Rationale for bladder-sparing surgery in patients with locally advanced colorectal carcinoma

A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer

INTRODUCTION

Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer.

METHODS

A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded.

FINDINGS

A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months.

CONCLUSIONS

This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.

Radical Resection for Locally Advanced Colon Cancer With Bladder Involvement Treated in a Tertiary Health Care Centre

Colorectal cancer with involvement of the urinary bladder is infrequent in the nonmetastatic setting. Procedures for advanced colorectal cancers with bladder involvement may include partial or complete bladder resections. Proper therapeutic management principles dictate radical surgery when negative margins can be obtained. High-resolution CT imaging along with endoscopic evaluation of the urinary bladder is frequently required to assess the extent of urinary bladder dissection. Here, we present a case of adenocarcinoma of the sigmoid colon with urinary bladder involvement and its treatment.

Risk factors that impact long-term outcomes in sigmoid colon cancer with urinary bladder involvement

PURPOSE

This study aimed to identify the risk factors impacting long-term outcomes in patients diagnosed with sigmoid colon cancer with urinary bladder involvement.

METHODS

A comprehensive analysis was conducted on a retrospective cohort of 118 patients who underwent multivisceral resection for sigmoid colon cancer with urinary bladder involvement between June 2002 and May 2017. Univariate and multivariate analyses were employed to identify risk factors associated with long-term outcomes.

RESULTS

Among the included patients, 10 (8.5%) experienced grade III-IV complications according to Clavien-Dindo classification, with 4 (3.4%) presenting anastomotic leaks. The postoperative mortality was 0.8%. R0 resection was achieved in 108 (91.6%) patients. Adjuvant chemotherapy was administrated to only 31 patient (26.3%). Local recurrence was observed in 8 (6.8%) cases. Risk factors for local recurrence-free survival and disease-free survival were CCI>3, grade III-IV postoperative complications according to Clavien-Dindo classification, positive resection margins, stage III of the disease, additional resected organs (excluding colon and bladder) and the absence of adjuvant chemotherapy. The same risk factors, with the exception of CCI, were associated with overall survival.

CONCLUSION

This study highlights that negative resection margins, a postoperative period without grade III-IV complications, and the implementation of adjuvant chemotherapy are crucial factors contributing to improve overall, disease-free and local recurrence-free survival in patients with sigmoid colon cancer with urinary bladder involvement.

Laparoscopic Pelvic Exenteration with Bladder Sparing for Men with Locally Advanced Rectal Cancer (with Video)

OBJECTIVE

The aim of this article was to introduce a fascial space priority approach for laparoscopic pelvic exenteration (PE) with bladder-sparing for men with locally advanced rectal cancer.

METHODS

We present a video of bladder-sparing laparoscopic PE with fascial space priority approach in a 70-year old man. The systematic de-arterialization of the prostate on the basis of complete separation of the avascular lateral pelvic spaces is introduced in detail.

RESULTS

The operation time was 360 min and the estimated intraoperative blood loss was 50 mL. The postoperative course was uneventful and the patient was discharged on postoperative day 14. Histopathological examination showed all margins to be tumor-free.

CONCLUSIONS

Bladder-sparing laparoscopic PE using a fascial space priority approach is a feasible and safe procedure that can be performed in well-selected patients following neoadjuvant chemoradiotherapy. Extensive multivisceral resection is possible without a permanent stoma.

Advanced colonic cancer with clinically suspected bladder invasion: Outcomes and prognosis from a multicentric study of 117 patients from the FRENCH research group

BACKGROUND

Bladder invasion by colon cancer is rare; however, its management is still controversial. Our objective was to report outcomes and identify risk factors for local recurrence in colon cancer with clinically suspected bladder invasion.

METHODS

We conducted a retrospective study in 23 centers in France. All patients who underwent colon surgery with bladder resection (2010-2017) were included. Metastatic and recurrent colon cancers were excluded.

RESULTS

One hundred and seventeen patients (men = 73) were included. Partial cystectomy occurred in 108 patients (92.3%), with a total cystectomy occurring in 9 patients (7.7%). Neoadjuvant treatment was given to 31 patients (26.5%). Major morbidity was 20.5%. R0 resection rates were 87.2%. Histologically confirmed bladder invasion was present in 47%. Thirty-four patients were pN+, while 60 patients (51.3%) received adjuvant chemotherapy. Mean follow-up was 33.8 months. Three-year overall survival and disease-free survival were 82.9% and 59.5%. Rates of local recurrence and distant recurrence were 14.5% and 18.8%, respectively; the local recurrences (11/17; 65%) were in the bladder, while 4 of these patients had a bladder recurrence despite not having histologically confirmed bladder invasion at the index surgery. The rate of bladder recurrence after histologic bladder invasion was 13% (7/55), while the rate of bladder recurrence without primary bladder invasion was 7% (4/62) (P = .343). Neoadjuvant therapy, type of cystectomy, and adjuvant therapy did not influence local recurrence (P > .445 each). R1 bladder resections, when compared with a R0 bladder resections, were associated with an increased rate of local recurrence (63% vs 10%; P < .0001).

CONCLUSION

Clinically suspected bladder invasion increases local recurrence even in the absence of histologically confirmed bladder invasion. Only complete resections with R0 margins decrease local recurrence. Careful, detailed postoperative surveillance is required, even without pathologic bladder invasion.

Resection of the urinary bladder for locally advanced colorectal cancer: a retrospective comparison of partial versus total cystectomy

Background

The postoperative and survival outcomes of patients with primary advanced colorectal cancer who undergo partial versus total cystectomy have not been adequately compared, as studies of this topic are rare and comprise relatively small cohorts. This study aimed to investigate the short- and long-term outcomes of patients who underwent en bloc partial or total cystectomy for primary advanced colorectal cancer that was suspected of adhering to or invading the urinary bladder.

