Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes

Urological Outcomes and Adverse Events Following Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: A Single-center Retrospective Study

OBJECTIVE

To assess urological complications in patients undergoing total pelvic exenteration (TPE) for locally advanced (LARC) and recurrent rectal cancer (RRC) as publications in this area are limited. Secondary objectives were to assess whether LARC vs RRC or radiation status affected urological outcomes.

METHODS

Single-center, retrospective study of TPE patients between January 2017 and December 2022. Electronic records were evaluated to extract data. Postoperative outcomes were analyzed using two-tailed t-tests, Mann-Whitney U tests and chi-squared tests. Urological complications were analyzed using simple logistic regression.

RESULTS

A total of 128 patients underwent TPE (97 LARC, 31 RRC). 90 (70.3%) received neoadjuvant radiotherapy. The overall urological complication rate was 51.6%. Transient acute kidney injury and urinary tract infection were the two most common complications occurring in 38 (29.7%) and 33 (25.8%) respectively. 23 (18.0%) had at least one major complication of Clavien-Dindo III/IV related to the urinary system. Ureteroenteric stricture rate was 7.0% and 14.1% needed a reoperation for urological complications. There was no association between the overall incidence of urological complications and radiation status (OR 0.81 [0.37-1.73], P=.586) or between patients with LARC and RRC (OR 1.68 [0.75-3.93], P=.216).

CONCLUSION

Urological complications are common post-TPE. The urological complication rate is similar in LARC and RRC and radiation status did not affect outcomes in this cohort.

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.

A radiologist's guide to the galaxy of complications post total pelvic exenteration for rectal cancers

Total pelvic exenteration (TPE) is a complicated morbid surgery with a patient having to cope with two permanent stomas lifelong. TPE is often the only option for potential cure that can be offered to patients with low/very low rectal cancers with multicompartment involvement. While the Clavien Dindo classification is used for clinically assessing the severity of complications, it does not guide making an imaging diagnosis (1). Radiologists are often unaware of the complications post-TPE surgery, what imaging modality to use, and how to diagnose these. The complications can be fatal if undiagnosed or misinterpreted and can be certainly managed with a good prognosis if promptly detected and treated (2). This article will focus on normal expected postoperative anatomy in the pelvis and perineum; with emphasis on recognition of signs that may aid in the diagnosis of complications in a bed of surgically altered anatomy. Systematic identification and evaluation of the various conduits and stomas; imaging appearances of normal and abnormal pelvic and perineal reconstruction techniques; and a patterned approach to the diagnosis of early and delayed complications post-TPE will be illustrated using a collection of cases.

Pelvic exenterations combined with cytoreductions for T4 rectal cancers with peritoneal metastasis: a safety analysis

BACKGROUND

Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure.

METHODS

Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed.

RESULTS

Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively.

CONCLUSION

Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.

Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do?

INTRODUCTION

In patients with locally advanced (LARC) or locally recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially offer a cure. The study aim was to compare PC and RC in PE patients in terms of oncological outcome, post-operative complications and quality-of-life (QoL).

MATERIALS & METHODS

This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC cancer with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC.

RESULTS

60 PC patients and 269 RC patients were included. Overall R0 resection was 84.3%. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (P = 0.008). Overall, 1-, 3- and 5-year OS was 90.8%, 68.1% and 58.6% after PC, and 88.7%, 62.2% and 49.5% after RC. Rates of urinary sepsis or urological leaks did not differ between groups, however, RC patients experienced significantly higher rates of perineal wound- and flap-related complications (39.8% vs 25.0%, P = 0.032).

CONCLUSION

PC as part of PE can be performed safely with good oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group.

The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective safety and efficacy study for the Bakri balloon

AIM

Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome.

METHOD

This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero-perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed.

RESULTS

Seventy-five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p = 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10.

CONCLUSIONS

Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon.

Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers

Purpose

Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database.

Methods

Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI).

Results

The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%-37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%-13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively.

Conclusion

MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.

Minimally invasive, 'en-bloc' seminal vesicle excision for locally advanced rectal adenocarcinoma: surgical technique and short-term outcomes

BACKGROUND

Isolated seminal vesicle invasion is a rare occurrence in patients with locally advanced rectal cancers. This study describes the surgical technique and the perioperative outcomes of minimally invasive 'en-bloc' seminal vesicle excision, preserving the bladder and the prostate.

METHODS

A retrospective review of 23 consecutive patients who underwent minimally invasive, en-bloc resection of seminal vesicles for locally advanced, non-metastatic rectal adenocarcinoma between May 2016 and November 2021. Perioperative outcomes and short-term oncological outcomes were defined.

RESULTS

Eighteen patients underwent a laparoscopic procedure while five received a robotic resection. All patients received preoperative radiation with or without consolidation chemotherapy. The median age was 42 years (range 20-64 years) and the median hospital stay was 8 days (range 3-19 days), respectively. Serious complications (Clavien-Dindo ≥ IIIb) were seen in six patients (26.1%). Two patients (8.7%) had an involved circumferential resection margin. At a median follow up of 19 months (range 2-52 months), four patients developed recurrences. The 2-year overall and disease-free survival was 84.4% and 73.6%, respectively.

CONCLUSION

Minimally invasive, en-bloc resection of one or both seminal vesicles for locally advanced rectal adenocarcinoma, is feasible in a select group of patients with acceptable morbidity and short-term outcomes.

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.

Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes

BACKGROUND

This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration.

METHODS

Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS).

RESULTS

Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS.

CONCLUSION

MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.

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.