Conventional Versus High-Complexity Total Pelvic Exenteration For Locally Advanced and Locally Recurrent Rectal Cancer: An International Multicenter Study

Abstract

Background: Pelvic exenteration is the treatment of choice for selected patients with locally advanced primary and recurrent rectal cancer. Involvement of major pelvic neurovascular structures and bone were historically considered contraindications due to unacceptably high rates of morbidity and low R0 resection rates.

Objective: To compare the outcomes of these "high-complexity" exenterative resections to those of "conventional" pelvic exenteration.

Design: International multicenter retrospective cohort study.

Settings: Sixteen specialized exenteration centers.

Patients: Those who underwent total pelvic exenteration for locally advanced primary and recurrent rectal cancer between 2018 and 2023 at participating centers.

Main outcome measures: Perioperative resource utilization, morbidity, mortality and R0 resection rates were reported.

Results: 763 patients underwent total pelvic exenteration, of which 478 (63%) and 285 patients (37%) required conventional and high-complexity procedures, respectively. High-complexity pelvic exenteration was associated with longer operating time (600 vs 480 mins, p < 0.001 for locally advanced primary rectal cancer, 623 vs 480 mins, p < 0.001 for locally recurrent rectal cancer), intensive care stay (2 vs 1 day, p < 0.001 and 3 vs 1 day, p < 0.001), hospital stay (19 vs 15 days, p = 0.008 and 23 vs 15 days, p < 0.001) and higher blood loss (2000 vs 1236 mL, p < 0.001 and 3000 vs 1600 mL, p < 0.001). Morbidity and mortality outcomes, and R0 resection rates were similar between the groups.

Limitations: Generalizability of findings outside of expert units.

Conclusions: High-complexity pelvic exenteration for the treatment of rectal cancer is associated with similar morbidity, mortality, and R0 resection rates, but significantly higher operative time, blood loss, and hospital resource utilization compared to conventional pelvic exenteration. In high volume, specialized centers, these techniques are considered the standard of care for appropriately selected patients with tumors that involve major pelvic bone or neurovascular structures. See Video Abstract.

Keywords: Complex total pelvic exenteration; Locally advanced rectal cancer; Locally recurrent rectal cancer; Surgical outcomes.