Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events

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.

An Extremely Rare Metastatic Prostate Tumor From Rectal Cancer With Characteristic MRI Findings Due to Necrosis

Colorectal carcinomas rarely metastasize to the prostate. Early detection of metastatic prostate tumors can lead to possible cure with less invasive treatment. A 71-year-old man was diagnosed with rectal cancer and underwent surgery for it. The postoperative pathological study showed atypical cells growing mainly cribriform and some large necrosis in the tubule-forming structures. After favorable control of the recurrent lesion for 30 months, the MRI showed the right lobe tumor with low signals on diffusion-weighted images. CT clarified the enlargement of the right lobe mass in the prostate four years after the surgery. The patient, therefore, underwent total pelvic exenteration, including prostatectomy. The postoperative pathological study showed metastatic adenocarcinoma from rectal cancer with massive garland necrosis. Diagnostic physicians should note that rectal cancer can, though extremely rarely, metastasize to the prostate and that the presence of garland necrosis can make image diagnosis difficult.

Urological complications following pelvic exenteration are comparable to those following radical cystectomy

INTRODUCTION

Radical cystectomy and urinary diversion is required for both primary muscle-invasive bladder cancer and in the setting of pelvic exenteration for advanced malignancy of pelvic organs. Acute and chronic complications following radical cystectomy can be a significant cause of morbidity. We compared the rates of urological complications following these two procedures at our tertiary referral centre.

METHODS

Patients who underwent radical cystectomy and urinary diversion either alone or as part of pelvic exenteration between June 2017 and April 2024 at our hospital were included. Short and long-term post-operative urological complications were collected, and data for patients who underwent PE were collected prospectively as part of a larger database.

RESULTS

One hundred eleven patients underwent cystectomy: 44 as part of pelvic exenteration (PE), 67 cystectomy alone. Post-operative urological complications occurred in 45% of patients undergoing PE and 42% undergoing cystectomy alone (P = 0.703). Urosepsis was the most frequent complication in both cohorts, occurring in 27% and 24% of patients who underwent PE and cystectomy alone respectively. Return to theatre was required in 9% of PE patients and 7% of non-PE patients. ASA status was predictive of complication development in the non-PE cohort, no factors analysed were predictive in the PE cohort.

CONCLUSIONS

In this cohort, the rate of urological complications and return to the theatre following radical cystectomy and urinary diversion were comparable among those undergoing PE and cystectomy alone. No individual factor was identified that was predictive of post-operative complications.

Patient-Reported Outcomes in Chinese Patients with Locally Advanced or Recurrent Colorectal Cancer After Pelvic Exenteration

BACKGROUND

Pelvic exenteration (PE) is often the only curative treatment option for selected locally advanced and locally recurrent colorectal cancer associated with significant morbidity. Open and laparoscopic approaches were accepted for this procedure.

OBJECTIVE

This study aimed to examine the Chinese patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after PE.

METHODS

A total of 122 enrolled participants were asked to complete PROs at baseline and 1, 3, 6, 9 and 12 months after PE. PROs included seven symptoms from the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). The HRQoL was assessed using the Functional Assessment of Cancer Therapy-Colorectal (FACT-C).

RESULTS

The overall postoperative complication rate was 41.0%. Patients experienced lower physical and functional well-being and FACT-C 1 month after surgery, then gradually recovered. The FACT-C score returned to baseline 9 months after surgery. Social and emotional well-being did not show signs of recovery until 6 months after the surgical procedure, and did not fully return to baseline until 12 months post-surgery. Symptom rates of insomnia, anxiety, discouragement, and sadness (composite score >0) did not improve significantly from baseline until 12 months after surgery.

CONCLUSIONS

PE is a feasible treatment choice for locally advanced primary and recurrent colorectal cancer. Social, psychological, and emotional recovery in the Chinese population after PE tends to be slower compared with the physical condition.

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.

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

INTRODUCTION

Total pelvic exenteration (TPE) for rectal cancers is associated with significant morbidity. We evaluated the complications related to urinary reconstruction following TPE and factors predicting urologic morbidity.

METHODS

Retrospective analysis of TPE patients with incontinent urinary diversions between August 2013 and January 2020.

RESULTS

One hundred TPE were performed with 96 ileal conduits (IC). Early complications occurred in 10 patients that included uretero-ileal leaks (5%), conduit-related complications (3%), and acute pyelonephritis (3%). Late complications were seen in 26% of patients with uretero-intestinal strictures in 11%. Mortality attributable to urinary complications was seen in 2%. No single factor, including prior radiation, recurrent disease, type of anastomosis, or blood loss, predicted development of urinary morbidity.

CONCLUSION

Conduit urinary diversion following TPE is associated with high urinary morbidity rate but low mortality. It can be safely performed even after previous surgeries and radiation by a dedicated colorectal team.