Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration

Imaging in pelvic exenteration-a multidisciplinary practice guide from the ESGAR-SAR-ESUR-PelvEx collaborative group

Pelvic exenteration (PE) is a radical surgical approach designed for the curative treatment of advanced pelvic malignancies, requiring en-bloc resection of multiple pelvic organs. While the procedure is radical, it has shown promise in enhancing long-term survival and is now comparable in surgical mortality to elective resections for primary pelvic cancers. Imaging plays a crucial role in preoperative planning, with MRI, CT, and PET/CT being pivotal in assessing the extent of cancer and formulating a surgical roadmap. This paper presents clinical practice guidelines for imaging in the context of PE, developed jointly by ESGAR, SAR, ESUR, and the PelvEx Collaborative. These guidelines aim to standardize imaging protocols and reporting to improve the preoperative assessment and facilitate decision-making in the multidisciplinary treatment of pelvic cancers. Our recommendations underscore the importance of a multidisciplinary approach and the need for clear and precise imaging reports to optimize patient care. CLINICAL RELEVANCE STATEMENT: Our recommendations underscore the importance of a multidisciplinary approach and the need for clear and precise imaging reports to optimize patient care. KEY POINTS: MRI is mandatory for local staging in pelvic exenteration. Structured reporting (using the template provided in this guide) is recommended. Multidisciplinary review of imaging is critical for surgical planning.

Total pelvic exenteration extended to pelvic bones with subsequent VRAM flap reconstruction in patient with recurrent anal squamous cell carcinoma following chemoradiotherapy

Anal squamous cell carcinoma, typically associated with human papillomavirus infection, remains a rare malignancy. This article outlines a case of local recurrence in a male patient with a history of HIV and hepatitis C virus infection, previously treated with chemoradiotherapy. Extensive tumour involvement called for total pelvic exenteration extended to anterior osteomuscular compartment and genitalia. The surgical approach involved multidisciplinary collaboration and detailed preoperative planning using three-dimensional reconstruction. Key surgical considerations comprised the following: achieving tumour-free margins (R0 resection), extensive osteotomies and intricate pelvic floor reconstruction with prosthetic mesh and flap reconstruction. The procedure successfully yielded an R0 resection, maintaining adequate lower limb functionality. Our case report underscores the benefits of pelvic exenteration in locally advanced or recurrent pelvic tumours, invariably following careful patient selection and exhaustive preoperative studies.

Novel and Innovative Surgical Strategies for Recurrent Rectal Cancer: Uncommon Resections, Local Interventions for Pelvic Reoccurrence, and Intraoperative Radiation Therapy

The frequency of recurrent rectal cancer has dropped significantly with improved surgical approaches and adjunctive therapies. These recurrences have proven challenging to obtain R0 resection with salvage operations. Meticulous planning, clear understanding of anatomy with imaging, and multispecialty support have become essential in local control and long-term survival with pelvic recurrence of rectal cancer. Technical considerations and prognosis indicators along with role of intraoperative radiation or boost radiation are discussed within.

Pelvic exenteration for chronic fistulating pelvic sepsis after multimodal treatment of pelvic malignancy

BACKGROUND

Chronic fistulating pelvic sepsis is an uncommon complication of multimodal treatment of visceral pelvic tumours. Radical multi-visceral resection is reserved for patients with persistent, debilitating symptoms despite less invasive treatments and for which there is minimal published data. This study aimed to report the rates of morbidity and long-term sepsis control after pelvic exenteration for chronic fistulating pelvic sepsis.

METHODS

This retrospective cohort study was conducted at a high-volume pelvic exenteration referral centre. Patients who underwent pelvic exenteration for chronic fistulating pelvic sepsis between September 1994 and January 2023 after previous treatment for pelvic malignancy were included. Data relating to postoperative morbidity, mortality and the rate of recurrent pelvic sepsis or fistulae were retrospectively collected.

