[Supralevator total pelvic exenteration for the treatment of radiation-induced vesicorec- tovaginal fistula].

چکیده اصلی

Objective: To investigate the clinical feasibility of supralevator total pelvic exenteration (SLTPE) for radiationinduced vesicorectovaginal fistula (RVRVF). Methods: The clinical data of a 43-year-old female patient diagnosed with R-VRVF and treated with SL-TPE at Shenzhen Second People's Hospital in February 2024 were retrospectively analyzed. Surgical procedures: (1)Laparoscopic exploration: the bowel at the descending-sigmoid colon junction was marked for resection. The posterior space of the left hemicolon was developed, the roots of the inferior mesenteric artery and vein were dissected and ligated, the colonic splenic flexure was mobilized, and a vascularized omental flap was harvested within the gastro-omental vascular arch. Bilateral gonadal vessels and uterine round ligaments were ligated, and the Toldt space and Retzius space were adequately developed; (2)Conversion to open laparotomy: all visceral branches of the internal iliac artery and vein were ligated, and bilateral ureters were ligated and transected adjacent to the bladder; (3) With transanal assistance, the distal rectal mucosa was transected at the dentate line, and the total pelvic organ specimen was en bloc removed; (4) The modified laparoscopic proximally extended colorectal resection with two-stage Turnbull-Cutait pull-through coloanal anastomosis (PE-Bacon) was performed for digestive tract reconstruction. The vascularized omental flap was delivered through the vaginal stump to obliterate the pelvic dead space, followed by application of a basementmembrane patch for abdominopelvic isolation;(5) Secondary coloanal anastomosis was performed 10 days postoperatively. Observation indicators included intraoperative and perioperative outcomes (operative duration, intraoperative blood loss, intraoperative and postoperative complications, and postoperative recovery). Imaging evaluation was performed to assess the efficacy of pelvic floor reconstruction and abdominopelvic isolation. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and low anterior resection syndrome (LARS) score were used to evaluate the patient's general health status and anal function. Results: The operation proceeded uneventfully, with an operative duration of 495 min and intraoperative blood loss of 400 mL. The patient had an uncomplicated postoperative recovery without surgeryrelated complications. Stomarelated flatus and defecation occurred on postoperative day 2; the patient was mobilized outofbed and initiated a liquid diet, with subsequent transition to a semiliquid diet on postoperative day 4. Symptoms including hematochezia and infection were effectively controlled. The patient was discharged on postoperative day 17. Pelvic MRI performed at the 6month followup showed satisfactory results of pelvic floor reconstruction and abdominopelvic isolation, with no signs of tumor recurrence, anastomotic leakage, or pelvic infection, and preserved anal function. On September 24, 2024, the patient underwent bilateral ureteroileal anastomosis plus an ileal conduit (Bricker procedure), combined with basementmembranepatchassisted abdominopelvic isolation and transverse colostomy closure. Postoperative pathological examination showed no residual tumor. The patient has been followed up for 27 months to date, with negative molecular residual disease and sustained tumorfree survival. All functional domains and the global health status of the QLQC30 showed a continuously improving trend, accompanied by marked improvement in quality of life. The LARS score was 8 at the last followup. Conclusion: The SL-TPE procedure is feasible and safe for the treatment of R-VRVF.

ترجمه فارسی چکیده

هدف: بررسی قابلیت بالینی جراحی اگزنتری کلیوی بالای دیافراگم (SLTPE) برای فستولای مجاری ادراری-رکتوواژینال ناشی از پرتودرمانی (RVRVF). روش‌ها: داده‌های بالینی یک بیمار ۴۳ ساله مبتلا به R-VRVF که در فوریه ۲۰۲۴ در بیمارستان مردم شنتن دوم تحت SL-TPE درمان شده بود، به صورت بازنگری تحلیل شد. عملیات شامل اکتشاف لاپاروسکوپی، تبدیل به باز، برداشتن نمونه با کمک مقعدی، بازسازی دستگاه گوارش با روش PE-Bacon، و اتصال مجدد روده به مقعد در مراحل مختلف بود. شاخص‌ها شامل نتایج حین و پس از عمل و ارزیابی تصویربرداری و کیفیت زندگی بود. نتایج: عملیات بدون عارضه انجام شد. بیمار بدون عارضه‌های مرتبط با جراحی بهبود یافت و در روز ۱۷ ترخیص شد. MRI در پیگیری ۶ ماهه نشان‌دهنده بازسازی موفق کف لگن و جداسازی شکمی-لگنی بود. در سپتامبر ۲۰۲۴، بیمار تحت عمل Bricker و بستن کولوستومی قرار گرفت. پیگیری ۲۷ ماهه نشان‌دهنده بقای بدون تومور و بهبود کیفیت زندگی بود. نتیجه‌گیری: روش SL-TPE برای درمان R-VRVF قابل انجام و ایمن است.

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