who is a surgical oncologist at Nepal Cancer Hospital and National Cancer Hospital, and he heads the department. So welcome, doctors. Thank you. Thank you, everyone. Today, I think I will be just talking briefly about our experience with total peculiar concentration with double barrel wet colostomy in these two centers where I'm working. And before this, we used to do this total pelvic excentration since long time, but it was in surgery, which we didn't like very much because we usually used to deal with advanced pelvic cancers, usually some with curative intent where the recurrent is centrally located. If it's associated with vagina, vulva, or locally advanced rectal carcinomas. The extensive surgery required complete R0 resection in most of the cases, and in some, when it is not possible, mainly palliation. I think this surgery was started with Brunswick in 1948, and it has been modified many times, and the latest modification was with Bricker's method. We know the indication usually that recurrent centrally located cancers, sorry, sorry. Centrally located cervical cancers, and most of them, they have already received definite radiation therapy, and any recurrence of pelvic tumor, if it has a chance of cure, this procedure is usually of choice. And if not, then usually we do this surgery for a palliation when we have local diseases, which is causing fistulas, several fistulas like rectovaginal fistulas or vesicovaginal fistulas. And we have to make sure that these patients do not have metastasis like peritoneal metastasis, skip metastasis to bowels, or any distant metastasis, if they have retroperitoneal lymph node dissection, and if they have pelvic salivary infiltrations. Though this is a relative contraindication because there's a procedure called laterally extended endopelvic resection, which is done now, but we have not had the chance of doing this, but these sometimes do take care of the pelvic salivary pelvic sidewalls involvement, which can be done by this method, but we have not done this so far in our settings. And usually if the patient has pedal edema, leg edema, ureteral obstructions, or leg pain, these are also relative contraindication because this suggests that the pelvic wall, like the bone structures or vessels have been infiltrated. So the requirement for this surgery usually is a very, very good imaging, usually with CT scan, now PET scan, or a pelvic MRI showing all the sidewalls involvement, if it's there or not. We usually do sometimes recommend for bone scan in patients who we suspect of bony metastasis and biopsy confirmation to see if the disease is there or not. Another main important part is the psychosocial counseling, which is very important. Like in most of our case, it nearly took us nearly two or three weeks to counsel these patients for these kinds of surgeries, because they are very mutilating and sometimes very depressing surgeries. The procedure we do is usually pelvic, total pelvic excision where we take out our bladder, the vagina and the uterus, along with bilateral salivary gland, both rectum and also the bladder. And they usually require divergence. Usually total pelvic excentration, it's done by two methods. One is supralevator excentration, where we do all the resection from inside the abdomen, where the vesicular urethral junction is resected, where the rectum is resected in the floor of the pelvis, the vagina below the level of tumor with adequate margin that is resected. And another way of doing is infralevator excentration, where we usually need a perineal approach. Here, we do a total vaginectomy, urethritomy, and also the resection of the anus. And this is usually the type of outcome that happens when we finish the surgery. We have two stomas, right and left, where one is an ileal conduit for urinary diversion, and one is the colostomy, where the fecal diversion is done. And we have multiple drains, which makes the people very depressing. Once I had done surgery for two patients in whom we had done these kind of diversions. And both of these patients, medically they did very well, but both of them lost their lives in six months duration, mainly due to depressions. So it was not a very encouraging surgery for a surgeon to do. The problems were difficult. It was a very difficult surgery, required multi-specialty. The complication rate was as high as 40 to 50%, and there was mortality in two to 5% of patients. We even lost one patient in this procedure. And most of the patients usually had at least one complications. But suddenly in 2019, we came across this article, a double barrel with colostomy for total pelvic excentration. I think this changed a lot for total pelvic excentration surgeries. And we started doing this. What we basically do in this is, we usually take the sigmoid colon and do a double barrel colostomy. And in the efferent side, we do a urinary diversion so that from the same stoma, we have both the wet and the bone contents coming out. And as it was just one stoma, it was morally well accepted by a lot of patients. So in our experience, we had nearly four patients. One first patient was a 55 years female with CA cervix. She had post-concurrent CTRT and post-salvage spectrometry was done in 2018. She had undergone chemotherapy with a relapsed rectovaginal fistula. And TPE was done in 2021. Second patient was a 44 year female, again with CA cervix, concurrent CTRT, and again, post-chemotherapy. She had a locally advanced recurrent mass invading the bladder and the rectum. And palliative CT was initiated in that case. This was done also in 2021. We did another case in 2023, but that patient sadly did not make it. And these kinds of surgeries are very rare. And the indication is very slim. So we do not get a lot of cases to do these kinds of surgeries, but we try to do it whenever the conditions are right and all the right parameters are met. And so lately we have done another case, which is our fourth patient. It's a 60 year old female diagnosed with cervical cancer. And sorry. And she had received concurrent radiotherapy 11 years back. And in 2022, she underwent a sigmoid colostomy for rectovaginal fistula. And after that, she came to us about one and a half month ago with a psychovaginal fistula. The biopsy from the ball showed recurrent disease and see the CT scan shows recurrent or residual disease with VVF and rectovaginal fistula. No meds were seen. And for her, we took her for surgery. And this was the first, when we opened the patient, we saw a lot of post radiation changes and a lot of additions. And it took us a very difficult time to undergo the surgery. And we successfully did the pelvic excentration. In this, we can see the catheter tip for the urethra. The rectal wall is somewhere around here and the vagina. We had gone deep down and which was repaired perineally. And then we did an, it was easier for this case because she had already undergone a sigmoid colostomy. So in the end loop from the rectum, we just, proximal rectum, we just did a urethra implant in the efferent sigmoid colon. And this is the right urethra implant. And this is the left urethra implant. And after which the stoma, this is from the article we took so that we could understand how it was done. This is the efferent loop and this is the efferent loop. And here is where we put the urethra and take the urinary diversion from this side whereas the fecal diversion is from this side. And this is the specimen that we took out. And we can see that here, sorry. We can see the rectovaginal fistula and the sacrovaginal fistula. The bladder anterior wall was completely added to the pelvic rim. So when it was taken out, it was, there was a little tear in that. These are the other specimen of the other patients. We did the same surgery. And this is the end result where we have a double barrel colostomy. And patient, because they only have one colostomy, it is more appealing and they have a more acceptable outcome for these patients. Till now, we've had three patients who have undergone this surgery. We are doing well. Two patients have been on follow-up since the last three years and they are doing quite well till now. Now we have another third patient on whom we have finished the surgery and she's just about to be discharged in a day or two. And the advantage of this surgery is that now she has only one stoma. There's a shorter operative time. We do not need bowel resection anastomosis for these cases. The complication rates are less and it really improves the quality of life of these patients and their self-perceptions. It is more acceptable for patients to undergo surgery with just one stoma. So in the end, I'd like to thank my colleagues, Dr. Chitendra, Dr. Anju, Dr. Anu, who are all senior gynecologist in my settings where I work and my colleague, Dr. Hemant Pathazu, who is a surgical oncologist with me and our anesthesia team of Dr. Sunita and her team who have helped us immensely in this surgery. Thank you very much. And if any question, I'd be more than happy to answer. And this is the article which is there in the website and it's a very good article and it really changed the way we do surgery for total pelvic excentration. And if possible, I'd like everyone to go through it. Thank you.

total pelvic exenteration

double-barrel wet colostomy

multidisciplinary team

advanced pelvic cancers

psychosocial outcomes