En-bloc resection of the pelvis (EnBRP) in patients with stage IIIC-IV ovarian cancer: A 10 steps standardised technique. Surgical and survival outcomes of primary vs. interval surgery.
Tozzi R., Hardern K., Gubbala K., Garruto Campanile R., Soleymani Majd H.
OBJECTIVE: In this study we describe the technique of the En-bloc resection of the pelvis (EnBRP) in 10 standardised and reproducible steps, whereby all pelvic organs, except the bladder, are removed together with the peritoneum. In addition, we compare the surgical and survival outcomes of patients who underwent upfront vs. interval surgery. METHODS: Retrospective analysis of patients with FIGO Stage IIIC-IV ovarian cancer treated with Visceral Peritoneal Debulking (VPD) who had EnBRP. The study population was divided into Group 1 (up-front VPD) and group 2 (VPD after neo-adjuvant chemotherapy). The aim was to assess the incidence of EnBRP. We also assessed rate of complete resection (CR), procedure-specific and overall morbidity, disease free and overall survival. Results were compared between group 1 and 2. RESULTS: Overall 92 out of 200 patients (46%) needed an EnBRP during the VPD. Forty-eight patients were in Group 1 and 44 patients in Group 2. CR was achieved in all patients. No intra-operative procedure specific morbidity was recorded. Dehiscence of bowel anastomosis was the only procedure specific morbidity. Rate was 2%, with 1 episode recorded in each group. Both patients were managed and settled with formation of a bowel diversion. The overall morbidity rate was 33%, 35% in group 1 and 31% in group 2. The mortality rate was 1%. Median disease free survival was 20months, 25 in group 1 vs. 15 in group 2 (P=0.009). CONCLUSIONS: EnBRP is a safe and effective technique to tackle the pelvic disease of patients with advanced ovarian cancer. The reduced blood loss, the high rate of clear margins and CR of the disease are accompanied by a low rate of surgical morbidity. These features are particularly suitable for patients who are due to start or re-start chemotherapy. The standardization of the technique will make it more reproducible and easier to be taught. In addition, it will facilitate comparison of results and the inclusion of this technique in the portfolio of procedures as part of debulking surgery.