procedures consisted of debridement (29), omental pedicle grafting (6), deviation of urinary tract (3) or intestinal tract (4) and including procedures due to complications (21). They were hospitalized for a median duration of 95 days (range 43-155) divided over several admissions (median 3, range 2-8). One patient died of sepsis during treatment. Complete recovery was achieved in all surviving patients with a median of 12 months (range: 9 to 20 months) after initial surgery. Early surgery, the limited extent of the procedures and omental transposition were the main components of our approach. We conclude that this approach has an acceptable morbidity and mortality rate, while a relatively good quality of life is achieved.

Adult↗

PubMed2007

Extended abdominoperineal resection in women: the Barbadian experience.

BACKGROUND AND OBJECTIVES: We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters. METHODS: Eighteen female patients (mean age: 62.9 years; range: 44-81 years) with a median follow-up of 14 months (range: 2-36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied. RESULTS: Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively. DISCUSSION: Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.

Journal Article↗

PubMed1992

The influence of some prognostic factors on the clinical outcome of patients with squamous cell carcinoma of the vulva.

The present paper examined the influence of patient age, surgical T stage, tumor size, tumor differentiation and lymphnodal status on the clinical outcome of 29 patients with primary vulvar squamous cell carcinoma treated with radical surgery. Eighteen patients underwent radical vulvectomy with bilateral inguinal-femoral lymphadenectomy alone; 10 patients had additional bilateral pelvic lymphadenectomy; another patient had additional bilateral pelvic lymphadenectomy and anterior pelvic exenteration for a carcinoma of the clitoris involving the urethra. Nine patients developed relapsing disease; the site of recurrence was local in 4 patients, inguinal in 2, both local and inguinal in one patient, pelvic in one, both pelvic and distant in one. Eight recurrences occurred within 24 months from surgery; another patient developed an inguinal recurrence 45 months after operation. The actuarial 5-year disease-free survival rates were as follows: 64% for patients younger than 70 years and 63% for patients 70 years of age or older (p = not significant); 79% for patients with surgical T1-T2 stage disease and 30% for those with surgical T3 stage disease (p = 0.01); 88% for patients with tumor size less than 3 cm and 31% for those with tumor size greater than 3 cm (p less than 0.001); 66% for patients with well or moderately differentiated tumor and 51% for those with poorly differentiated tumor (p = not significant); 82% for patients with negative groin lymph nodes and 39% for those with positive groin lymph nodes (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1985

Diagnosis and operation for locally recurrent rectal cancer.

Local recurrence of rectal cancer following abdominoperineal resection is rarely amenable to limited resection. Six patients with deeply invading recurrent lesions had pelvic exenteration combined with sacral resection. This procedure seems a reasonable treatment for palliation and the chance of cure in selected patients. In order to select good candidates for this extensive procedure, carcinoembryonic antigen (CEA) assays and the diagnosis of locally recurrent tumor with pelvic computed tomography (CT) were evaluated. CEA assay is valuable for diagnosing most recurrent rectal cancers, but it is inadequate for early detection. A high CEA level often indicates extrapelvic tumor spread. CT examination is very valuable for the early detection and localization of recurrence in relation to pelvic structures.

Adenocarcinoma↗

PubMed1992

[Pelvic multivisceral resection from the viewpoint of surgery].

Even rectal carcinomas, carcinomas of the female genital tract, and retroperitoneal sarcomas of the pelvis with invasion of adjacent organs are potentially curable by extending the operation to the relevant structures. In the Surgical Department of the University of Erlangen, 1535 patients with a first diagnosis of rectal carcinoma were treated from 1978 to 1988. Among these patients, 97 multivisceral pelvic resections (patients with distant metastases excluded) were performed. True tumor invasion had occurred in 48%, the others were operated on for inflammatory adhesion. In 54 patients, the anal sphincter was preserved. Postoperative mortality was 7%. The 5-year survival of those patients with tumor invasion of adjacent organs and R0-resection (n = 26) was 32%. Excluding the five patients with a tear or incision of the tumor (n = 5), the 5-year survival of the remaining patients was 44%. One patient who was operated on for a leiomyosarcoma of the rectum with a multivisceral resection of the rectum, prostate, and urine bladder is still alive 9 years after the operation without recurrence. The history of this patient argues for pelvic exenteration also in males, if a R0 resection can be performed.