Methods

The study included 90 patients who underwent various degrees of cystectomy between 1993 and 2013 to treat locally advanced primary colorectal cancer that was suspected of involving the urinary bladder. Patients in whom total cystectomy was performed solely because of prostate-invading lower rectal cancer were excluded. Data on patient characteristics and their short- and long-term outcomes were collected retrospectively to evaluate differences between partial cystectomy (the P group; n = 72) and total cystectomy (the T group; n = 18). Postoperative and oncologic outcomes were also analyzed.

Results

The T group had significantly greater operating times than the P group (median, 572 vs. 346 min); blood loss volume was also greater in the T group (median, 3092 vs. 1112 mL). The postoperative overall complication rate was significantly greater in the T group than in the P group (94.4% vs. 51.4%). With a median follow-up duration of 62 months, local recurrences were observed in 22.2 and 6.9% of patients in the T and P groups, respectively. On multivariate Cox regression analyses using partial cystectomy as the reference, total cystectomy was independently associated with poorer local recurrence-free survival (hazard ratio [HR], 4.0 95% confidence interval [CI], 1.1–15.0), relapse-free survival (HR, 2.9; 95% CI, 1.2–6.9), and overall survival (HR, 2.1; 95% CI, 1.0–4.3).

Conclusions

Patients who undergo en bloc total cystectomy for locally advanced colorectal cancers have worse postoperative and oncologic outcomes than those who undergo partial cystectomy.

Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study

AIM

Involvement of the anterior mesorectal fascia (iAMRF) after neoadjuvant treatment leads to either resection of the involved organ alone [extended resection of the rectum (ERR)] or total pelvic exenteration (TPE). The purpose of this study was to compare the rate of recurrence and survival of patients undergoing ERR or TPE for iAMRF after neoadjuvant treatment. The outcome of patients who underwent total mesorectal excision after downstaging was also compared.

METHOD

This was a retrospective study of primary rectal cancer patients.

RESULTS

Of 237 patients, 61 (21.5%) patients with nonmetastatic carcinoma rectum had iAMRF at baseline. Ten patients defaulted before completion of neoadjuvant chemoradiotherapy. After neoadjuvant chemoradiotherapy, 22 patients (43.1%) developed systemic metastases, seven patients (13.8%) were downstaged to free anterior mesorectal fascia and underwent total mesorectal excision (anterior resection/abdominoperineal resection) and the remaining 22 patients (43.1%) had persistent iAMRF. Thirteen patients with persistent iAMRF underwent ERR, whereas nine patients underwent TPE. The median duration of hospital stay in the TPE group was 13 days (10-26), whereas it was 7 days (5-21) in the ERR group. A clear circumferential resection margin, R0 resection, was achieved in all patients with TPE and ERR. After a median follow-up of 31.6 months, five patients with TPE (55.6%), four patients with ERR (30.7%) and three patients in the downstaged group (42.9%) developed systemic recurrence. None of the patients with TPE and the downstaged group developed local recurrence, whereas three patients with ERR (23.1%) developed local recurrence. Median disease-free survival was 12.3 months in the TPE group, 18.9 months in the ERR group and 10.6 months in the downstaged group, whereas mean overall survival was 36.2, 32.8 and 27.9 months, respectively.

CONCLUSION

Although there is no significant difference in the overall survival and disease-free survival, ERR is associated with a high risk of local recurrence compared to TPE and the downstaged group.

Bladder Invasion in Patients with Advanced Colorectal Carcinoma

Involvement of the bladder by colorectal cancer is sufficiently rare to be encountered by an individual surgeon on an infrequent basis. Extirpative procedures for advanced colorectal cancers can involve partial/total bladder resections. In patients without evidence of distant metastatic disease, a reasonable therapeutic effect can be expected when negative surgical margins are obtained. The decision to perform a bladder-sparing procedure or a total pelvic exenteration (TPE) will be based on the extent of the primary lesion as well as patient characteristics. In this study, we report our experience in the management of operable locally advanced colorectal carcinomas involving the urinary bladder. We retrospectively reviewed the hospital records of all patients with advanced colorectal cancer invading the urinary bladder. The age, gender, clinical presentation, physical examination findings, and imaging records were noted. Colonoscopy reports and images were noted and biopsy findings recorded. Similarly, cystoscopy findings and biopsy reports were noted and analyzed. Eight (88%) patients had a primary sigmoid tumor and one (11%) had primary rectal tumor. The clinical staging of the primary tumor was T3 in three (33%) and T4 in six (66%). A biopsy taken during cystoscopy confirmed the malignant lesion in all the nine patients. Four (44%) patients received neoadjuvant chemotherapy with 5-fluorouracil. Eight (88%) patients underwent bladder-sparing resection and the remaining one underwent total pelvic exenteration with ileal conduit for urinary drainage. The mean overall survival was 44 months. The wide spectrum of possible bladder involvement by colorectal cancer requires individual patient-specific and disease-specific approaches. En bloc bladder resection for adherent or invading colorectal cancers achieves good local control and prognosis. The potential for cure in completely excised, node-negative tumors is good. Bladder reconstruction is achievable in most patients.

Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy

Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.