RESULTS

19 patients who underwent radical resection for chronic fistulating pelvic sepsis after previous pelvic cancer treatment were included. 11 patients were male (58 %) and median age was 62 years (range 42-79). Previously treated rectal (8 patients, 42 %), prostate (5, 26 %) and cervical cancer (5, 26 %) were most common. 18 patients (95 %) had previously received high-dose pelvic radiotherapy, and 14 (74 %) had required surgical resection. Total pelvic exenteration was performed in 47 % of patients, total cystectomy in 68 % and major pubic bone resection in 37 %. There was no intraoperative or postoperative mortality. Major complication rate was 32 %. 12-month readmission rate was 42 %. At last follow up, 74 % had no signs or symptoms of persisting pelvic sepsis.

CONCLUSIONS

Pelvic exenteration for refractory pelvic sepsis following treatment of malignancy is safe and effective in selected patients.

Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery

OBJECTIVE

Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes.

BACKGROUND

Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself.

MATERIALS AND METHODS

Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest.

RESULTS

All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated.

CONCLUSIONS

A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.

Local Recurrences in Rectal Cancer: MRI vs. CT

Rectal cancers are often considered a distinct disease from colon cancers as their survival and management are different. Particularly, the risk for local recurrence (LR) is greater than in colon cancer. There are many factors predisposing to LR such as postoperative histopathological features or the mesorectal plane of surgical resection. In addition, the pattern of LR in rectal cancer has a prognostic significance and an important role in the choice of operative approach and. Therefore, an optimal follow up based on imaging is critical in rectal cancer. The aim of this review is to analyse the risk and the pattern of local recurrences in rectal cancer and to provide an overview of the role of imaging in early detection of LRs. We performed a literature review of studies published on Web of Science and MEDLINE up to January 2023. We also reviewed the current guidelines of National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO). Although the timing and the modality of follow-up is not yet established, the guidelines usually recommend a time frame of 5 years post surgical resection of the rectum. Computed Tomography (CT) scans and/or Magnetic Resonance Imaging (MRI) are the main imaging techniques recommended in the follow-up of these patients. PET-CT is not recommended by guidelines during post-operative surveillance and it is generally used for problem solving.

Bladder preserving robotic pelvic exenteration for locally advanced rectal cancer-technique and short-term outcomes

AIM

In selected patients with advanced rectal cancers involving the prostate or seminal vesicles, the bladder can be preserved to avoid the complications associated with an ileal conduit. The study was aimed at reviewing the technique and short-term outcomes of patients that underwent bladder sparing robotic pelvic exenteration with suprapubic cystostomy (SPC).

METHODS

Case series of bladder preserving exenteration from a single tertiary care center. Technique for en-bloc prostatectomy with abdominoperineal resection is described.

RESULTS

Five patients underwent bladder sparing robotic pelvic exenteration with SPC, all had R0 resections. Four patients had prostatic invasion and one patient had prostatic adenocarcinoma. Postoperative complications were seen in three patients of which two were re-explored. At a median follow-up of 10 months, two patients developed systemic relapses. There were no local recurrences.

CONCLUSION

Robotic bladder sparing exenteration is technically feasible, provides acceptable short-term outcomes, and avoids complications of ileal conduit.

State-of-the-art surgery for recurrent and locally advanced rectal cancers

Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.

Pathology reporting of pelvic exenteration specimens for locally recurrent rectal cancer

INTRODUCTION

Reporting of pelvic exenteration specimens for locally recurrent rectal cancer (LRRC) can be challenging for structured pathological analysis and currently, there is a lack of specific guidelines. The aim of this study was to assess the quality of pathology reporting in a cohort of patients who underwent pelvic exenteration for LRRC in a high-volume tertiary unit.

MATERIALS AND METHODS

In a retrospective analysis of histopathology reports of consecutive patients who underwent pelvic exenteration for LRRC from 1996 to 2018, the quality of pathology reporting was assessed using the Structure Reporting Protocol for Colorectal Cancer. The primary endpoint was the completeness of pathology reporting, secondary endpoints were the association between the reporting style (narrative versus synoptic), reporting period (the first half versus the second half), as well as the activity of the pathologists with the completeness of pathology reporting.

