Opportunities and Limitations of Pelvic Exenteration Surgery

Purpose: The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view. Methods: This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993–2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used. Results: A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2–5%), the still relatively high morbidity rate (32–84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79–82% of patients report satisfying results according to PROs (patient-reported outcomes). Conclusion: Due to multimodality treatment strategies combined with extended surgical expertise and patients’ preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.

Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation

Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.

P279 Early detection of mucinous adenocarcinoma within fistulating peri-anal Crohn’s disease

Background The development of peri-anal fistula mucinous adenocarcinoma (MA) is a presumed rare but recognised event in patients with fistulating peri-anal Crohn’s disease. The true incidence is unknown, with a lack of robust registry data. Fistula mucinous cancers may evade early diagnosis, presenting with locally advanced intra-pelvic disease, necessitating debilitating and morbid exenterative surgery. Given the limitations of endoluminal assessment of this region in the context of an often extra-luminal disease process, MRI studies were reviewed in conjunction with EUA and endoscopic findings. Methods We performed a retrospective analysis of 8 cases of biopsy-proven mucinous adenocarcinoma (MA) that had developed within known Crohn’s related anal fistula. Serial MRI studies pre-dating the diagnosis of malignancy were reviewed in order to establish whether there are early predictive features of MA development within a fistula tract. Demographic, disease and surgical history were collected including the time of fistula diagnosis and histological confirmation of mucinous adenocarcinoma. Results The median time to histological diagnosis of MA from the time of diagnosis of Crohn’s disease was 426 (96–480) months and from diagnosis of fistulating disease 66 (24–156) months. On review of sequential MRI fistula protocol studies, a characteristic ‘budding’ appearance within the T2 high signal ‘sepsis’/fistula tract is noted in all of our MA fistula cancer cases (Fig1 and 2). This finding pre-dates the histological diagnosis of MA by a median of 42(12–156) months. Weight loss was a presenting symptom in 4 of the 8 (50%) patients and all 8 patients reported a new significant peri-anal pain and high volume discharge which prompted reassessment and referral. Metastatic disease was not detected in any of the 8 cases. Potentially curative pelvic exenteration was possible in 7 patients. Conclusion Mucinous adenocarcinoma within this cohort often culminates in exenterative surgery by the time a diagnosis is made. There is an opportunity for early detection on MRI of the development of MA in an anal fistula by recognition of ‘budding’ within the tract. An earlier diagnosis may lessen the magnitude and morbidity of subsequent radical surgery following prolonged growth of these lesions. Long-standing Crohn’s anal fistula should be surveyed with MRI and any finding of ‘budding’ within the tract on T2 sequences should prompt urgent examination under anaesthetic and biopsy.

The Role of Exenterative Surgery in Advanced Urological Neoplasms

Pelvic exenterative surgery is both complex and challenging, especially in the setting of locally recurrent disease. In recent decades, improved surgical techniques have facilitated more extensive resection of both locally advanced and recurrent pelvic malignancies, but its role in urological cancer surgery is highly selective. However, it remains an important part of the armamentarium for the management of bladder and prostate cancer cases where there is local invasion into adjacent organs or localized recurrence. Better diagnostics, reconstructive options and centralized care have reduced associated morbidity considerably, and it is still used rarely in palliative settings. Despite this, there is sparse prospective evidence reporting on long-term oncological or quality of life outcomes.