Sciatic and Femoral Nerve Resection During Extended Radical Surgery for Advanced Pelvic Tumours

Abstract

Objective: To report survival, functional, and quality-of-life (QoL) outcomes after extended radical resection for advanced pelvic tumors with en bloc sciatic or femoral nerve resection. Background: Advanced pelvic tumors involving the sciatic or femoral nerve have traditionally been considered inoperable. Small studies have suggested acceptable functional outcomes can be achieved after pelvic exenteration with en bloc sciatic nerve resection. Method: Consecutive patients who underwent extended radical pelvic surgery with en bloc resection of the sciatic or femoral nerves at a single center were included. Results: Of 713 radical pelvic resections, 68 patients (9.5%) had en bloc sciatic or femoral nerve resection. Complete sciatic, partial sciatic, and complete femoral nerve resection was performed in 26 (38%), 38 (56%), and 4 patients (6%), respectively. Overall and major postoperative complication rates were 63% and 40%, respectively. R0 resection was achieved in 65% of patients, which translated to 55% and 76% overall and local recurrence-free 5-year survival in those with colorectal cancer. Twenty-two (96%) and 25 (92%) patients could mobilize independently after complete and partial sciatic nerve resection, respectively. Physical QoL was significantly lower at 6 months after surgery compared with baseline (P = 0.041), but returned to baseline at 12 months (P = 0.163). There was no difference in mental or overall QoL at 6 or 12 months compared with baseline. Conclusion: En bloc sciatic and femoral nerve resection can be performed during extended radical pelvic resections with morbidity and survival outcomes comparable with existing exenteration literature, including in patients with recurrent rectal cancer. Physical QoL may be impaired after surgery, but returns to baseline by 12 months.

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

“…Historically, the presence of hydronephrosis, gross lower limb oedema, and invasion of the sciatic notch or involvement of the aortoiliac axis suggested inoperable disease. Various studies have demonstrated the safety and efficacy of major extra-anatomic resections involving these structures in selective patients [ 64 , 65 , 66 ]. En bloc sciatic nerve and/or lumbosacral trunk resections for tumours extending laterally into the piriformis muscle have demonstrated similar R0 rates to central pelvic tumours [ 13 ].…”

Locally Recurrent Rectal Cancer

“…En bloc resection of the sciatic nerve and/or lumbosacral trunk for tumors which extend more laterally into the piriformis muscle has R0 resection rates similar to central pelvic tumors and functional outcomes better than anticipated [45][46][47][48]. Radical resection of the sciatic nerve (partial or complete) with or without resection of the sciatic notch can be done either through the abdominal perineal access or transgluteal/prone access championed in London [45]. Partial or complete sciatic nerve resection can be more easily performed by these approaches.…”

“…Partial or complete sciatic nerve resection can be more easily performed by these approaches. Almost all patients (96%) who require a complete sciatic nerve resection are able to mobilize postoperatively with intensive physiotherapy and orthotics input [45]. Patients mobilize by fixation of their resultant foot drop using ankle orthotics and raising of the ipsilateral hip followed by locking of the knee joint with the quadriceps (femoral nerve) on landing (the so-called rolling gait of sciatic nerve palsy).…”

“…The patient is placed on a nonslip gel mattress in the modified Lloyd-Davies position. The gel mattress distal end is rolled back over 10 cm, or a rolled towel is placed under the patient in the lumbar curve in order to raise the pelvis free of the operating table when an abdomino-lithotomy sacrectomy is planned [45]. The gel mattress provides security from slippage when in steeper Trendelenburg and allows for perineal reflection of the gluteus muscles free of the sacral bone posteriorly without compression of the skin on the sacrum ready for transection.…”

“…Once exposed, complete or partial sciatic nerve resection can be performed (Fig. 32.10) [45]. Extension of tumors outside the true lateral compartment can involve excision of the psoas muscle and dissection and/ or resection of the femoral nerve.…”