RESULTS

221 patients who underwent pelvic exenteration for LRRC were included into the study. There was a high variability in completeness of pathology reporting within the cohort, ranging from 9.5% to 100%. Notably, microscopic clearance was reported in only 92.4% of the reports. Overall, a significantly higher rate of completeness was observed in synoptic reports when compared to narrative reports and in more recent compared to earlier reports. There was no significant association between the activity of pathologists and the completeness of reporting.

CONCLUSIONS

This study shows a significant variability in the quality of reporting in pelvic exenteration for LRRC. The use of synoptic reporting clearly resulted in more complete reports.

Complete resection of the iliac vascular system during pelvic exenteration: an evolving surgical approach to lateral compartment excision

Tumour infiltration of the lateral pelvic compartment has previously been associated with the highest rate of involved resection margins and carries significant risk of morbidity. In this study, consecutive patients undergoing pelvic exenteration at a single centre between 1994 and 2019 who required en bloc resection of the common or external iliac artery or vein were included.The results demonstrate that complete resection of the iliac vascular system, including resection and reconstruction of the common and external iliac vessels, can be performed safely during pelvic exenteration with oncological outcomes comparable to more central tumours.

Pelvic exenteration: Pre-, intra-, and post-operative considerations

This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.

Excellent Outcomes After Extended Radical Pelvic Resection for Locally Advanced and Recurrent IBD-Associated Anorectal Cancer

BACKGROUND

Anorectal cancer arising in IBD can be challenging to manage. There is a paucity of reports describing locally advanced and recurrent anorectal cancer in this setting.

OBJECTIVE

This study aimed to describe patients who underwent extended radical pelvic resection for locally advanced and recurrent IBD-associated anorectal cancer.

DESIGN

This is a retrospective review of a prospectively maintained database of extended radical pelvic resection.

SETTINGS

This study was conducted at a quaternary pelvic malignancy referral center.

PATIENTS

All of the patients who underwent extended radical pelvic resection for IBD-associated anorectal cancer between September 1994 and September 2019 were included.

MAIN OUTCOME MEASURES

Demographic, operative, and oncologic outcomes were assessed.

RESULTS

Ten patients (1.3%) were identified of 765 (6 men; median age = 51 y). The average time from the diagnosis of IBD to cancer was 23 years. Five patients had surgery for primary cancer previously. All of the patients had previous complex abdominal and perineal surgical interventions. There were 7 adenocarcinomas and 3 squamous cell carcinomas. Nine underwent pelvic exenteration and 1 rectal resection with radical vaginectomy. The median operating time, intraoperative blood loss, and blood transfusion were 698 minutes, 1.8 L, and 4.5 units. The median hospital stay was 24 days. The operative mortality and morbidity rates were 0% and 60%. At a median follow-up of 51.3 months, 7 patients remained alive and free of cancer.

LIMITATIONS

This is a retrospective study of a small number of patients.

CONCLUSIONS

Extended radical pelvic resection offers a potential cure for locally advanced and recurrent IBD-associated anorectal cancer with acceptable operative mortality and morbidity rates. A high index of suspicion is required to achieve early diagnosis. Multiple factors need to be considered in the multimodal treatment of such complex patients. See Video Abstract at http://links.lww.com/DCR/B418.

EXCELENTES RESULTADOS DESPUS DE LA RESECCIN PLVICA RADICAL EXTENDIDA POR CNCER ANORRECTAL RECURRENTE Y LOCALMENTE AVANZADA, ASOCIADA A ENFERMEDAD INFLAMATORIA INTESTINAL

