Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes

Abstract

Background This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration. Methods Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS). Results Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS. Conclusion MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.

Learning curves for minimally invasive total mesorectal excision beyond the competency phase – a risk‐adjusted cumulative sum analysis of 1000 rectal resections

“…The primary limitation is the crossover of learning from more complicated cases to standard TME operations, since over 30% of the colorectal work in the authors' institution involved extended and beyond‐TME operations by MIS [17]. This crossover phenomenon was not modelled into the learning curve charts.…”

Minimally invasive, ‘en‐bloc’ seminal vesicle excision for locally advanced rectal adenocarcinoma: surgical technique and short‐term outcomes

“…Minimally invasive multi-visceral rectal resection is feasible both with the laparoscopic and robotic approach, and is associated with the benefits of minimally invasive surgery. 4 The PelvEx database had 20% R1 resections and 35% major morbidity rates. 1 The results from our experience with seminal vesicle excisions appear comparable (8.7% R1 and 26.1% major morbidity) thus justifying the procedure with regards to short-term oncological outcomes.…”

“…Minimally invasive multi‐visceral rectal resection is feasible both with the laparoscopic and robotic approach, and is associated with the benefits of minimally invasive surgery 4 . The PelvEx database had 20% R1 resections and 35% major morbidity rates 1 .…”

“…With advancements in surgical technique, instrumentation and the implementation of robotic assistance, such extended TME resections are amenable to the minimally invasive approach with acceptable morbidity and long‐term outcomes 4 . We present our technique, perioperative results and oncological outcomes of 23 consecutive patients undergoing a minimally invasive, ‘en‐bloc’ resection of one or both seminal vesicles for locally advanced rectal adenocarcinoma infiltrating or abutting the seminal vesicles, in a specialized colorectal unit at a tertiary cancer centre.…”

“…Though pelvic exenteration offers a three-year overall survival of 56.4% in patients with an R0 resection, this is a morbid procedure with nearly 40% of patients having one or more major complication. 1,4 Following the procedure, patients have to deal with the lifelong colostomy and urinary conduit. 5 Functional outcomes and quality of life are significant issues for long term survivors following total pelvic exenteration (TPE).…”