Laparoscopic-assisted abdominoperineal resection combined with en-bloc prostatectomy using the trans-sacral approach for locally invasive rectal cancer: A case report

Laparoscopic-assisted abdominoperineal resection and en-bloc prostatectomy using the trans-sacral approach for locally invasive rectal cancer that invades only the prostate is useful in order to avoid total pelvic exenteration. The patient was a 63-year-old man with cT4b (prostate) N1M0, stage IIIC rectal cancer. Curative resection was performed. Histopathological findings did not indicate definitive invasion into the prostate gland. The patient was discharged from the hospital on postoperative day 32 with an anastomotic leak and a ureteral catheter. The patient is able to urinate and has had no cancer recurrence. Laparoscopic bladder-preserving surgery for locally invasive rectal cancer can preserve postoperative quality of life and provides oncological curability.

Efficacy of an additional flap operation in bladder-preserving surgery with radical prostatectomy and cystourethral anastomosis for rectal cancer involving the prostate

Purpose

Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation.

Methods

The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps.

Results

Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8–108 weeks) in those without a flap and 16 weeks (8–20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery.

Conclusion

An additional flap operation may decrease the risk of leakage from a CUA.

Combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy for synchronous double cancer of the rectum and the prostate

Here we report a combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy. A 74-year-old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic-assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

AIM

The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options.

METHOD

A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the status of the pathological circumferential resection margin (CRM) and local recurrence.

RESULTS

A consecutive series of 126 men with rectal cancer threatening (44) or affecting (82) the prostatic plane on preoperative staging and operated with local curative intent between 1998 and 2010 was analysed. In patients who did not have chemoradiotherapy but had a preoperative threatened anterior margin the CRM-positive rate was 25.0%. In patients who did not have preoperative chemoradiotherapy but did have an affected margin, the CRM-positive rate was 41.7%. When preoperative radiotherapy was given, the respective CRM infiltration rates were 7.1 and 20.7%. In patients having preoperative chemoradiotherapy followed by prostatic resection the rate of CRM positivity was 2.4%. Partial prostatectomy after preoperative chemoradiotherapy resulted in a free anterior CRM in all cases, but intra-operative urethral damage occurred in 36.4% of patients who underwent partial prostatectomy, resulting in a postoperative urinary fistula in 18.2% of patients.

CONCLUSION

Preoperative chemoradiation is mandatory in male patients with a threatened or affected anterior circumferential margin on preoperative MRI. In patients with preoperative prostatic infiltration, prostatic resection is necessary. In this group of patients partial prostatectomy seems to be oncologically safe.

Cystoprostatectomy versus prostatectomy alone for locally advanced or recurrent pelvic cancer

BACKGROUND

There is minimal published data evaluating the oncological outcome of rectal resection with prostatectomy alone versus rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer. This study aims to evaluate the oncological and functional outcomes of performing rectal resection with prostatectomy alone compared with rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration.

METHODS

Consecutive patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer between 1998 and 2012 were identified from a prospectively maintained database. Patients undergoing rectal resection with prostatectomy alone were compared with a control group who underwent rectal resection with cystoprostatectomy and urostomy formation. The primary outcome was overall survival. Secondary outcomes analysed in the prostatectomy group included completeness of resection, continence and erectile function.

RESULTS

Eleven rectal resections with prostatectomy were compared with 20 rectal resections with cystoprostatectomy. R0 resection was achieved in 73 and 65% respectively. There was no difference in overall survival (P = 0.40). Urinary continence was achieved in 36% of prostatectomy alone patients, while 27% experienced mild incontinence. Erectile function was poor, with only one patient able to maintain normal erections.

CONCLUSION

In appropriately selected patients with invasive pelvic tumours, rectal resection with prostatectomy alone provides adequate oncological outcomes. The ability to achieve an R0 resection was not compromised and overall survival is comparable with cystoprostatectomy. Urinary function is reasonable in most patients, although sexual function is compromised in almost all.

Combined radical prostatectomy and abdominoperineal resection for locally invasive rectal cancer

INTRODUCTION

An infiltration of urological organs is found in 5–10% of patients with colorectal carcinoma. Total pelvic exenteration is the standard procedure for locally advanced rectal cancer. In selected patients with rectal cancer involving the prostate or seminal vesicles, the bladder can be preserved and en bloc radical prostatectomy with abdominoperineal rectal resection can be performed. We report two patients who treated with this combined approach.

PRESENTATION OF CASE

Two patients with symptoms of rectal bleeding and pelvic pain were investigated. Colonoscopy demonstrated a tumor in the lower rectum. Biopsies revealed adenocarcinoma. Both pelvic MRI and endorectal ultrasound showed tumors that invaded the prostate and the seminal vesicles directly but without invasion of the bladder. After neoadjuvant chemoradiation, combined radical prostatectomy and abdominoperineal amputation was performed. None has developed local recurrence, but one of them was operated on for a single lung metastasis. After a follow-up of 28 and 20 months, respectively, the patients are alive without evidence of local recurrence or distant disease.

DISCUSSION

This procedure obviates the need for urinary diversion without compromising the local tumor control. Intraoperative and postoperative diagnostic difficulties, and clinical aspects in relation to postoperative anastomotic leak and survival of patients are discussed.

CONCLUSION

En bloc radical prostatectomy and proctosigmoidectomy is feasible in selected patients with rectal cancer and invasion limited to the prostate or seminal vesicles because it provides good local tumor control and significantly improves the patient's quality of life in comparison to total pelvic exenteration.

Outcome of urinary bladder recurrence after partial cystectomy for en bloc urinary bladder adherent colorectal cancer resection

PURPOSE

Around 10 % of colorectal cancers are locally advanced at diagnosis. There are higher incidences for sigmoid and rectal cancer adhered to urinary bladder (UB) rather than other segments of colon cancer. Surgeons often performed partial cystectomy as possible for preservation of patient's life quality. This study investigates prognostic factors in patients who underwent bladder preservation en bloc resection for UB adherent colorectal cancer.

