Acute pulmonary edema during anesthesia and operation in a healthy young patient.
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Adult↗
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Results for “PELVIC EXENTERATION”
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Urinary diversion following radical pelvic surgery.
PURPOSE OF REVIEW: To describe the reconstructive techniques in urinary diversion utilized by the gynecologist after radical pelvic surgery. The radical resection of pelvic malignancies remains an important part of the armamentarium of the gynecological oncologist. Techniques in continent urinary diversion should be used to restore these women to an acceptable quality of life. Reconstruction is the surgical challenge of this and future generations of pelvic surgeons. It is imperative that pelvic surgeons begin to consider the quality of life and the functional reintegration into society of the patients we are able to salvage with these radical surgical efforts. RECENT FINDINGS: The advent of continent urostomies has significantly improved the quality of life of patients who undergo radical tumor resection involving the bladder. Such techniques prevent the need for urostomy bags, and thus all the physical and psychological ramifications associated with them. We will review recent literature associated with the complications and the management of these complications. SUMMARY: Familiarity with techniques in continent urinary diversion by the gynecologist is an important part of the management of patients with gynecological malignancies and permanent bladder atony.
Algorithms↗
Vaginal reconstruction after extended radical pelvic surgery for cancer: comparison of two techniques.
An immediate partial or total vaginal reconstruction is frequently proposed in cases of exenterative or extended radical pelvic surgery for cancer treatment. One of the main complications after this reconstruction is the vagina obliteration caused by the healing process. This study compares the results of two different reconstructive techniques, particularly focusing on general complications and the risk of vaginal occlusion. A transversus rectus abdominis musculoperitoneal (TRAMP) composite flap has been performed in five cases, and an inverted inferior transverse rectus abdominis musculocutaneous flap (TRAM) has been used in another five cases. Recovery was uneventful in eight cases. One patient (case 5) developed an aortofemoral embolism requiring a bilateral transfemoral embolectomy and heparin administration. Another patient (case 9) experienced severe peritonitis because of the partial leak of the rectal anastomosis, and therefore a Mikulicz's colostomy was performed. Four patients who underwent the TRAMP flap developed a complete closure of the neovagina. In one patient with a TRAMP flap, a severe shortening (2 cm) of the neovagina occurred. Five patients out of five who underwent a reconstruction with a TRAM flap had a stable length of the neovagina (6 to 12 cm) and no shrinkage in diameter occurred, even though a vaginal stent was not used. The conventional inferior TRAM flap with a skin paddle seems to better maintain a stable length of the neovagina than the TRAMP composite flap with peritoneum.
Adult↗
The sigmoid conduit as a means of urinary diversion.
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Colon, Sigmoid↗
Surgery for urogenital rhabdomyosarcoma.
The treatment and prognosis of rhabdomyosarcoma of the urogenital tract have changed dramatically over the past few decades. Until the 1970s radical cystectomy and pelvic exenteration were the only therapeutic options in rhabdomyosarcoma of the bladder/prostate and of the vagina/uterus. Since then, multiagent chemotherapy has achieved remarkable cure rates. Consequently, organ-saving surgical techniques were advocated, with the goal to improve patients' quality of life. The available long-term survival data with these techniques demonstrate excellent survival in rhabdomyosarcoma of the vagina/uterus, with a high percentage of organ preservation. On the contrary, increased rates of local recurrence and death from disease in patients with rhabdomyosarcoma of the bladder/prostate who undergo primary chemotherapy with or without tumour excision, and complications following combined radiotherapy critically question the long-term benefit of these organ-sparing surgical techniques in this group.
Female↗
Laparoscopic radical cystectomy in the female.
PURPOSE: We detail the technique of completely intracorporeal laparoscopic radical cystectomy in the female patient, which has previously not been well described in the literature. Additionally, perioperative and short-term oncological outcome data are presented. MATERIALS AND METHODS: Since 2000, 11 female patients underwent laparoscopic radical cystectomy for bladder carcinoma. Data were collected with respect to patient demographics, perioperative outcomes and short-term oncological followup. RESULTS: Mean patient age was 66 years (range 42 to 80) and the mean body mass index was 25 (range 17 to 34). Mean total operative time was 8.5 hours (range 6.5 to 10.5), including an average radical cystectomy time of 2 to 2.5 hours. Estimated blood loss was 489 cc (range 150 to 1,000). Reconstructive procedures were an ileal conduit in 8 patients, Studer orthotopic neobladder in 2 and continent Indiana pouch in 1. Mean hospital stay was 6 days (range 5 to 12). No case was converted to open surgery. Complications occurred in 4 patients, including internal hernia requiring laparotomy 19 days postoperatively, deep vein thrombosis with pulmonary embolism, dehydration and urinary tract infection in 1 each. At a median followup of 7.1 months (range 1 to 19) 8 patients (73%) had no evidence of disease, 1 (9%) had metastasis and 2 (11%) had died. CONCLUSIONS: Laparoscopic radical cystectomy in the female is technically efficacious. Our techniques of anterior pelvic exenteration, and uterus/fallopian tube/ovary and nerve sparing laparoscopic female radical cystectomy are presented. Short-term functional and oncological outcomes appear favorable.