ANTECEDENTES:Cáncer anorrectal surgiendo de la enfermedad inflamatoria intestinal, puede ser difícil de manejar. Hay escasez de informes que describan el cáncer anorrectal localmente avanzado y recurrente en este contexto.OBJETIVO:El estudio tiene como objetivo, describir a los pacientes que se sometieron a resección pélvica radical extendida por cáncer anorrectal recurrente y localmente avanzada, asociada con enfermedad inflamatoria intestinal.DISEÑO:Esta es una revisión retrospectiva, de una base de datos mantenida prospectivamente de resección pélvica radical extendida.AJUSTES:El estudio se realizó en un centro de referencia cuaternaria en malignidad pélvica.PACIENTES:Se incluyeron a todos los pacientes sometidos a resección pélvica radical ampliada por cáncer anorrectal, asociada a enfermedad inflamatoria intestinal entre septiembre de 1994 y septiembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los resultados demográficos, quirùrgicos y oncológicos.RESULTADOS:Diez pacientes (1.3%) fueron identificados de 765 (seis masculinos; mediana de edad 51 años). El tiempo promedio desde el diagnóstico de la enfermedad inflamatoria intestinal hasta el cáncer, fue de 23 años. Cinco pacientes fueron previamente sometidos a cirugía por cáncer primario. Todos los pacientes tuvieron previamente, intervenciones quirúrgicas abdominales y perineales complejas. Hubo siete adenocarcinomas y tres carcinomas de células escamosas. Nueve se sometieron a exenteración pélvica y una a resección rectal con vaginectomía radical. La mediana del tiempo de operación, pérdida de sangre intraoperatoria y transfusión sanguínea, fueron 698 minutos, 1.8 litros y 4.5 unidades respectivamente. La mediana de la estancia hospitalaria fue de 24 días. Las tasas de mortalidad y morbilidad operatoria fueron 0% y 60% respectivamente. En una mediana de seguimiento de 51,3 meses, siete pacientes permanecieron vivos y libres de cáncer.LIMITACIONES:Es un estudio retrospectivo con número pequeño de pacientes.CONCLUSIONES:La resección pélvica radical extendida, ofrece una cura potencial para el cáncer anorrectal recurrente y localmente avanzada, asociada a0 enfermedad inflamatoria intestinal y con tasas aceptables de mortalidad y morbilidad operatoria. Se requiere un alto índice de sospecha para obtener un diagnóstico temprano. Se deben considerar múltiples factores en el tratamiento multimodal de pacientes tan complejos. Consulte Video Resumen en http://links.lww.com/DCR/B418. (Traducción-Dr Fidel Ruiz Healy).

Surgical anatomy of the pelvis for total pelvic exenteration with distal sacrectomy: a cadaveric study

PURPOSE

Intraoperative bleeding from the pelvic venous structures is one of the most serious complications of total pelvic exenteration with distal sacrectomy. The purpose of this study was to investigate the topographic anatomy of these veins and the potential source of the bleeding in cadaver dissections.

METHODS

We dissected seven cadavers, focusing on the veins in the surgical resection line for total pelvic exenteration with distal sacrectomy.

RESULTS

The presacral venous plexus and the dorsal vein complex are thin-walled, plexiform, and situated on the line of resection. The internal iliac vein receives blood from the pelvic viscera and the perineal and the gluteal regions and then crosses the line of resection as a high-flow venous system. It has abundant communications with the presacral venous plexus and the dorsal vein complex.

CONCLUSION

The anatomical features of the presacral venous plexus, the dorsal vein complex, and the internal iliac vein make them highly potential sources of bleeding. Surgical management strategies must consider the anatomy and hemodynamics of these veins carefully to perform this procedure safely.

Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more?

There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.

Locally recurrent rectal cancer: what the radiologist should know

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.

Pelvic exenteration in gynecologic cancer: complications and oncological outcome

Introduction

Pelvic exenteration (PE) is indicated in cases of unresponsive, recurrent pelvic cancer or for palliative intent. Despite the fact that the surgery is associated with a high rate of morbidity, it is currently the only real option that can effect a cure.

Material and methods

Patients who underwent PE between January 2011 and July 2017 in our centre were retrospectively reviewed. Data related to surgery, complications and outcomes were recorded.

Results

Twenty-three patients were included. PE was performed due to recurrent gynaecological cancer, persistence of disease and after first diagnosis in 19 (82%), 2 (9%) and 2 patients (9%), respectively. Total PE was performed in 15 cases (65%), followed by anterior PE in 5 cases (22%) and posterior PE in 3 cases (13%). Early grade II, III and IV complications occurred in 15 (65%), 5 (22%) and 2 patients (9%), respectively. No mortality was observed within 30 days. Medium-late grade II, III, IV and V complications occurred in 15 (65%), 11 (48%), 3 (13%) and 2 cases (9%), respectively. Two patients died after > 30-day period from surgery-related complications. The overall survival (OS) and disease-free survival (DFS) at 48 months after PE was 41.6% and 30.8% respectively.

