Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

Partial versus radical cystectomy in localized colorectal cancer: a systematic review and meta-analysis

PURPOSE

Locally advanced colorectal tumors frequently invade adjacent organs, particularly the urinary bladder in the sigmoid colon and upper rectum, complicating multivisceral resections. This study compared postoperative outcomes of partial cystectomy (PC) and total cystectomy (TC) in patients with locally advanced colorectal cancer.

METHODS

A systematic review was conducted in PubMed, Scopus, Central Register of Clinical Trials, and Web of Science for studies published up to November 2024. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed with I2 statistics. Statistical analyses were performed in R Software 4.4.1.

RESULTS

Nine retrospective studies including 894 patients were analyzed. Among them, 433 (48.43%) underwent PC, and 461 (51.57%) underwent TC. Compared to TC, PC was associated with significantly lower rates of surgical site infection (OR 0.33; 95% CI 0.13-0.80; p = 0.015), shorter operative time (MD - 169.7 min; 95% CI - 214.1 to - 125.3; p < 0.01), reduced blood loss (MD - 1005.9 ml; 95% CI - 1362.1 to - 649.8; p < 0.01), and shorter hospital stay (MD - 6.6 days; 95% CI - 9.4 to - 3.9; p < 0.01). No significant differences were observed between groups in local or distant recurrence, urinary and intestinal leaks, pelvic abscess, ileus, urinary tract infection, or 90-day mortality.

CONCLUSION

Partial cystectomy demonstrated superior postoperative outcomes, including fewer surgical site infections, reduced operative time, less blood loss, and shorter hospitalization. Oncological outcomes and other postoperative complications were comparable between PC and TC, supporting PC as a safe and effective option in selected patients.

Patterns of Care and Oncologic Outcomes after Pelvic Exenteration for Locally Advanced Rectal Cancer in the United States

BACKGROUND

Pelvic exenterations (PEs) are technically demanding procedures performed with curative intent for advanced malignancies to improve patient survival while balancing morbidity and functional outcomes. The majority of United States (US) data regarding PE for rectal cancers originate from single-center series.

OBJECTIVE

We aimed to investigate patterns of care and oncologic outcomes for primary rectal cancer patients undergoing PE in a national registry.

METHODS

The National Cancer Database (2004-2019) was queried for adults with a pT4 rectal adenocarcinoma. Logistic regression identified factors associated with positive margins. Multivariable Cox regression estimated treatment effects on overall survival (OS).

RESULTS

Of 673 patients (73% <65 years of age, 39% male, 82% White), median follow-up was 39 months. The majority received neoadjuvant chemotherapy (76%) and radiation (75%), while adjuvant chemotherapy (37%) and radiation (13%) were less common. Twenty-four percent had positive margins (R1 = 98, R2 = 11, R + NOS = 48). Univariable analysis demonstrated that only nodal involvement was associated with higher positive margin rates (odds ratio 1.75, 95% confidence interval [CI] 1.22-2.51). Five-year OS for R0 and R+ resections were 55% and 33%, respectively. On multivariable analysis, age <65 years (hazard ratio [HR] 0.73, 95% CI 0.53-0.99) and adjuvant chemotherapy (HR 0.62, 95% CI 0.47-0.82) were associated with improved OS, while N+ status (HR 2.13, 95% CI 1.67-2.70) and positive margins (HR 1.82, 95% CI 1.41-2.35) portended worse prognosis. No significant associations were observed between outcomes and institutional volume.

CONCLUSION

One in four US patients undergoing PE for locally advanced rectal cancer had an R+ resection regardless of center volume. Quality of surgical resection to achieve negative margins remains the most relevant prognostic factor.

Early failure following pelvic exenteration: Who are the bad actors?

BACKGROUND

Pelvic exenteration for locally advanced (LARC) or recurrent rectal cancer (LRRC) is technically challenging with considerable morbidity for the patient. Though surgery can confer long-term survival in selected patients, early failure, defined as recurrence with one year, represents a major issue as both survival and quality of life are severely impacted. This study aims to highlight the "bad actors" associated with early failure.

METHODS

A retrospective study of patients who underwent exenteration for LARC & LRRC in a quaternary referral unit was performed. Specifically, characteristics of patients with early recurrence were identified and compared to those who recurred after one year.