METHODS

From 2000 to 2011, 123 patients with clinically UB involvement colorectal cancer underwent primary colorectal cancer with urinary bladder resection. Seventeen patients were excluded because of the concurrent distant metastasis at diagnosis and another 22 patients were excluded because of total cystectomy with uretero-ileal urinary diversion. Finally, 84 patients with clinical stage IIIC (T4bN0M0, according to AJCC 7th edition) that underwent en bloc colorectal cancer resection with partial cystectomy were enrolled into this study for further analysis.

RESULTS

Preoperative colovesical fistula and positive CT result were significantly more in the urinary bladder invasion group (p = 0.043 and 0.010, respectively). Pathological UB invasion is an independent predictor of intravesical recurrence (p = 0.04; HR, 10.71; 95 % CI = 1.12∼102.94) and distant metastasis (p = 0.016; HR, 4.85; 95 % CI = 1.34 ∼ 17.53) in multivariate analysis.

CONCLUSIONS

For bladder preservation en bloc resection of urinary bladder adherent colorectal cancer, the pathological urinary bladder invasion is significantly associated with more urinary bladder recurrence and distant metastasis. This result helps surgeons make decisions at surgical planning and establish follow-up protocol.

[Major urologic surgical procedures in locally advanced colorectal cancers]

OBJECTIVE

To evaluate the outcomes of major urological procedures performed in patients with locally advanced colorectal cancer.

MATERIAL AND METHODS

Data of 37 patients with locally advanced colorectal cancer who underwent major urological surgical procedures along with simultaneous cancer surgery between the years of 2005 and 2010 were retrospectively evaluated.

RESULTS

The mean age was 58.3 years. Male/Female ratio was 2.7. 59% of the patients were primary, and 41% were recurrent cases of colorectal cancer. Bladder, ureters, urethra, kidneys and prostate were found as invaded in 19, 9, 5, 2 and 2 cases, respectively. The following single or combined procedures were performed; partial (n=11) or total (n=8; 2 combined with urethrocutaneostomy, 6 with ileal-conduit) cystectomy, urethroplasty (n=5), nephroureterectomy (n=2), radical nephrectomy (n=1), partial nephrectomy (n=1), ureteroneocystostomy (n=7), Boari's flap (n=4), transureteroureterostomy (n=3). Prolonged drainage was the most common surgical complication (27%). Urethrocutaneous fistula and total urinary incontinence were encountered in 1 and 1 patient, respectively. The incidence of hydronephrosis and elevated creatinine were 38% (preoperative 27%; postoperative 11%) and 24% (11% preoperative; 13% postoperative), respectively. Two deaths occurred in the first month of operations. Mean duration of follow up was 18(6-28) months for surviving 13 patients. Overall survival in 24 cases resulting in death was 21(1-42) months.

CONCLUSIONS

Since the most important eventual effects of locally advanced colorectal cancer are on the kidneys from the urological point of view; the aim of an urologist, as a member of surgical team, should be preserving renal function in addition to helping complete removal of the tumor.

En bloc urinary bladder resection for locally advanced colorectal cancer: a 17-year experience

BACKGROUND AND OBJECTIVES

En bloc bladder resection is often required for treating colorectal cancer with suspected urinary bladder invasion. Our aim was to review our institutional experience in en bloc resection of locally advanced colorectal cancer involving the urinary bladder over a period of 17 years.

METHODS

The hospital records of 72 patients with locally advanced colorectal cancer who underwent en bloc urinary bladder resection at our institution between July 1987 and December 2004 were retrospectively reviewed. Clinical and oncologic outcomes were evaluated.

RESULTS

The mean duration of follow-up was 64.3 months. Genuine tumor invasion into the urinary bladder was confirmed in 34 patients (47%) by histopathology. Forty patients (56%) underwent primary closure of the urinary bladder, while 32 patients (44%) required various kinds of urologic reconstructive procedures. Operative mortality occurred in four patients (6%). The overall postoperative morbidity rate was significantly higher in patients undergoing urologic reconstruction (81% vs. 45%, p = 0.002) when compared to that in patients undergoing primary closure. This was mostly attributable to significantly higher rates of urinary anastomotic leak (21.9% vs. 0%, p = 0.002) and urinary tract infection (50% vs. 18%, p = 0.003) in the urologic reconstruction group. For the 57 patients (79%) who underwent curative resection, the 5-year overall survival rate was 59%, and the local recurrence at 5 years was 15%. Both parameters were not significantly affected by the presence of pathologic bladder invasion or the extent of surgical procedures.

CONCLUSIONS

En bloc bladder resection for locally advanced colorectal cancer involving the urinary bladder can produce reasonable long-term local control and patient survival.

Bladder Reconstruction and Diversion during Colorectal Surgery

Extirpative procedures for advanced colorectal cancers can involve multivisceral pelvic resections. In patients without evidence of distant metastatic disease, a reasonable therapeutic effect can be expected when negative surgical margins are obtained. For patients with bladder involvement, the decision to perform a bladder-sparing procedure or a total pelvic exenteration will be based on the extent of the primary lesion as well as patient characteristics. In this article, the authors describe bladder-sparing techniques with and without enterocystoplasty as well as options for urinary diversion in patients requiring total pelvic exenteration. Contraindications and clinical decision making regarding bladder reconstruction or replacement are discussed.

