Application of Robot-Assisted Laparoscopic Pelvic Exenteration in Treating Gynecologic Malignancies
Pelvic exenteration (PE) is a radical surgical procedure involving the en bloc resection of pelvic organs, often performed to treat advanced or recurrent gynecologic malignancies. First introduced by Brunschwig in 1948, PE has evolved significantly over the decades, becoming a critical intervention for patients with cervical, endometrial, vulvar, vaginal, and ovarian cancers. The procedure aims to achieve complete tumor resection, thereby improving overall survival (OS) rates. However, PE is associated with significant morbidity and complications, particularly in patients who have undergone prior radiotherapy, which increases tissue fragility and inflammation.
The advent of robot-assisted laparoscopic surgery has revolutionized the field of minimally invasive surgery. Building on the principles of traditional laparoscopy, robotic surgery offers enhanced precision, a three-dimensional visual field, and advanced instrumentation, including tremor filtering and wristed instruments. These features allow for more accurate and less traumatic surgical procedures, reducing intraoperative blood loss and postoperative complications. In 2009, Lim et al. performed the first robot-assisted laparoscopic pelvic exenteration (RALPE) combined with ileal loop urinary diversion for a patient with recurrent cervical cancer. Since then, RALPE has gained traction worldwide as a viable option for treating gynecologic malignancies.
This article provides a comprehensive review of the application of RALPE in gynecologic malignancies, focusing on its indications, surgical methods, feasibility, complications, and follow-up outcomes.
Indications for RALPE
Gynecologic malignancies pose a significant threat to women’s health, often leading to severe complications due to the invasion of surrounding tissues and organs. Surgery is generally not the first-line treatment for advanced or metastatic cancers, as its curative potential is limited in such cases. However, PE has emerged as a valuable option for selected patients with locally advanced or recurrent tumors.
The indications for PE have evolved over time. Initially, PE was primarily used for centrally persistent or recurrent cervical cancer. However, its scope has expanded to include locally advanced primary cancers and recurrent endometrial, vulvar, vaginal, and ovarian cancers. Notably, pelvic sidewall recurrence, once considered an absolute contraindication, is now considered a potential indication for PE in certain cases. The selection of appropriate candidates for PE requires careful evaluation of factors such as previous treatment history, tumor size, distant metastasis, surgical margins, patient general condition, economic status, and treatment intent.
Recent studies have highlighted the shift from palliative to curative intent in PE. Improved patient selection and surgical techniques have contributed to higher success rates. However, the role of nodal involvement remains controversial, with some studies associating it with poor prognosis, while others do not consider it a contraindication. Preoperative imaging, including positron emission tomography-computed tomography (PET-CT), is recommended to exclude distant metastasis and ensure optimal patient outcomes.
Surgical Methods and Feasibility of RALPE
Surgical Preparation and Techniques
RALPE involves a complex preparation process, including patient positioning, trocar insertion, and docking of the robotic arms. An experienced surgical team can complete these steps within 15 minutes. The robotic system provides a comfortable and flexible platform for the surgeon, particularly in time-consuming multidisciplinary procedures like PE.
PE can be classified into three types based on the extent of resection: anterior pelvic exenteration (APE), posterior pelvic exenteration (PPE), and total pelvic exenteration (TPE). APE involves the removal of the bladder, PPE involves the removal of the rectum, and TPE involves the removal of both organs. Reconstruction following PE is a critical component of the procedure. Urinary reconstruction options include incontinent urinary diversion (e.g., ileal conduit), continent urinary diversion (e.g., Miami pouch), and orthotopic neobladder. Incontinent urinary diversion is the most commonly used method due to its simplicity and lower complication rates. However, continent diversion offers better long-term quality of life, albeit with a higher risk of late complications.
Gastrointestinal reconstruction options include coloanal anastomosis and colostomy. The choice of reconstruction depends on the patient’s condition and the surgeon’s expertise. In general, colostomy is preferred for patients with low anastomotic sites or excessive tension.
Feasibility and Safety of RALPE
RALPE has been shown to be a safe and feasible procedure with several advantages over traditional open surgery. Among the 23 reported cases of RALPE, 17 underwent APE, with an average operation time of 317.65 minutes, average blood loss of 229.41 mL, and average postoperative hospital stay of 11.6 days. Urinary reconstruction was performed using the Miami pouch in five cases and ileal conduit in 12 cases.
TPE was performed in six patients, with an average operation time of 447.67 minutes, average blood loss of 490 mL, and average postoperative hospital stay of 19.6 days. Urinary reconstruction methods included ureterocutaneostomy, ileal conduit, and ureterosigmoidostomy. Intestinal reconstruction involved end colostomy in four cases and coloanal anastomosis in two cases.
RALPE is associated with reduced blood loss and lower complication rates compared to open surgery. However, due to the limited number of cases, there is a need for more prospective clinical trials to compare the outcomes of RALPE with traditional laparoscopy and open surgery.
Postoperative Complications
Postoperative complications following RALPE are primarily related to urinary and gastrointestinal reconstruction. Among the 23 cases, complications included perineal abscess, Miami stoma fistula, pyelonephritis, ureteral stenosis, septic shock, renal insufficiency, and colonic anal anastomotic fistula. These complications were more common in patients who underwent continent urinary diversion, particularly those over 55 years of age.
To minimize complications, it is recommended that continent urinary diversion be performed by experienced surgical teams, while incontinent diversion (e.g., ureterocutaneostomy or ileal conduit) is preferred for elderly patients or those with impaired renal function. Careful evaluation of the anastomotic site is essential for gastrointestinal reconstruction, with colostomy being a safer option in cases of low anastomosis or excessive tension.
Follow-up Outcomes
The survival rate following PE has improved significantly in recent years, with postoperative survival rates increasing from 20% to 60%. Among the 16 cases with follow-up data, 31.25% experienced recurrence or metastasis. Negative surgical margins were achieved in 92.86% of cases, highlighting the importance of complete tumor resection.
Preoperative PET-CT is recommended to exclude distant metastasis and improve long-term outcomes. Despite the risks and costs associated with PE, it remains a valuable option for selected patients with advanced or recurrent gynecologic malignancies.
Conclusion
RALPE is a promising minimally invasive approach for treating gynecologic malignancies, particularly recurrent cervical cancer. The procedure offers several advantages, including reduced blood loss, fewer complications, and faster recovery. However, its application remains limited, and further research is needed to establish its efficacy compared to traditional surgical methods. Comprehensive preoperative evaluation, including PET-CT, is essential to ensure optimal patient outcomes. The experience of the surgical team and the patient’s general condition should also be considered when selecting reconstruction methods.
doi.org/10.1097/CM9.0000000000000202
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