Adult↗
Surgical resection of locally recurrent cervical cancer: a single institutional 70 patient series.
Pelvic recurrence of cervical cancer is a life-threatening situation and only local control can provide hope for remission. The aim of this study was to evaluate the role of surgery in the treatment of cervical cancer recurrence. This retrospective study analyzed a series of 70 patients who underwent resection of cervix locoregional recurrence. Thirteen patients had palliative salvage surgery for pelvic complications. Twenty-nine resections were considered as curative. Fifty recurrences required pelvic exenterations. The hospital mortality rate was 9% and the morbidity rate was 44%. Overall 5-year actuarial survival rate was 23%. Survival was significantly higher: (a) after curative resection and (b) after centropelvic recurrence resection. Local control was obtained in 48% of the cases and 13 patients are alive with a median follow-up of 75 months. In conclusion, the results of this small and heterogen series seem to justify an attempt to resection for centropelvic recurrences whenever possible. Palliative surgery should be reserved to salvage therapy and highly selected patients.
Adult↗
Hemiresective reconstruction of a redundant ileal conduit with severe bilateral ileal conduit-ureteral re fl ux.
A 58-year-old man was referred to our hospital with high fever and anuria. Since undergoing a total pelvic exenteration due to bladder-invasive sigmoid colon cancer, urinary tract infections had frequently occurred. We treated with the construction of a bilateral percutaneous nephrostomy (PCN), and chemotherapy. Although we replaced the PCN with a single J ureteral catheter after an improvement of infection, urinary infection recurred because of an obstruction of the catheter. Urological examinations showed that an ileal conduit-ureteral reflux caused by kinking of the ileal loop was the reason why frequent pyelonephritis occurred. We decided to resect the proximal segment to improve conduit-ureteral reflux for the resistant pyelonephritis. After the surgery, the excretory urogram showed improvement and the urinary retention at the ileal conduit disappeared. Three years after the operation, renal function has been stable without episodes of pyelonephritis. Here we report a case of open repair surgery of an ileal conduit in a patient with severe urinary infection.
Humans↗
Long-term follow-up, further experience with and modifications of the transverse colon conduit in urinary tract diversion.
In the past 6 years, an additional 22 patients with extensive pelvic irradiation have had their upper urinary tracts diverted employing the transverse colon conduit. Most procedures were performed with radical cystectomy following high dose radiotherapy in patients with bladder cancer or with pelvic exenteration for recurrent cervical cancer. The operative mortality rate was unchanged at 4%. Upper urinary tracts and renal function have remained stable or improved in 88 and 95% of patients respectively. Although most conduits were constructed with refluxing ureterocolic anastomoses and without stents, the more recent procedures have employed both antireflux submucosal tunnel anastomoses and stents. Nineteen of 25 patients diverted by this method between 1970 and 1976 have been followed for up to 155 months. All patients with recurrent or persistent malignancy have died (mean survival 44 months). Seven patients (37%) are living and well (mean survival 104 months). Upper urinary tracts remain normal in two-thirds of those with the longer follow-up. Major complications requiring additional surgery continue to occur in one-third of this highly selected group of patients in whom the transverse colon conduit remains the preferred diversionary technique.
Adult↗
Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma.
OBJECTIVE: To report a retrospective chart review of patients who developed recto-urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer. PATIENTS AND METHODS: In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60-81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York-Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization. RESULTS: All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York-Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty. CONCLUSIONS: Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York-Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.
Adenocarcinoma↗
Multifocal endometrial type carcinoma involving 5 primary sites in the pelvis.
A case of widespread endometrioid carcinoma is reported. The concept of multifocal carcinoma in the pelvis is discussed.
Adenocarcinoma↗
The Martius flap neovagina revisited.
The Martius bulbocavernosus flap has been used frequently in the repair of various vaginal fistulas. It can also be a useful source for the construction of a neovagina if used in the appropriate patient. We present a case of a patient who underwent a total pelvic exenteration for recurrent cervical cancer. For her neovagina, a novel variation of the Martius flap was constructed. In carefully selected patients, this can be a useful option for neovagina reconstruction.
Adult↗
A case of cancerous familial adenomatous polyposis in urinary bladder due to migration of colonic mucosa through rectovesical fistula.
