Application of robot-assisted laparoscopic pelvic exenteration in treating gynecologic malignancies

Abstract

Introduction Pelvic exenteration (PE) refers to the en bloc resection of the involved pelvic organs along with pelvic reconstruction so as to enhance the survival rate for tumor patients. First reported by Brunschwig in 1948,[1] PE has thereafter been utilized to treat rectal cancer, bladder cancer, prostate cancer, and cervical cancer as a curative or palliative treatment for advanced or recurrent malignancies. It is critical to carry out surgical resection of all the involved tumor lesions so as to prolong the overall survival (OS) of patients; nonetheless, such medical manipulation will induce various complications. For patients undergoing radiotherapy in the initial treatment, the increased tissue fragility, together with inflammation, has become trouble intraoperatively.[2] Robot-assisted laparoscopic surgery is developed on the basis of traditional laparoscopy, which has completely inherited the superiorities of laparoscopic surgery. More importantly, it can achieve a more stereoscopic visual field as well as more precise operation through establishing the three-dimensional visual field, and using the inner wrist system as well as the tremor filtering system. Moreover, it can accurately return to the last operation area through the presetting and memory function of its system software, which can, thus, contribute to avoid miscarriage, further reduce intraoperative blood loss, and decrease the occurrence of intraoperative complications.[3,4] In 2009, Lim et al[5] had first performed the robot-assisted laparoscopic PE (RALPE) combined with ileal loop urinary diversion for a relapsed cervical cancer patient. The operation time was 375 min, the blood loss was about 375 mL, and no intra- or post-operative complications were observed. Thereafter, surgical teams from countries all over the world have continuously applied RALPE in treating gynecologic malignancies. This study aimed to review the application of RALPE in treating gynecologic malignancies, including its indications, methods and feasibility, complications, and follow-up. Indications for RALPE Gynecologic malignancies have not only posed a severe threat to women's lives, but also caused various complications due to the invasion to surrounding tissues and organs, thus seriously affecting the quality of life of these patients. Surgery is not recommended in the guidelines to be the preferred choice for advanced cancer; in addition, surgical treatment has been generally recognized to be of limited value for patients developing distant metastasis.[6] As a result, physicians should carefully and strictly select the appropriate patients so as to ensure the safety and effectiveness of surgery. Specifically, factors including previous treatment history, size of recurrent tumors, distant metastasis, negative margin, the general condition of patients, economic conditions, and treatment intention should be evaluated preoperatively. Over the last decades, the indication for PE has evolved from the classical indication of centrally persistent or recurrent cervical cancer to the locally advanced primary cancers or the recurrent endometrial, vulvar, vaginal, and ovarian cancers in selected cases; notably, pelvic sidewall recurrence is no longer an absolute contraindication.[2,7,8] In a recent monocentric cohort study carried out by Knight et al,[9] the frequency of PE performed during four successive periods had been evaluated, and it was concluded that the indications for PE had evolved toward the curative intents, though PE was initially developed to manage palliative situations with severe pelvic symptoms (such as fistulas, bleeding, visceral, and parietal pain) with no other therapeutic options. Typically, the increased success rate of curative PE can be attributed to the better selection of patients. However, it remains controversial regarding the importance of nodal involvement, though some studies have associated it with poor patient prognosis.[10,11] Meanwhile, some other st