Female↗

PubMed2000

Feasibility and first results of multimodality treatment, combining EBRT, extensive surgery, and IOERT in locally advanced primary rectal cancer.

PURPOSE: To assess the outcome of aggressive multimodality treatment with preoperative external beam radiation therapy (EBRT), extended circumferential margin excision (ECME) and intraoperative electron beam radiation therapy (IOERT) in patients with locally advanced primary rectal cancer. METHODS AND MATERIALS: Thirty-eight patients with primary locally advanced rectal cancer, but without distant metastases, received multimodality treatment. CT-scan showed extension to other structures in 15 patients (39%) and definite infiltration into the surrounding structures in 23 patients (61%). All patients received preoperative EBRT (dose range 25-61 Gy) and 82% received 50.4 Gy. The resection types were: 12 low anterior resections (31%), 14 abdomino-perineal resections (37%), 6 abdomino-transsacral resections (16%), and 6 pelvic exenterations (16%). The IOERT dose ranged from 10 to 17.5 Gy depending on the completeness of the resection. RESULTS: There was no perioperative mortality. The resection margins were microscopically negative in 31 patients (82%), microscopically positive in 4 (10%), and positive with gross residual disease in 3 patients (8%). Pelvic recurrences were observed in 5 patients (13%) including 3 IOERT infield failures. The overall 3-year local control, disease-free survival (DFS), and survival rates were 82%, 65%, and 72%, respectively. Negative resection margins were the most significant prognostic factor with regard to DFS (p = 0.0003) and distant control (p = 0.002) compared with cancer involved surgical margins. CONCLUSION: A high percentage of curative resections can be achieved in this group of patients with locally advanced rectal cancers. Adding IOERT to preoperative EBRT and ECME achieves high local control rates and possibly improves survival.

Adult↗

PubMed1993

Low colorectal anastomosis and reconstruction after gynecologic cancer.

Radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist despite significant advances in radiation oncology and chemotherapy. Total pelvic exenteration can be the only hope of women who have not responded to more conservative therapy. The time has come where it is appropriate to use contemporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck and breast surgery. This article reviews the techniques that are available in the reconstruction of a functional rectum with elimination of colostomy.

Anastomosis, Surgical↗

PubMed2002

Recurrent vulvar cancer.