Pathology studies of combined radical resection of seminal vesicle in the treatment of rectal cancer

To inhibit local recurrence of rectal cancer, it is very important to ensure that there is a sufficient circumferential resection margin. We evaluated pathology studies of combined radical resection of seminal vesicles in the treatment of rectal cancer. We analyzed data from 7 cases of combined radical resection of the seminal vesicle in the treatment of rectal cancer; we also analyzed data from 35 control cases without seminal vesicle resection. The circumferential resection margin averaged 5.97 mm for cases that had combined radical resection of the seminal vesicle, and this was significantly longer than for cases without resection (P < 0.001). Local recurrence was not seen in cases that had combined radical resection of the seminal vesicle, whereas 3 cases (5.9%) occurred in the group that did not undergo resection. Combined radical resection of the seminal vesicle in patients with rectal cancer ensures that the distance of the circumferential resection margin is sufficient to inhibit local recurrence.

Pelvic exenteration for clinical T4 rectal cancer: oncologic outcome in 93 patients at a single institution over a 30-year period

BACKGROUND

Patients with stage T4 rectal cancer are known to have poor survival and often require pelvic exenteration (PE). We describe the oncologic outcome of PE for patients with clinical T4 rectal cancer over a 30-year period.

METHODS

Data for 93 patients with primary rectal cancer who underwent PE between 1975 and 2005 were reviewed retrospectively.

RESULTS

Curative resection was performed in 91 patients (97.9%). Estimated 5-year overall survival (OS) and 5-year recurrence-free survival (RFS) rates were 52% and 46%, respectively. Irradiation was administered in 18 patients (19.4%). Local recurrence was observed in 7 patients, of whom 6 had lymph node (LN) involvement. Estimated local recurrence rate at 2 years was 8.6% (2.0% in node-negative and 16.4% in node-positive patients). Multivariate analysis demonstrated that lateral pelvic LN involvement (P = .03), a carcinoembryonic antigen level of >10 ng/dL (P = .04), and lymphovascular invasion (P = .04) were significantly associated with decreased OS. Only lateral pelvic LN involvement was significantly associated with decreased RFS (P = .01).

CONCLUSION

For patients with clinical T4 rectal cancer, PE can provide an opportunity for long-term survival and good local control. Patients with lateral pelvic LN involvement should be offered adjuvant treatment pre- or postoperatively to improve prognosis after PE.

Bladder-Sparing Extended Resection of Locally Advanced Rectal Cancer Involving the Prostate and Seminal Vesicles

PURPOSE

Total pelvic exenteration (TPE) is the standard procedure for locally advanced rectal cancer involving the prostate and seminal vesicles. We evaluated the feasibility of bladder-sparing surgery as an alternative to TPE.

METHODS

Eleven patients with advanced primary or recurrent rectal cancer involving the prostate or seminal vesicles, or both, underwent bladder-sparing extended colorectal resection with radical prostatectomy. The procedures performed were abdominoperineal resection (APR) with prostatectomy (n = 6), colorectal resection using intersphincteric resection combined with prostatectomy (n = 4), and abdominoperineal tumor resection with prostatectomy (n = 1). Local control and urinary and anal function were evaluated postoperatively.

RESULTS

Cysto-urethral anastomosis (CUA) was performed in seven patients and catheter-cystostomy was performed in four patients. Coloanal or colo-anal canal anastomosis was also performed in four patients. There was no mortality, and the morbidity rate was 38%. All patients underwent complete resection with negative surgical margins. After a median follow-up period of 26 months there was no sign of local recurrence, and ten patients were alive without disease, although distant metastases were found in three patients. Five patients had satisfactory voiding function after CUA, and three had satisfactory evacuation after intersphincteric resection (ISR).

CONCLUSION

These bladder-sparing procedures allow conservative surgery to be performed in selected patients with advanced rectal cancer involving the prostate or seminal vesicles, without compromising local control.

Survival in colorectal cancer patients with urinary tract invasion

PURPOSE

We compared overall survival and disease-free survival in colorectal cancer patients with and without invasion of urinary organs.

METHODS

We clarified the potential predictors of the overall and disease-free survivals after surgery, the factors associated with direct tumor invasion of the urinary organs, postoperative complications, recurrence sites, and survival in patients with and without urinary organ resection in 171 patients with Stage III colorectal cancer who underwent surgery, including 23 patients with tumor invasion of the urinary organs and 148 patients without invasion.

RESULTS

Old age (65 years or older), rectal cancer, and macroscopic Type 3 and 4 disease were found to be independent poor prognostic factors for the overall and disease-free survivals in all patients. The overall and disease-free survivals in patients with direct tumor invasion of the urinary organs were not shorter than those in patients without invasion. A large extent of tumors located in the cross-sectional circumference of the bowel (> or =72 percent) and a large maximum tumor size (>50 mm) were significant tumor characteristics associated with positive direct tumor invasion of the urinary organs by sigmoid and rectal cancers. Although the local recurrence of patients with tumor invasion of the urinary organs occurred more frequently in patients without invasion, there were no differences in the overall and disease-free survivals between the patients without a urinary organ resection and those with a local resection of urinary bladder or ureter.

CONCLUSIONS

The survival of patients with a urinary invasion was not shorter than that of patients without urinary invasion.

Bladder-sparing surgery in locally advanced nonurological pelvic malignancy

INTRODUCTION

The urinary bladder is commonly involved in pelvic malignancy. The incidence of apparent extension into adjacent organs in locally advanced colorectal malignancy is 5-12%. It is not known with other pelvic malignancy. No guidelines are available for its management. Often a dilemma exists between cystectomy and a bladder-sparing procedure. We studied the validity of bladder-sparing surgery (BSS) in locally advanced nonurological pelvic malignancy.

METHODS

Hospital records of patients who underwent BSS along with other surgeries (abdomino-perineal resection, anterior resection, anterior exenteration, debulking surgery and total pelvic exenteration) from January 1992 to May 2003 were reviewed.

