Total pelvic exenteration for pelvic recurrence with complex recto-vaginal and vesicovaginal fistula after surgically treated endometrial cancer

contraindicate the ABSTRACT Local recurrences after surgically treated endometrial cancer with associated vesical and rectal fistula represent a par-ticular eventuality in which the only chance for cure is represented by extended pelvic resections. The aim of the current paper is to present the case of a 62 year old patient diagnosed with a local recurrence invading the urinary bladder and the rectum leading to the development of a complex fistula involving both the urinary and digestive tract after surgically treated endometrial cancer. Although initially the patient was not submitted to pelvic radiation therapy, at the time of relapse the presence of this fistula contraindicated any kind of radiation therapy. Therefore the patient was submitted to a total pelvic exenteration with cutaneous ureterostomy and terminal left colostomy. Another particularity of the patient was the fact that she had an ureteral duplication on the right side, both ureters being functional and exteriorized in right ureterostomy. In conclusion, pelvic exenteration might be a good therapeutic alternative for pelvic recurrences with complex fistulas after surgically treated endometrial cancer.


INTRODUCTION
Endometrial cancer represents one of the most com monly encountered gynecologic malignancies which is usually diagnosed in early stages of the dis ease due to the fact that most often it causes postmen opausal vaginal bleeding which worries the patient and determines her to self refer to the gynecologist [1,2]. In such cases surgery consisting of total hyster ectomy with bilateral adnexectomy and pelvic lymph node dissection remains the first therapeutic option. Meanwhile, this surgical treatment commonly neces sitates association of adjuvant therapeutic strategies such as adjuvant therapeutic radiation therapy, hor monal therapy or chemotherapy. In certain cases re lapse might occur and, depending on the initial treat ment, different therapeutic strategies might be pro posed; therefore, in such cases the proposed ther apy might range from external radiation to bra chytherapy and surgery [35]. However, in such cases the management is chosen accordingly to the dimen sions of the tumors and to the presence of local com plications such as complex digestive and urinary fis tulas. Such complications usually contraindicate the ABSTRACT Local recurrences after surgically treated endometrial cancer with associated vesical and rectal fistula represent a particular eventuality in which the only chance for cure is represented by extended pelvic resections. The aim of the current paper is to present the case of a 62 year old patient diagnosed with a local recurrence invading the urinary bladder and the rectum leading to the development of a complex fistula involving both the urinary and digestive tract after surgically treated endometrial cancer. Although initially the patient was not submitted to pelvic radiation therapy, at the time of relapse the presence of this fistula contraindicated any kind of radiation therapy. Therefore the patient was submitted to a total pelvic exenteration with cutaneous ureterostomy and terminal left colostomy. Another particularity of the patient was the fact that she had an ureteral duplication on the right side, both ureters being functional and exteriorized in right ureterostomy. In conclusion, pelvic exenteration might be a good therapeutic alternative for pelvic recurrences with complex fistulas after surgically treated endometrial cancer.
Keywords: pelvic recurrence, complex fistula, ureteral duplication option of radiotherapy and transforms surgery into the only valid option; therefore, due to the presence of local tumoral invasion multiple visceral resections might be imposed.

CASE REPORT
The 62 year old patient with known history of en dometrial cancer was initially submitted to surgery two years previously; at that time a total hysterecto my with bilateral adnexectomy and pelvic lymph node dissection was performed, the histopathologi cal studies confirming the presence of a stage II en dometroid endometrial adenocarcinoma. However, the patient refused at that moment to be submitted to further adjuvant oncological therapy and did not un dergo to the standard oncological follow up plan. Two years later the patient self referred to our hospi tal for vaginal discharge of urine and stool and was diagnosed with a large pelvic recurrence invading both the urinary bladder and the rectum. Due to the presence of this complex fistula the patient could not be submitted to radiation therapy and therefore she was submitted to surgery. Intraoperatively a large tu mor invading the rectum and the urinary bladder was found; meanwhile lateral extension on the left side was identified. A laterally extended total pelvic exenteration was performed, no macroscopic residu al tissue being encountered at the end of the surgical procedure. The proximal end of the left colon was ex teriorized through left terminal colostomy while the

DISCUSSIONS
Endometrial cancer represents the most com monly encountered gynecologic malignancy diag nosed in women living in developed countries, most cases being found in early stages of the disease [6]. Fortunately most cases are diagnosed in early stages of the disease, when surgery with curative intent fol lowed by radiation therapy represents the most ap propriate therapeutic strategy. In such cases the risk of recurrence in the first three years is lower than 15%, being strongly influenced by the initial histo pathological type, by the initial stage of the lesion and by the completeness of the adjuvant therapy [7].
However, cases in which the adjuvant oncological treatment is not correctly conduced have a signifi cantly higher risk of developing local and even dis tant relapse. Local administration of radiation thera py provides a better sterilization of the surface, therefore diminishing the risks of developing pelvic recurrences; meanwhile, cases in which these recur rences develop might be submitted to radiation ther apy if initially radiotherapy was not administered or the patient was submitted to low doses of irradiation. In cases presenting large pelvic recurrences radia tion therapy is strongly debated due to the fact that the large lesions cannot be destroyed by using only irradiation and due to the fact that local complica tions such as complex digestive and urinary fistulas might be induced; meanwhile, cases in which such abnormal communications already exist become for mal contraindications for radiotherapy [79].
In the case that we came to present the patient neglected the initial diagnosis of malignancy and re fused to complete the standard therapeutic protocol consisting of the administration of adjuvant radia tion therapy; therefore, at the time when the pelvic relapse was diagnosed the first option of treatment could be irradiation; however, the presence of the di gestive and urinary fistulas made impossible the ad ministration of such a treatment, the only possible chance for controlling the local evolution of the dis ease being represented by surgery. In this respect, a total pelvic exenteration was performed with good outcomes, the histopathology report confirming the presence of negative resection margins.
Another particularity of the case that we came to report is the presence of two functional ureters on the right side, both of them being successfully stented and exteriorized in right cutaneous ureterostomy. Ureteral duplication represents an anatomical par ticularity which is found in 0,9% of routine autopsies being more frequently encountered in women [10]. It usually remains asymptomatic for a long period of time and might be only incidentally encountered; in other cases it might be associated with vesicoureteral reflux, urinary tract infection or urolithiasis [11]. In the case we presented, the patient had no symptoms related to this anatomical particularity, this finding being an intraoperative surprise.

CONCLUSIONS
Although most often early stage endometrial can cer has an indolent course and an overall good prog nostic, in certain cases relapse might occur especially if the standard therapeutic protocol is not entirely respected. In such cases local and even distant metas tases might occur; the therapeutic strategy should be tailored accordingly to the anteriorly performed treatment and to the local conditions and particular ities of each case.