Laparoscopic Anterior Exenteration With Intracorporeal Uretero-Sigmoidostomy

Abstract

Study Objective

To demonstrate the feasibility of laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy.

Design

After Institutional Review Board approval was obtained, patients who had undergone laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy were analyzed.

Patients and Methods

Fifty-seven patients with advanced cervical carcinoma, stage IV A, since 2005 were analyzed retrospectively. The preoperative workup was done with contrast-enhanced computed tomography abdomen-pelvis and positron emission tomography (PET) scans. Patients were analyzed for operative time, blood loss, and complications. Patient follow-up was done monthly for the first 3 months, every 3 months for 1 year, and then every 6 months for 3 years. Postoperative follow-up was done with PET scans.

Setting

Galaxy Care Laparoscopic Institute, Pune, India.

Interventions

Operative steps were as follows:

• The ureter was exposed by making an opening medial to the infundibulopelvic ligament.

• The pouch of Douglas was dissected.

• The pararectal space was dissected.

• The ilio obturator lymph node was dissected.

• The bladder was dissected in the prevesical space to the vesicouretharal junction.

• The urethra was separated.

• The specimen delivered through the vagina in an endobag.

• The vault was closed.

• Uretrosigmoidostomy was done with 4-0 Vicryl.

Measurements and Results

The mean operative time was 180 minutes (range, 140-240 minutes), and mean blood loss was 100 mL (range, 50-200 mL), as measured by the amount of blood in the suction machine. The median duration of hospital stay was 4 days (range, 3-7 days). The mean number of lymph nodes retrieved was 12 (range, 9-21). Surgical margins were negative in all patients with a lateral margin >2 cm. Twenty-eight patients had positive lymph nodes. Chemoradiotherapy was given to the patients with positive lymph nodes. Minor leak was present in 11 patients in the immediate postoperative period, for which no active intervention was required. Hyperchloremic metabolic acidosis which was seen on biochemical parameter but clinically patient have no manifestation and was treated with sodium bicarbonate. A postoperative PET scan was done at 6 months after the completion of adjuvant therapy in lymph node–positive patients and 6 months after surgery in node-negative patients.

Conclusion

Exenteration has a definitive role in the treatment of advanced cervical cancer. Results have demonstrated the feasibility of this procedure [1, 2, 3, 4].