Pelvic exenteration for locally advanced rectal cancer (LARC) and locally advanced sigmoid
cancer LARC includes tumours threatening the mesorectal fascia or invading adjacent organs
and structures (9). Locally advanced sigmoid cancer is defined as tumors extending through
the colon wall with perforation and/or invasion of adjacent organs or structures (10).
Surgical removal is the standard curative approach for these tumours, and achievement of
complete tumour removal, or R0 resection, is prognostically important. The Residual tumour
(R) classification defines R0 resection as having > 1 mm margin between the tumour and
surrounding normal tissue, R1 resection as ≤ 1 mm margin, and R2 as local macroscopic
residual tumour after resection (11). If R0 resection is achieved, the outcome for the
patient is dramatically superior compared to when resection is incomplete. In a large study
of 1291 LARC cases, the overall survival was 43 months in R0 cases compared to 21 months if
R1 resection was achieved (12).
Neoadjuvant therapy including chemotherapy and (chemo) radiotherapy ((C) RT) has resulted in
improved local control (13), presumably by increasing the rate of complete surgical tumour
removal (14), when the patient is operated. Total radiation dose towards the pelvis are
usually 25-50 Gy, often with concomitant fluoropyrimidine-based chemotherapy. Although the
neoadjuvant radiotherapy improves prognosis (14), it also imposes challenges. The surgery
itself might be difficult because of edema and fibrosis resulting in potentially involved
margins, and the healing after surgery is impaired leading to increased postoperative
morbidity. This holds true for all tumours in the pelvis that receive radiotherapy before
surgery. Despite neoadjuvant therapy, tumours still often require resection of neighboring
organs in order to achieve R0-resection.
First described in 1948, total pelvic exenteration can be defined as the removal of the
bladder, removal of the prostate (in males), removal of the uterus or the vaginal vault and
partial or total resection of the vagina (in females), and the removal of the rectum with or
without the anus (15). Total pelvic exenteration is extensive surgery with reconstructions
that include two stomas. Locally advanced rectal cancers and locally advanced sigmoid cancers
with multiorgan involvement e.g. rectal cancer invading the prostate or the urinary bladder
are candidates for total pelvic exenteration.
Pelvic exenteration for recurrent cervical and endometrial cancer previously treated with
radiochemotherapy and selected cases of primary advanced vulva cancer For patients with
gynecologic cancer, pelvic exenteration is sometimes the only available curative treatment.
Particularly patients with recurrent cervical and endometrial cancer previously treated with
chemoradiation are considered candidates for pelvic exenteration. Selected cases of primary
advanced vulva cancer are also considered for more extensive pelvic surgery such as modified
anterior or posterior pelvic exenteration. In Norway, pelvic exenteration for recurrent
cervical cancer is centralized to the Department for Gynecologic Oncology at the Oslo
University Hospital and annually, approximately 10-15 patients are treated with total pelvic
exenteration. An ongoing project in our Institution evaluating the clinical outcome of 95
patients treated with open pelvic exenteration for one of the above mentioned diagnoses
revealed that about 50 % of the patients developed at least one severe complication (grade 3
or above according to the contracted Accordion severity grading system of surgical
complications). 87% had negative surgical margins on final histology, but after median follow
up time of 3.2 years, 59% of the patients had relapsed. About a third of those were
central/pelvic recurrences. The high complication rate warrants further improvement of the
surgical technique and minimally invasive surgery has emerged as a promising approach for
selected patients (16, 17). Recently, case reports utilizing laparoscopic robot-assisted
surgery have been published (18, 19). The reports indicate satisfactory oncological results
and less surgical morbidity compared to open surgery.
In many of the case reports on gynecological exenterations the reconstruction of the urinary
tract is done extra-corporally. In our Institution, robot-assisted intra-corporal urinary
diversion is well established. Thus, the robotic approach for pelvic exenterations is
attractive and feasible in our multidisciplinary surgical group.
Study design Open label observational study. Study objectives This study is a feasibility
study of laparoscopic robot-assisted total pelvic exenteration for pelvic cancers.
Feasibility will be assessed through:
Determining the R0 resection rate in included study patients
Assessment of conversion rate to open surgery
Assessment of perioperative and postoperative complications