The patient was a 50-yr-old man who had undergone low anterior resection for rectal cancer at the age of 24 yr in 1966. At that time, gastric and colonic polyposis were indicated. Postoperative anastomotic dehiscence occurred and, by 1985, a rectovesical fistula had formed. In 1986, when the patient was 44 yr old, he was examined at our hospital for constriction of the rectum due to the rectovesical fistula. Abdominoperineal excision of rectum and surgical closure of the fistula were performed, and the patient was kept under observation because of a diagnosis of familial adenomatous polyposis. In 1988, when the patient was 46 yr old, early ascending colon cancer was discovered and total colectomy was performed. Then, in December, 1991, gross hematuria was found. Further examination revealed a tumor on the posterior wall of the urinary bladder lumen, and biopsy showed adenocarcinoma. Pelvic recurrence of the rectal cancer was diagnosed, and total pelvic exenteration was performed. There were no distant metastases; histologically, the tumor of the bladder was thought to be due to colonic mucosa of familial adenomatous polyposis that had migrated to the bladder lumen via the rectovesical fistula and had become cancerous.
Adenomatous Polyposis Coli↗
Curative surgery for local pelvic recurrence of rectal cancer.
BACKGROUND/AIMS: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. METHODS: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. RESULTS: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. CONCLUSIONS: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.
Aged↗
Extent of surgery in rhabdomyosarcoma of urogenital structures.
After high inguinal semicastration in group-1 paratesticular rhabdomyosarcoma (RMS), the patient having undergone chemotherapy can be followed closely by CT scanning without retroperitoneal lymphadenectomy. In contrast, retroperitoneal RMS should be operated on as radically as possible after downstaging the tumor mass. In RMS of the female genitalia locally limited organ-preserving surgery is the method of choice. The prognosis is excellent with adjuvant chemotherapy. Only 20% of all bladder RMS arise from the bladder dome or the movable part of the bladder, where primary partial resection including a safety margin of 3 cm of healthy tissue is possible. The majority, however, arising from the submucous tissue of the bladder base, trigonal area and bladder neck, infiltrates the prostatic urethra and the surrounding pelvic fascia. Therefore differentiation between primary bladder or prostate RMS is often doubtful. The current strategy of downstaging by chemotherapy or chemo-radiotherapy followed either by limited organ-preserving surgery or by a wait-and-see policy includes the high risk of residual tumor or local tumor recurrence, which has proved to have the worst prognosis of all. As organ-preserving therapy was recommended as the method of choice, mainly to avoid anterior pelvic exenteration and urinary diversion, the question of advantages in comparison to the risk of tumor recurrence is still open. The routine use of chemoradiotherapy and increasing follow-up has called attention to a variety of chronic sequelae, such as contracted bladders with reduced capacity and upper urinary tract deterioration, which subsequently require secondary urinary diversion. Progress in continent urinary diversion may be an alternative procedure for better life quality.(ABSTRACT TRUNCATED AT 250 WORDS)
Antineoplastic Combined Chemotherapy Protocols↗
Phaeochromocytomas of the bladder.
Phaeochromocytomas of the bladder are rare, only about 100 cases having been reported previously. Four adults with these lesions have been managed at Hammersmith Hospital in the past 10 years. Three patients had hypertension, together with syncopal attacks and/or headaches, induced by micturition. The fourth patient presented with haematuria. After control of blood pressure and localization of the tumours by various combinations of cystoscopy, intravenous urography, venous sampling, ultrasound, angiography and computerized coaxial tomography (CT scanning), 3 patients underwent partial cystectomy, and the fourth pelvic exenteration. Two patients were apparently cured of the disease, but 2 were not. One developed modal metastases and recurrence of hypertension after 18 months and one rapidly developed metastases in the lungs and elsewhere. Effective therapy probably requires a high index of suspicion in diagnosing the condition and possibly an aggressive surgical and radiotherapeutic policy.
Adult↗
Cardiac failure associated with hypocalcemia.
Rapid transfusion of citrated whole blood was associated with acute hypotension and a rising central venous pressure in a patient undergoing pelvic exenteration and hemipelvectomy. Evidence of cardiac failure was accompanied by a precipitous decrease in serum ionized calcium (Ca++) concentration. When the rate of blood transfusion was slowed, arterial blood pressure returned to the control level and serum Ca++ increased.
Adult↗
Abdominal sacral resection for posterior pelvic recurrence of rectal carcinoma: analyses of prognostic factors and recurrence patterns.
BACKGROUND: Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns. METHODS: Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted. RESULTS: Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8-28]), a local disease-free interval of <12 months (4.2 [1.8-9.8]), and pain radiating to the buttock or further (4.2 [1.6-11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4-40]). Of the patients with recurrence, 56% had failures confined locally or to the lung. CONCLUSIONS: ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease-free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.
Adult↗