Improving Surgical Outcomes in Pelvic Exenteration Surgery

Abstract

Objective: To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. Background: In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. Methods: A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. Results: A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time (P<0.01) and more blood loss (P<0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections (P<0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) (P=0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively (P=0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. Conclusions: Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.