1. Nalley, Catlin

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Researchers found that the rate of 30-day postoperative complications following pelvic exenteration remains high among gynecologic cancer patients. Study findings were recently presented at the Society of Gynecologic Oncology 2021 Virtual Annual Meeting.

Gynecologic cancer. ... - Click to enlarge in new windowGynecologic cancer. Gynecologic cancer

"There are several gynecologic indications for pelvic exenteration, including central recurrence or persistence of cervical cancer or other gynecologic malignancy within a radiated field," explained Alyssa Mercadel, MD, at UT Southwestern Medical Center, who noted that other potential indications for this procedure include primary debulking of ovarian cancer, primary stage IVA cervical cancer with a vesicovaginal or rectovaginal fistula, or for palliative measures.


Pelvic exenterations were first described by Dr. Alexander Brunschwig in 1948, according to Mercadel. "They were performed as a palliative procedure for pain and other discomforts attributed to locally advanced gynecologic cancer," she said. "During the study, he did not take into account preoperative factors such as the patient's age, nutritional or functional status, or medical comorbidities. The first surgeries were associated with significant morbidity and mortality, and 23 percent of patients died within 16 days of surgery."

Alyssa Mercadel, MD.... - Click to enlarge in new windowAlyssa Mercadel, MD. Alyssa Mercadel, MD

Several decades later, a retrospective review of exenterations performed at Memorial Sloan Kettering Cancer Center between 1972 and 1981 found a significant improvement in operative mortality, with a decrease to 9.2 percent from a previously observed rate nearing 25 percent, Mercadel reported.


"They suggested that the improved mortality rate was due to more extensive preoperative evaluation and preparation, improved surgical techniques, better blood banking, and more modern ICU facilities," she noted. "From their cohort, they noted urinary tract infections, pneumonia, pelvic cellulitis, and intra-abdominal infections as significant causes of postoperative morbidity."


More recent data suggests a continued improvement in postoperative complication and mortality rates. "Even as we see declining complication rates in the setting of modern medicine, we strive to improve our patients' outcomes," Mercadel said. "Beyond newer techniques and surgical advances, patient selection can further decrease the associated morbidity and mortality of an exenteration procedure."


Methodology & Results

The current study sought to evaluate 30-day postoperative complication rates following pelvic exenterations for gynecologic malignancies, as well as identify associated patient and perioperative risk factors. Researchers used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. They identified patients who underwent pelvic exenterations for a gynecologic cancer from 2012 to 2018.


"Comparative analyses were performed and stratified by postoperative complication development to evaluate demographics, preoperative and interoperative variables, and surgical outcomes," noted Mercadel.


The median age at the time of surgery was 59 years old and median BMI was 26.1. Most patients were Caucasian and functionally independent. The majority of indications for exenterations in this patient cohort were either cervical or ovarian cancer, according to Mercadel.


"Postoperative complications were identified in 74 percent of those performed for gynecologic malignancies," she reported. "The most common [postoperative complication] by far was the administration of blood products with over two-thirds of patients undergoing either an intraoperative or postoperative transfusion.


"Nearly a quarter of patients develop a surgical site infection, and 20 percent of patients were readmitted to the hospital within 30 days," she continued. "There was no significant difference in median age or BMI between those who did and did not develop postoperative complications."


While lower rates of postoperative complications were observed in Asian and Black patients, Mercadel noted that there was only a small number of minority patients included in the database.


"We evaluated the role of preoperative risk factors on postoperative complications," Mercadel said. "Lower preoperative albumin and hematocrit levels and higher ASA (American Society of Anesthesiology) classes were associated with postoperative complications. There was no difference seen in preoperative functional status, but overall, most patients were completely independent."


Additionally, Mercadel reported that longer operative times and myocutaneous flap or urinary conduit procedures performed at the time of exenterations were associated with postoperative complications.


Seventy-nine percent of patients were discharged home, 20 percent of patients went to an acute care or rehab facility, and 0.4 percent of patients expired within 30 days of surgery, according to Mercadel.


"Lower preoperative albumin and hematocrit levels, longer operative times, higher ASA class, and concurrent flap or urinary conduit procedures were associated with higher postoperative complication rates," she outlined. "When adjusting for these factors on multivariate analysis, preoperative albumin levels and longer operative times remained independent risk factors for higher complication rates."


Concluding the presentation, Mercadel noted that there remains a high rate of 30-day postoperative complications following pelvic exenteration. "Although, based on our data, a significant proportion of the complications are driven by surgical site infections and administration of blood transfusions," she noted.


"The contemporary mortality rate appears to be lower than previously recorded historical rates, which is likely due to continued advances in surgical technique and minimally invasive approaches," Mercadel explained. "Unfortunately, at this time there is no CPT code for laparoscopic pelvic exenteration and, therefore, we are unable to differentiate between open and minimally invasive exenteration.


"This study represents one of the largest cohorts to date of patients with gynecologic cancer undergoing public exenteration," she concluded.


Catlin Nalley is a contributing writer.