Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

Patient-Reported Outcome After Extended Total Mesorectal Excision for Locally Advanced Rectal Cancer in Male Patients

This study looks at sexual and urinary dysfunction and quality of life in male patients undergoing extended total mesorectal excision. This cross-sectional study used International Prostatic Symptom Score (IPSS) and the International Index of Erectile Function Score (IIEF) questionnaire-based retrospective analysis of male patients who underwent extended total mesorectal excision from 2015 to 2022. Quality of life was assessed using EORTC QLQ C-30 and EORTC QLQ CR-29. Sixty-eight male patients were included, with a median age of 44 years. Urinary retention and incontinence occurred in 10.3% of patients, and 2 required lifelong catheterization. Nineteen percent and 49% patients had severe urinary and sexual dysfunction as per IPSS and IIEF scores. As per the EORTC C-30 QOL analysis, participants scored a global health status mean score of 33.3 with a standard deviation of 10.76. The highest functional scale score was for cognitive functioning: 78.7 ± 18.67. The symptom scale ranged from 9.30 ± 13.26 for nausea and vomiting to 44.19 ± 27.9 for financial difficulties. According to the EORTC CR 29, impotence (43.41 ± 55.17) and problems with stoma care (37.20 ± 22) scored highest. On the function scale, anxiety about future health (62.79 ± 24.35), interest in sex (65.11 ± 45.4), and body image (65.12 ± 16) scored lowest in this order. The patient had significant urinary and sexual symptoms, resulting in concern about weight, loss of interest in sex, and anxiety about future health. In a high-volume , eTME is not without urinary and sexual dysfunction.

Advantages of Robotic Total Mesorectal Excision With Partial Prostatectomy Compared With Open Surgery for Rectal Cancer: A Single-Center Retrospective Cohort Study

AIM

Robotic total mesorectal excision (TME) with resection of adjacent organs has been increasingly used for locally advanced rectal cancer; however, few studies have focused on robotic TME with partial prostatectomy. Therefore, this study aimed to demonstrate the advantages of robotic TME with partial prostatectomy compared with open surgery for rectal cancer.

METHOD

This retrospective cohort study examined consecutive patients with rectal cancer who underwent robotic or open TME with partial prostatectomy at a high-volume center in Japan from April 2003 to March 2022. The patients were divided into robotic (n = 14) and open (n = 11) surgery groups. The short- and long-term outcomes of these patients were compared.

RESULTS

More transabdominal partial prostatectomies were performed in the robotic surgery group than in the open surgery group (71.4% vs. 9.1%, p = 0.001). Moreover, sphincter-preserving surgery was performed in 35.7% of patients in the robotic surgery group. The robotic surgery group had shorter operative times (401 min vs. 435 min, p = 0.047), less blood loss (56 mL vs. 484 mL, p < 0.001), lower complication rates (28.6% vs. 72.7%, p = 0.047), and shorter postoperative hospital stays (8 days vs. 18 days, p < 0.001) than the open surgery group. No significant differences were observed in the positive radial margin rate (7.1% vs. 9.1%, p = 1.000) or long-term outcomes between the two groups.

CONCLUSION

Compared with open surgery, robotic TME with partial prostatectomy facilitates transabdominal partial prostatectomy, resulting in more sphincter-preserving surgeries and better short-term outcomes.

Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer

AIM

Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration.

METHOD

The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up.

RESULTS

One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS.

CONCLUSION

The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.

Therapeutic effects and limitations of chemoradiotherapy in advanced lower rectal cancer focusing on T4b

PURPOSE

This study aimed to elucidate the benefits and limitations of preoperative chemoradiotherapy (CRT) in rectal cancer treatment, specifically in T4b rectal cancer.

METHODS

This retrospective cohort study reviewed 1014 consecutive patients with clinical T3/4a/T4b adenocarcinomas of the lower rectum, who underwent total mesorectal excision at the Department of Surgical Oncology of the University of Tokyo Hospital and 22 referral institutions affiliated with the Japanese Study Group for Postoperative Follow-up of Colorectal Cancer. Patients were divided into two cohorts: cohort 1 comprised 298 consecutive patients who underwent CRT followed by radical surgery and cohort 2 comprised 716 consecutive patients who underwent curative surgery without preoperative therapy. We assessed the prognostic differences between the two cohorts, focusing particularly on T stages.