RESULTS

BSS was done in 15 patients. 10 had locally advanced colorectal malignancy, 3 with soft tissue masses of the lateral pelvic wall, 1 had ovarian malignancy and the other had residual mass following radiotherapy and chemotherapy of cancer cervix. In those with locally advanced colorectal malignancy, symptoms suggestive of lower urinary tract involvement were present in 8 (80%). Urine examination and ultrasonography was not helpful in suggesting bladder involvement, unlike CT scan of abdomen and pelvis. Preoperative cystoscopy showed endoscopic evidence of bladder involvement in 7 (87.5%). Bladder was involved supratrigonally in 7. Partial cystectomy was done in 9 patients. The left ureter was involved in 6 patients, and they required ureteric reimplantation. Palliative transurethral resection was done in 1 patient with tumor infiltration at the bladder neck and prostate. 50% patients had bothersome lower urinary tract symptoms at 1 year. One patient died in the immediate postoperative period due to a nonurological cause. Overall 3-year survival rate was 40%.

CONCLUSION

Unlike primary bladder cancers these lesions are not multifocal and hence en block conservative bladder-sparing surgery can be offered. Preoperative CT scan or MRI can predict lower urinary tract involvement and help in decision-making by both surgeon and patient. The ultimate decision for bladder sparing is based on intraoperative findings. Sparing the bladder might provide better quality of life by avoiding urinary diversion without altering survival.

Abdominoperineal excision with partial anterior en bloc resection in multimodal management of low rectal cancer: a strategy to reduce local recurrence

PURPOSE

Total mesorectal excision is the gold standard in the performance of an abdominoperineal resection but little has changed in the way the perineal operation is performed. A frequent problem is anterior dissection. The aim of this study was to present the results of abdominoperineal resection using selected partial anterior en bloc resection to reduce recurrence.

METHODS

The data were population-based and prospectively registered. Two experienced surgeons performed the operations. In selected cases, depending on clinical and magnetic resonance imaging findings, parts of the vagina or prostate close to the tumor were resected. All specimens were examined according to Quirke.

RESULTS

Sixty-three patients underwent abdominoperineal resection with total mesorectal excision; 56 received preoperative radiotherapy. The tumors involved the anterior bowel wall in 40 cases and in 23 (58 percent) of them, en bloc resections were performed. The distance from the tumor to the conventional resection margin (without en bloc resection) was 0 mm in ten cases. The median follow-up period was 37 months. So far, one (1.7 percent) local recurrence has been detected in 58 (92 percent) curative and indeterminate cases. The cancer-specific five-year survival in these cases was 87 percent (Kaplan-Meier).

CONCLUSION

A multimodal management regimen in patients with low rectal cancer, including preoperative radiotherapy and abdominoperineal resection with a high frequency of partial en bloc resection of the vagina or prostate, resulted in excellent local control and survival. In some male patients, excenteration with urinary stoma can be avoided.

Reconstruction of urinary tract combined with surgical management of locally advanced non-urological cancer involving the genitourinary organs

INTRODUCTION

The objective of this study was to review our experience with urinary reconstruction in patients undergoing surgical management for locally advanced pelvic cancer, and to evaluate the role of urologists in these procedures.

MATERIALS AND METHODS

This study included a total of 37 patients undergoing some type of urinary reconstruction due to invasion of the urological organs by locally advanced pelvic cancers, including 17 rectal cancers, 9 cervical cancers, 4 sigmoid cancers, 4 retroperitoneal sarcomas, 2 ovarian cancers and 1 appendiceal cancer. Among these 37, 18 were recurrent cancers following initial surgery for primary tumors. The clinical outcomes of these approaches were retrospectively analyzed.

RESULTS

Of the 37 patients, 9 underwent cystectomy (group A) with the following urinary diversions: ileal neobladder in 3, ileal conduit in 5 and colon conduit in 1, and 12 underwent partial cystectomy (group B), among whom 11 received additional urinary reconstruction as follows: bladder flap repair in 5, psoas hitch in 2, ileal ureter in 2, bladder augmentation in 1 and ureteroureterostomy in 1, while the remaining 16 (group C), in whom complete bladder preservation was possible, underwent the following types of urinary reconstruction: bladder flap repair in 6, psoas hitch in 3, en bloc removal of the rectum with prostate in 3, ileal ureter in 2, and ureteroureterostomy in 2. There were 10 early urological complications, including leakage of urine in 7 and acute pyelonephritis in 3. As a late urological complication, hydronephrosis was observed in 8 patients, but ureteral stent was not required in any of these 8. There were no significant differences in the incidence of postoperative complications, the status of surgical margin and the survival among groups A-C.

CONCLUSION

Our experience with extended surgical management of non-urological pelvic cancer with reconstruction of the urinary tract suggests that the urological portion of this procedure can be performed with acceptable morbidity, and that the role of the urological surgeon during this procedure is potentially important.

Preservation of bowel and urinary continence in the management of locally recurrent rectal cancer

BACKGROUND

The management of locally recurrent rectal cancer should achieve local tumor control and potentially improving disease-free and overall survival. Radical pelvic resection has traditionally been associated with permanent fecal and urinary diversion. However, as advanced techniques have evolved to allow restoration of intestinal and urinary continence, we reviewed the use of these techniques in patients with recurrent rectal cancer.

METHODS

Patients with recurrent rectal cancer who underwent a resection at Norris Comprehensive Cancer Center between 1993 and 1999 were retrospectively reviewed. Data collected included demographic data, surgical and oncological history, patterns of recurrence, treatment modalities, and outcome. Follow-up data was obtained from the last clinic visit and/or tumor registry.