Recurrent vulvar cancer occurs in an average of 24% of cases after primary treatment after surgery with or without radiation. The relatively few primary vulvar cancers, combined with the low proportion of recurrences, has made it difficult to perform randomized studies to document the most appropriate therapeutic modalities. Most reports are small retrospective studies and anecdotal reviews that have emphasized the importance of surgery and have led to new approaches with respect to chemoradiation. Traditionally, the most accepted treatment of vulvar cancer has been and continues to be surgery. Recently, radiation and chemotherapy have been combined with very encouraging results. The therapeutic modality used depends on the location and extent of the recurrence. Most recurrences occur locally near the original resection margins or at the ipsilateral inguinal or pelvic lymph nodes. Lateralized local vulvar recurrences treated with a wide radical local excision with inguinal lymphadectomy results in an excellent cure rate of 70%. With a central pelvic recurrence with antecedent radiotherapy involving the urethra, upper vagina, and rectum, total pelvic exenteration is indicated in a select group of patients with curative intent. Radiotherapy or chemoradiation concomitantly with wide radical local excision of an advanced vulvar has proven successful in avoiding an exenteration, with improved survival and less morbidity. Prospective and retrospective studies have shown excellent results using radiation or chemoradiation with wide radical local excision in patients with locally advanced disease in whom adequate resection margins are difficult to achieve (with a central lesion requiring exenteration) or with debilitating medical conditions that preclude surgery. In these patients, chemoradiation has shown favorable results when used before a wide local resection. In patients with advanced local disease, external beam and interstitial radiation has been used for palliative and curative intent with encouraging results. Regional recurrences to the inguinal and pelvic lymph nodes have been shown to have a poor prognosis with a high mortality rate. We recommend that inguinal recurrences without prior radiation therapy undergo excision followed by radiotherapy with chemosensitization. In patients with previous radiation to the inguinal lymph nodes, we try to avoid any excisional procedures because of the high rate of complications. We offer these patients brachytherapy for palliation. With pelvic recurrences, we recommended chemoradiation as the treatment modality. In the subset of patients with distant metastasis, chemotherapy may be offered; however, few studies have been performed to advocate any single combination. The literature supports the use of 5-fluorouracil or cisplatin as single agents or in combination to have sensitivity against squamous cells. There are few studies revealing improvement in 5-year survival, thus these patients may benefit from recruitment into research protocols.

Antineoplastic Agents↗

PubMedDate not supplied

Bladder/prostate rhabdomyosarcoma: results of the multi-institutional trials of the Intergroup Rhabdomyosarcoma Study.

Rhabdomyosarcomas (RMS) occurring in pelvic sites are almost entirely of the embryonal histologic subtype and are relatively responsive to chemotherapeutic agents. When treated by radical surgery, pelvic irradiation, and intensive chemotherapy for 2 years, survival rates of higher than 85% have been achieved. However, the effects of such therapeutic approaches have resulted in major changes in the quality of life of survivors, because of the loss of pelvic organs, primarily the bladder. Current efforts are directed towards achieving long range survival with procedures that are less extensive than pelvic exenteration or total cystectomy and by regimens that eliminate or reduce the intensity of radiotherapy. Until the past 5 years, these efforts have been relatively unsuccessful in both North America and Europe. However, the most recent studies of the IRS and European cooperative groups suggest that a majority of these patients can survive with intact pelvic organs when treated with currently available chemotherapeutic agents in conjunction with radiotherapy and limited surgery.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2005

Salvage surgery for bulky local recurrence of prostate cancer following radical prostatectomy.

PURPOSE: We report our experience with salvage radical surgery as palliative treatment in patients with bulky recurrence of prostate cancer following radical prostatectomy (RP). MATERIALS AND METHODS: From files at the department of urology we identified 5 patients who had biopsy confirmed, bulky recurrence of prostate cancer after initial RP and subsequent salvage radiation therapy (4), prior to presentation at our cancer center. Positive surgical margins were present in all 5 patients. All received androgen ablation and 4 also received systemic chemotherapy. Due to persistent bulky tumors in the 5 patients and debilitating unrelenting symptoms, including refractory hematuria, obstructive uropathy and pelvic pain in 4, salvage radical surgery was performed. Total pelvic exenteration was done in 4 patients and wide tumor resection with continent urinary diversion was done in 1. RESULTS: Four patients were permanently relieved of local symptoms following surgery and another had entero-urethral fistula formation. Revision of a continent urinary diversion was necessary in another patient who was otherwise free of cancer and of local pelvic symptoms. Long-term symptom-free survival was achieved in 2 patients following surgery at 26 and 56 months, respectively. One patient died of metastatic disease 3.5 months after surgery but he had been rendered free of local symptoms by surgery. The other 2 patients are currently free of local symptoms 5 and 7 months following surgery, respectively. Wound infection, delirium and prolonged ileus occurred in 1 patient each. Otherwise surgery was well tolerated. CONCLUSIONS: Salvage radical surgery is feasible and it provides effective palliation in patients with bulky local recurrence following RP.

Aged↗