Conclusions

PE provides about a 40% 4-year survival chance in a selected group of patients. The early-complications rate and 30-day mortality were acceptable. Nevertheless, the medium-late complication grades II–V were 65, 48, 18 and 9%, respectively. We must focus on identifying those patients who could potentially benefit most from PE.

Transperineal retropubic approach in total pelvic exenteration for advanced and recurrent colorectal and anal cancer involving the penile base: technique and outcomes

BACKGROUND

Complete pathological resection of locally advanced and recurrent anorectal cancer is considered the most important determinant of survival outcome. Involvement of the retropubic space with cancer threatening or involving the penile base poses specific challenges due to the potential for margin involvement and blood loss from the dorsal venous plexus. In the present study we evaluate a new transperineal surgical approach to excision of anterior compartment organs involved or threatened by cancer which facilitates exposure and visualisation of the bulbar urethra and the deep vein of the penis caudal to the retropubic space and penile base.

METHODS

A retrospective study was performed on male patients with tumour extension into the penile base treated at our institution using the transperineal surgical approach. Descriptive data for patient demographics, radiology, operative details, postoperative histology, complications and outcomes were collated.

RESULTS

Ten male patients with tumour extension into the penile base were identified. Two patients had recurrent anal cancer, 6 had locally advanced primary rectal cancer and 2 had recurrent rectal cancer. All patients had exenterative surgery with excision of the penile base utilising the transperineal approach. All patients had R0 resection. No local recurrence developed after a median follow up period of 15 months.

CONCLUSIONS

The transperineal approach to the penile base and retropubic space allows for high rates of R0 resection margin status with direct visualisation of the dorsal venous plexus, thereby minimising blood loss. In our experience, this technique is the preferred approach to excision of cancers threatening and involving the penile base and also for most male patients requiring total pelvic exenteration.

[Resection of recurrent rectal cancer]

A curative treatment of locally recurrent rectal cancer (LRRC) can only be achieved with a complete resection and microscopically tumor-free surgical margins (R0). Imaging techniques are the most important investigations for the preoperative staging of local and systemic diseases. Due to substantial improvements in surgical strategies and techniques, previously unresectable tumors can now be excised. Several publications have demonstrated the oncological benefits of high sacral resection for LRRC. High subcortical sacrectomy (HiSS), extended lateral resection and extended lateral pelvic sidewall excision (ELSiE) belong to the newer surgical options. Biological meshes, various myocutaneous flaps, titanium and bone allografts can be used for reconstruction. Specialized centers provide an efficient management of complications and postoperative treatment.

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.

Advances in surgical management for locally recurrent rectal cancer: How far have we come?

Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.

The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases

Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.

Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer

INTRODUCTION

Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist.

OBJECTIVE

This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration.

DESIGN

A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period.

SETTINGS

This study was conducted at a tertiary level exenteration unit.

MAIN OUTCOME MEASURES

Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality.

RESULTS

Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6-15) hours, and median blood loss was 2971 (range, 300-8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4-12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common.

LIMITATIONS

This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample.

CONCLUSION

Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.

Surgery for Locally Recurrent Rectal Cancer: Tips, Tricks, and Pitfalls

Rectal cancer can recur locally in up to 10% of the patients who undergo definitive resection for their primary cancer. Surgical salvage is considered appropriate in the curative setting as well as select cases with palliative intent. Disease-free survival following salvage resection is dependent upon achieving an R0 resection margin. A clear understanding of applied surgical anatomy, appropriate preoperative planning, and a multidisciplinary approach to aggressive soft tissue, bony, and vascular resection with appropriate reconstruction is necessary. Technical tips, tricks, and pitfalls that may assist in managing these cancers are discussed and the roles of additional boost radiation and intraoperative radiation therapy in the management of such cancers are also discussed.