RESULTS

Sixty-seven patients with locally recurrent rectal cancer (male/female 45/22, age 32-81 years) were included in the analysis. Continence was re-established in 22 (33%) patients, urinary continence was restored in 12 patients, and intestinal continuity in 14 patients (both in 4 patients). A temporary diverting ostomy was necessary in 5 out of 14 (36%) patients. Mortality was zero and morbidity was low and included two urinary leaks and one fecal leak all of which could be managed non-operatively. At a median follow-up of 16 months (range 5-55), 11 (50%) patients were still alive, 7 (31%) without evidence of disease. Comparison of the groups of patients either with or without continence preservation showed no statistically significant difference in disease-free survival and overall survival rates. High quality of life was achieved with restoration of continuity, no patient with restored continuity expressed a desire for a diversion.

CONCLUSION

If an oncologically adequate resection of the recurrent rectal cancer can be performed without impairment of the pelvic floor integrity, continence preservation is feasible and results in good functional and oncological outcome.

Treatment of locally advanced rectal cancer

Historically, locally advanced rectal cancer is known for its dismal prognosis. The treatment of locally advanced rectal cancer is subject to continuous change due to development of new and better diagnostic tools, radiotherapeutic techniques, chemotherapeutic agents and understanding of the subject. It is clear, that a multimodality approach is the only way to achieve satisfactory local recurrence and survival rates in this type of cancer. However, which multimodality strategy is to be used still remains a point of controversy. This review summarises recent developments in imaging, (neo-) adjuvant therapy and surgical techniques in the treatment of primary locally advanced rectal cancer.

[Cystectomy for indications other than bladder cancer]

A cystectomy for indications other than transitional cell cancer of the bladder or general bladder cancer is frequently performed in cooperation with other surgical specialties such as general surgery or gynecology. In these cases the urological procedure as well as the oncological and surgical concepts of other specialties have to be combined. We studied our cystectomy patients who had undergone such a combined procedure for a non-urothelial indication concerning perioperative and postoperative complications.A total of 204 cystectomies were performed by the Department of Urology at the University of Hamburg, Germany between 1995 and 2003. Bladder cancer was the indication for cystectomy in 162 patients, but 42 patients had a non-urothelial indication for this procedure. These patients included 12 cases of advanced rectal cancer, 9 cases of advanced cervical cancer, 6 cases of advanced sigmoid cancer, 4 cases of advanced prostate cancer, 1 case of prostate sarcoma, 5 cases of complex vesicointestinal fistulae, 2 cases of urachal cancer, 1 leiomyosarcoma, 1 rhabdomyoma, and 1 rhabdomyosarcoma, respectively. Perioperative and postoperative complications of those patients were compared to patients who underwent cystectomy for transitional cell cancer of the bladder.Those 42 patients who underwent cystectomy for non-urothelial indications included 14 male and 28 female patients. The mean age was 58.2 years with a range of 3-78 years. For urinary diversion 30 ileum conduits, 4 sigma conduits, and 8 ileum neobladders were used. The mean operative time was 6.25 h. The mean blood loss was 2200 ml. An average of four red blood cell concentrates (RBC) had to be given. Postoperative hydronephrosis had to be treated in three (7%) patients unilaterally and in two (5%) patients bilaterally with a temporary nephrostomy. Postoperative urinary leakage lasting more than 30 days was found in two (5%) patients. A deep vein thrombosis as well as an ileus was found in five (12%) patients each, respectively. There was no perioperative mortality in this study. When comparing the complications of those patients with the 162 patients who underwent cystectomy for bladder cancer, the only significant difference ( p=0.033, chi-square test) was a higher ileus rate in the patients with cystectomy for a non-urothelial indication. Complications with cystectomy for non-urothelial indications are in large comparable to those for transitional cell carcinoma of the bladder. The higher ileus rate in non-urothelial patients can be explained by the more radical procedures in this group of patients. Even though the group of patients undergoing cystectomy for indications other than bladder cancer was small in this trial, the procedure is standardized in combination with other specialties. Larger patient numbers and a longer follow-up will lead to more data in this special group of patients.

High incidence of urinary bladder involvement in carcinomas of the sigmoid and rectum: a retrospective review of 580 patients with colorectal carcinoma

BACKGROUND AND OBJECTIVES

It is not uncommon for colorectal carcinomas to invade the urinary bladder. However, the actual incidence of urinary bladder invasion of colorectal carcinomas and the common sites of the original tumors are still unclear.

METHODS

The clinical records of 580 patients diagnosed with colorectal carcinoma were retrospectively reviewed. A further review of patients with urinary bladder invasion was performed.

RESULTS

Of the 580 patients, 17 (2.9%) had a diagnosis of urinary bladder invasion intraoperatively. The incidence of bladder involvement was significantly higher in carcinomas of the sigmoid and rectum than in carcinomas of other colon segments (4.1 vs. 0.5%, P = 0.017). Although a combination of computed tomography (CT) and cystoscopy predicted 80% of the bladder involvement, preoperative diagnostic modalities could not provide information for the differentiation between macroscopic and pathological invasion or the necessity for total cystectomy.

CONCLUSIONS

The sigmoid colon and rectum were common sites of the original tumors invading the urinary bladder compared with other colon segments. CT and cystoscopy are recommended for preoperative screening of the bladder involvement of sigmoid colon and rectal cancer. However, it appeared to be difficult to predict the pathological invasion of malignant cells and the necessity for total cystectomy preoperatively.

Urinary tract involvement by colorectal cancer

PURPOSE

Involvement of the urinary tract by colorectal cancer is sufficiently rare to be encountered by an individual surgeon on an infrequent basis. The aim of this review is to highlight technical and oncologic issues that should be considered when dealing with complex colorectal cancer that involves the urinary tract.