RESULTS

159 and 85 patients underwent pelvic exenteration for LARC and LRRC, respectively. Of these, there were 61 (38.3 %) recurrences in the LARC and 74 (87.1 %) LRRC cohorts. For LARC, 18 patients had an early failure. Expectantly, these patients had a higher proportion of positive margins (R1) (50 % vs. 21 % in the remaining 141 patients, ∗p = 0.04). Interestingly, early failure was also associated with more genetic mutations (33 % vs. 22 %), extramural venous invasion (32 % vs. 24 %), lymphovascular invasion (38 % vs. 22 %), and other adverse histopathological features including poor-differentiation, signet-ring and/or mucinous disease (38 % vs. 21 %). Median and 3-year overall survival (OS) in the early failure group compared to the rest of the cohort was 96 months versus 30 months and 35 % versus 73 %, respectively (∗p = 0.003). There were 18 early failures in the LRRC cohort. Similarly, there were more patients with positive margins in the early failure group (55 % versus 39 %, ∗p = 0.02). The early failure group was also associated with extramural venous invasion (38 % versus 23 %) and adverse histopathological features (55 % versus 28 %). Median and 3-year overall survival (OS) in the early failure group compared to the non-early-failure group was 15 versus 0 months and 17 % versus 68 % respectively (∗p=<0.001).

CONCLUSION

Tailoring treatment strategies according to tumour characteristics is increasingly important in the management of advanced rectal cancer. Multicentre data is needed to validate these findings and would have a profound impact to patient counselling and outcome expectations.

Survivorship issues in long-term survivors of locally recurrent rectal cancer: A qualitative study

AIM

There are increasing numbers of long-term survivors following curative treatment for locally recurrent rectal cancer (LRRC); however, their experiences remain relatively underreported. The aim of this qualitative study was to identify the long-term survivorship issues relevant to these patients.

METHOD

Adults who remained disease free >3 years following treatment for LRRC were invited to participate in an international multicentre study. Semistructured qualitative interviews were conducted either in person, via telephone or via Microsoft Teams and were analysed using a framework method of thematic analysis.

RESULTS

A total of 26 participants were recruited from 11 sites in seven countries. Sixteen (61.5%) participants were male, the median age was 70.5 (33.0-85.0) years, participants were a median of 5.0 (3.0-17.0) years posttreatment, most had undergone surgery for LRRC (n = 24, 92.3%), two participants received neoadjuvant chemo/radiation for LRRC with a complete response. Eight major survivorship themes were identified: (1) experience of long-term follow-up care, (2) unmet needs and areas for improvement, (3) long-term physical effects of cancer and treatment, (4) living with a stoma, urostomy or other urinary device, (5) long-term psychological impact, (6) impact on sexual function and intimate relationships, (7) impact on daily life and (8) feelings surrounding life now, adapting and the future.

CONCLUSION

Participants experienced a wide range of long-term survivorship issues, reflecting the complexity of both LRRC and its treatment. Despite this, most had adapted well. Further work regarding survivorship care in LRRC is required to address the unmet needs and issues highlighted in this study, such as support regarding sexual function.

A Prospective Observational Cohort Study Comparing High-Complexity Against Conventional Pelvic Exenteration Surgery

Background: Conventional pelvic exenteration (PE) comprises the removal of all or most central pelvic organs and is established in clinical practise. Previously, tumours involving bone or lateral sidewall structures were deemed inoperable due to associated morbidity, mortality, and poor oncological outcomes. Recently however high-complexity PE is increasingly described and is defined as encompassing conventional PE with the additional resection of bone or pelvic sidewall structures. This observational cohort study aimed to assess surgical outcomes, health-related quality of life (HrQoL), decision regret, and costs of high-complexity PE for more advanced tumours not treatable with conventional PE. Methods: High-complexity PE data were retrieved from a prospectively maintained quaternary database. The primary outcome was overall survival. Secondary outcomes were perioperative mortality, disease control, major morbidity, HrQoL, and health resource use. For cost-utility analysis, a no-PE group was extrapolated from the literature. Results: In total, 319 cases were included, with 64 conventional and 255 high-complexity PE, and the overall survival was equivalent, with medians of 10.5 and 9.8 years (p = 0.52), respectively. Local control (p = 0.30); 90-day mortality (0.0% vs. 1.2%, p = 1.00); R0-resection rate (87% vs. 83%, p = 0.08); 12-month HrQoL (p = 0.51); and decision regret (p = 0.90) were comparable. High-complexity PE significantly increased overall major morbidity (16% vs. 31%, p = 0.02); and perioperative costs (GBP 37,271 vs. GBP 45,733, p < 0.001). When modelled against no surgery, both groups appeared cost-effective with incremental cost-effectiveness ratios of GBP 2446 and GBP 5061. Conclusions: High-complexity PE is safe and feasible, offering comparable survival outcomes and HrQoL to conventional PE, but with greater morbidity and resource use. Despite this, it appears cost-effective when compared to no surgery and palliation.

