Short- and long-term outcomes of selective pelvic exenteration surgery in a low-volume specialized tertiary setting

A single centre experience on the formation of double barrelled uro-colostomy in pelvic exenteration surgery: a cohort study

BACKGROUND

Double barrelled uro-colostomy (DBUC) is an alternative to traditional ileal conduit (IC) and separate colostomy in patients requiring simultaneous urinary and faecal diversion for reconstruction in pelvic exenteration surgery (PES).

METHODS

This cohort study evaluated short- and long-term morbidity and mortality associated with DBUC formation in 20 consecutive adult patients undergoing PES in an Australian Complex Pelvic Surgical Unit. Data were obtained from a prospective database.

RESULTS

Mean age 59 years (range 27-76 years). PES was performed for malignant disease in 18 patients (curative intent in 17). Mean operative duration 11.8 h (range 7-17 h). Mean follow-up duration 29.1 months (range 2.6-90.1 months). Early DBUC-related complications occurred in four patients (20.0%): urinary tract infection (UTI)/urosepsis (n = 4) and early ureteric stenosis requiring intervention (n = 1). Late DBUC-related complications occurred in five patients (25.0%): recurrent UTI/urosepsis (n = 4), chronic kidney disease (n = 4), ureteric stenosis (n = 2) and parastomal hernia (n = 4). No mortality occurred secondary to a DBUC complication.

CONCLUSION

DBUC is a safe reconstructive option with acceptable morbidity profile in patients requiring simultaneous urinary and faecal diversion.

Double barrelled uro-colostomy versus Ileal conduit for urinary diversion following pelvic exenteration: a single centre experience

INTRODUCTION

The ideal method for urinary diversion following total pelvic exenteration (TPE) remains unclear. This study compares the outcomes of double-barrelled uro-colostomy (DBUC) and ileal conduit (IC) in a single Australian centre.

METHODS

All consecutive patients who underwent pelvic exenteration with the formation of either a DBUC or an IC between 2008 and November 2022 were identified from the prospective database from the Royal Adelaide Hospital and St. Andrews Hospital. Demographic, operative characteristics, general perioperative, long-term urological and other relevant surgical complications were compared via univariate analyses.

RESULTS

Of 135 patients undergoing exenteration, 39 patients were eligible for inclusion: 16 patients with a DBUC, and 23 patients with an IC. More patients in the DBUC group had previous radiotherapy (93.8% vs. 65.2%, P = 0.056) and flap pelvic reconstruction (93.7% vs. 45.5%, P = 0.002). The rate of ureteric stricture trended higher in the DBUC group (25.0% vs. 8.7%, P = 0.21), but in contrast, urine leak (6.3% vs. 8.7%, P>0.999), urosepsis (43.8% vs. 60.9%, P = 0.29), anastomotic leak (0.0% vs. 4.3%, P>0.999), and stomal complications requiring repair (6.3% vs. 13.0%, P = 0.63) trended lower. These differences were not statistically significant. Rates of grade III or greater complications were similar; however, no patients in the DBUC group died within 30-days or had grade IV complications requiring ICU admission compared with two deaths and one grade IV complication in the IC group.

CONCLUSION

DBUC is a safe alternative to IC for urinary diversion following TPE, with potentially fewer complications. Quality of life and patient-reported outcomes are required.

Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia

BACKGROUND

Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data.

METHODS

All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020.

RESULTS

Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020).

CONCLUSION

The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.

Short-term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre

BACKGROUND

Pelvic exenteration surgery (PE) offers potentially curative resection for locally advanced malignancy but is associated with significant complexity and morbidity. Specialised teams are recommended to achieve optimal patient outcomes. This study aims to analyse short-term outcomes at a tertiary setting before and after creating a dedicated PE service.

METHODS

Patients undergoing PE between 2008 and October 2021 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia were included, with prospective data collection since June 2017. Patients operated on prior and post the creation of the PE service were compared via univariate analyses.

RESULTS

In total, 113 patients were included, with a significant increase in volume of cases post creation of the PE service, (n = 46 pre versus n = 67 post). There were significant differences in the type of neoadjuvant therapy and patient co-morbidity, with more advanced disease stage and a higher likelihood of bone involvement (P < 0.05) in the latter period. An increased proportion of patients had flap reconstruction (40.3 versus 33.9%, P = 0.010) as well as lateral lymph node dissection (13.4 versus 2.2%, P = 0.046). Despite this, peri-operative outcomes such as urosepsis (11.9 versus 28.3%, P = 0.028) and Clavien-Dindo grade of complications grade improved. R0 resections were achieved in 93.9% of curative cases (93.9 versus 84.2%, P = 0.171).

CONCLUSION

The development of a PE service significantly improved short term patient outcomes, despite the inclusion of patients with more advanced disease and comorbidity.

Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit

Backgrounds

Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ).

Methods

Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+).

Results

A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001).

Conclusion

Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.