METHODS

The relevant literature from 1975 to 2001 was identified using the MEDLINE database of the U.S. National Library of Medicine and reviewed. Because of the diversity of forms of presentation of urologic involvement, few randomized, controlled trials are available, with most evidence derived from retrospective studies.

RESULTS

Three distinct clinical situations in which the urinary tract may be affected by colorectal cancer were identified: involvement by primary colorectal cancer, involvement by recurrent cancer, and unexpected intraoperative findings of urinary tract involvement. Management strategies to identify and treat locally advanced primary or recurrent colorectal cancer involving the urinary tract improve survival with acceptable morbidity and mortality. Careful preoperative assessment of all patients with colorectal cancer will reduce unexpected identification of urinary tract invasion at the time of surgery. In patients in whom cure is not possible, endourologic techniques combined with judicious surgical resection can provide high-quality palliation. Optimal care of many of these conditions is facilitated by specialist urologic advice.

CONCLUSIONS

The wide spectrum of possible urinary tract involvement by colorectal cancer requires individual patient-specific and disease-specific consideration. The literature offers important guidelines that aid decision making and improve management of these challenging problems.

Aggressive surgical treatment for patients with T4 rectal cancer

OBJECTIVE

To investigate the outcome of surgical treatment for patients with T4 rectal cancer and to evaluate prognostic factors influencing 5-year disease-free survival.

PATIENTS

Of 1600 rectal cancers seen between 1985 and 1998, there were 197 patients with T4 of whom 128 were treated with curative intent. In this retrospective study organ invaded, the type of treatment and outcome were analysed.

RESULTS

Of the 128 patients, 89% had visceral involvement and 11% had pelvic wall involvement. The most frequently involved organ was bladder, followed by prostate and vagina. Low anterior resection was performed in 52, abdomino-perineal resection in 35 and total pelvic exenteration in 41 patients. Of 81 with urinary tract invasion, 50% were treated with bladder-sparing surgery. Pathological examinations showed bladder involvement in only 44 of these and overall 5-year disease-free survival was 57%. Multivariate analysis revealed that body mass index, lymph node metastasis and inflammatory reaction were significant predictors of survival.

CONCLUSION

Completeness of resection is the essential factor influencing oncological outcome.

Radical prostatectomy for locally advanced primary or recurrent rectal cancer

AIM

Three papers including five patients have described en bloc radical prostatectomy for locally advanced rectal cancer.

METHODS

Six patients (median age 63 years) underwent en bloc radical prostatectomy for locally advanced (3) or recurrent (3) rectal cancer involving the prostate. Quality of life questionnaires were answered postoperatively and the data prospectively entered in a database.

RESULTS

One primary case had low anterior resection (LAR), the others abdominoperineal resections (APR) of R0 stage. Two recurrent cases had APRs and one tumour resection-all R1 stage. Anastomotic leakage led to construction of an ileal conduit in one patient and in two healed on conservative treatment. Follow up was 10-50 months. One patient died from distant metastases at 29 months postoperatively, one was operated for a single lung metastasis and one has disseminated lung metastases. None has developed local recurrence. Four of the five with anastomoses had good quality of life and none wanted an ileal conduit.

CONCLUSION

In spite of a relatively high urinary leak rate the total complication rate seems to be lower than after pelvic exenteration. En bloc radical prostatectomy seems an option in selected patients otherwise needing pelvic exenteration for locally advanced or recurrent rectal cancer.

Urologic manifestations of nonurologic diseases gastrointestinal disorders

A variety of common, gastrointestinal diseases result in significant genitourinary tract pathology. In general, knowledge of these associated disease processes permit rapid and accurate diagnosis and treatment. The underlying thread is the recognition of one pathophysiological process to explain patterns of a single disease.

Surgical management of the urinary tract in patients with locally advanced colorectal cancer

OBJECTIVES

To review cases of colorectal cancer requiring urologic management to clarify the role the urologist should play in the surgical procedures. A deterrent to radical surgery for advanced colorectal carcinoma with urinary involvement is the technical complexity and associated morbidity and mortality of this procedure.

METHODS

Thirty-six tumors in 35 patients, including 19 sigmoid cancers (Stage II, 17; Stage III, 2), 12 rectal cancers (Stage II, 11; Stage III, 1), and 5 local recurrences of colorectal carcinoma in the pelvis were reviewed. All tumors had invaded the bladder, prostate, or ureter. The demographic and clinical characteristics, type of operative procedure, and postoperative complications were analyzed.

RESULTS

Of the patients with a sigmoid tumor, partial cystectomy was performed in 15 patients who underwent a bladder-sparing procedure; an ileal conduit and ileal neobladder were created in 2 patients each who required cystectomy. Four patients with rectal cancer underwent a bladder-sparing procedure: partial cystectomy in 1, partial cystectomy with ileal ureter in 1, and prostatectomy in 2. The remaining 8 patients underwent cystectomy with the following types of reconstruction: colonic neobladder in 1, ileal neobladder in 4, Indiana pouch in 1, ileal conduit in 1, and ureterocutaneostomy in 1 patient. The bladder was spared in a greater percentage of patients with sigmoid cancer than in those with rectal cancer. The incidence of complications was greater in patients with rectal cancer and local recurrence than in those with sigmoid tumors. The complication rate was especially low in patients who underwent a bladder-sparing procedure (10.5%) compared with patients who required cystectomy (58.3%). The survival in patients with sigmoid cancer who underwent bladder-sparing surgery also was better than in those who underwent cystectomy.

CONCLUSIONS

The treatment of advanced colorectal cancer is best managed by a committed team that includes an experienced urologist. Urologists play a critical role in determining the surgical options and creating appropriate urinary diversions to achieve curative resection with the highest quality of life.

Management of locally advanced rectal cancer

The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.