RESULTS

In T3/4a patients, cohort 1 showed a significantly lower local recurrence rate than cohort 2 (4.8% vs. 9.4%, p=0.024), but not in T4b patients (23.5% vs. 16.0%, p=0.383). In contrast, no significant differences in survival were observed between T3/4a and T4b patients. T4b classification was found to be an independent predictive factor of local recurrence in cohort 1, but not in cohort 2.

CONCLUSION

In T4b rectal cancer, preoperative CRT demonstrated a limited benefit for local control and survival. In cases of suspected T4b rectal tumors, additional therapies such as induction chemotherapy to conventional CRT may contribute to better outcomes.

Efficacy and Incontinence Rates After Urethroplasty for Radiation-induced Urethral Stenosis: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the efficacy of urethroplasty and rates of de novo stress urinary incontinence (SUI) in the specific setting of radiation-induced urethral stenosis.

METHODS

A systematic search of databases (PubMed and EMBASE) was performed between 1980-2019 (CRD42020144845). Inclusion criteria were: (1) prior pelvic radiotherapy; (2) surgical urethroplasty; (3) rates of successful treatment and/or SUI development and (4) total case number provided. The pooled summary of stenosis resolution rate and SUI were calculated using the random-effects model weighted by the inverse variance. Accessory analyses were performed by reconstructive technique and type of RT.

RESULTS

Ninety-six studies were identified, of which 8 retrospective studies met inclusion criteria, comprising 256 patients. The proportion of cases treated with external beam RT (EBRT), brachytherapy (BT), or combination (EBRT+BT) were 52%, 33%, and 15%, respectively, of studies that specified modality. Most strictures involved the bulbomembranous region (n = 212; 83%). Sixty-one percent of cases (n = 157) entailed primary anastomosis, while the remainder underwent augmentation reconstruction (graft or flap). The mean follow-up time after urethroplasty varied from 10 to 50.5 months. The pooled stenosis resolution rate was 80% (95% CI: 74%-86%). There were no significant associations between stenosis resolution rate and reconstructive technique (rho=0.20, P = .74) or RT modality (rho=-0.31, P = .53). Fifty-three cases developed subsequent SUI, with a pooled complication rate of 19% (95% CI: 10%-31%).

CONCLUSIONS

Urethroplasty after radiation-induced urethral stenosis is effective for 80% of cases, independent of prior RT modality or urethroplasty technique; however, 1 out of every 5 patients develops SUI post-procedure.

Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study

AIM

Involvement of the anterior mesorectal fascia (iAMRF) after neoadjuvant treatment leads to either resection of the involved organ alone [extended resection of the rectum (ERR)] or total pelvic exenteration (TPE). The purpose of this study was to compare the rate of recurrence and survival of patients undergoing ERR or TPE for iAMRF after neoadjuvant treatment. The outcome of patients who underwent total mesorectal excision after downstaging was also compared.

METHOD

This was a retrospective study of primary rectal cancer patients.

RESULTS

Of 237 patients, 61 (21.5%) patients with nonmetastatic carcinoma rectum had iAMRF at baseline. Ten patients defaulted before completion of neoadjuvant chemoradiotherapy. After neoadjuvant chemoradiotherapy, 22 patients (43.1%) developed systemic metastases, seven patients (13.8%) were downstaged to free anterior mesorectal fascia and underwent total mesorectal excision (anterior resection/abdominoperineal resection) and the remaining 22 patients (43.1%) had persistent iAMRF. Thirteen patients with persistent iAMRF underwent ERR, whereas nine patients underwent TPE. The median duration of hospital stay in the TPE group was 13 days (10-26), whereas it was 7 days (5-21) in the ERR group. A clear circumferential resection margin, R0 resection, was achieved in all patients with TPE and ERR. After a median follow-up of 31.6 months, five patients with TPE (55.6%), four patients with ERR (30.7%) and three patients in the downstaged group (42.9%) developed systemic recurrence. None of the patients with TPE and the downstaged group developed local recurrence, whereas three patients with ERR (23.1%) developed local recurrence. Median disease-free survival was 12.3 months in the TPE group, 18.9 months in the ERR group and 10.6 months in the downstaged group, whereas mean overall survival was 36.2, 32.8 and 27.9 months, respectively.

CONCLUSION

Although there is no significant difference in the overall survival and disease-free survival, ERR is associated with a high risk of local recurrence compared to TPE and the downstaged group.

A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer

OBJECTIVE

The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer.

SUMMARY OF BACKGROUND DATA

Resection margin is important to guide therapy and to evaluate patient prognosis.

METHODS

A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature.

RESULTS

The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates.

CONCLUSIONS

Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.