Advances in beyond total mesorectal excision surgery: Behind the scenes

The management of locally advanced rectal cancer involving adjacent organs and extending beyond the surgical planes of total mesorectal excision has evolved over the past few decades both in terms of the effectiveness of preoperative treatments and surgical innovation. The use of a robotic platform is increasing, even in complex surgery such as pelvic exenteration together with the advantages of minimally invasive procedures. However, satisfactory surgical, oncological, and functional outcomes are achieved not only minimizing the impact of a demolitive surgery but also when a multidisciplinary specialized team focuses on experienced surgeons, mandatory rules of surgical oncology, appropriate medical treatments, accurate preoperative planning, and an acceptable quality of life.

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.

Evaluating postoperative hernia incidence and risk factors following pelvic exenteration

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.

METHOD

A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.

RESULTS

A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.

CONCLUSION

This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

Multimodality Imaging to Direct Management of Primary and Recurrent Rectal Adenocarcinoma Beyond the Total Mesorectal Excision Plane

Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.

Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence

Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.

Navigation-Assisted Surgery for Locally Advanced Primary and Recurrent Rectal Cancer

BACKGROUND

In some surgical disciplines, navigation-assisted surgery has become standard of care, but in rectal cancer, indications for navigation and the utility of different technologies remain undetermined.

METHODS

The NAVI-LARRC prospective study (NCT04512937; IDEAL Stage 2a) evaluated feasibility of navigation in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC). Included patients had advanced tumours with high risk of incomplete (R1/R2) resection, and navigation was considered likely to improve the probability of complete resection (R0). Tumours were classified according to pelvic compartmental involvement, as suggested by the Royal Marsden group. The BrainlabTM navigation platform was used for preoperative segmentation of tumour and pelvic anatomy, and for intraoperative navigation with optical tracking. R0 resection rates, surgeons' experiences, and adherence to the preoperative resection plan were assessed.

RESULTS

Seventeen patients with tumours involving the posterior/lateral compartments underwent navigation-assisted procedures. Fifteen patients required abdominosacral resection, and 3 had resection of the sciatic nerve. R0 resection was obtained in 6/8 (75%) LARC and 6/9 (69%) LRRC cases. Preoperative segmentation was time-consuming (median 3.5 h), but intraoperative navigation was accurate. Surgeons reported navigation to be feasible, and adherence to the resection plan was satisfactory.

CONCLUSIONS

Navigation-assisted surgery using optical tracking was feasible. The preoperative planning was time-consuming, but intraoperative navigation was accurate and resulted in acceptable R0 resection rates. Selected patients are likely to benefit from navigation-assisted surgery.

Clinical algorithm for the management of advanced pelvic tumours involving the aortoiliac axis

Pelvic exenteration offers potentially curative treatment for locally advanced and recurrent pelvic tumours. Laterally infiltrating tumours involving the pelvic sidewall have historically been considered unresectable. Highly specialised exenteration units have accumulated experience with en bloc resection of part or all of the iliac vascular system for tumours with major vessel involvement. These approaches involve complex vascular dissection and reconstructive techniques requiring collaboration with the vascular surgery unit. Adding to the complexity is the paucity of evidence on oncovascular techniques in the pelvis given its developing nature. An algorithm for the workup to determine resectability and the vascular reconstruction approach for advanced pelvic tumours involving the aortoiliac axis is suggested based on current literature and personal experience from the authors' unit.

Oncovascular surgery for advanced pelvic malignancy

BACKGROUND

The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement.

METHODS

This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed.

RESULTS

Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510-678 min) and significant blood loss (median 2-5 l). R0 resection can be achieved in 58-82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30-40 per cent) and perioperative mortality is acceptable (0-4 per cent). Long-term survival is achievable in approximately 50 per cent of patients.

CONCLUSION

En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.