Morbidity, mortality and oncological outcomes of pelvic exenteration surgery for advanced and recurrent pelvic malignancy

Abstract

Pelvic exenteration involves en bloc resection of multiple pelvic organs, often with excision of neurovascular and bony tissues at the periphery of the pelvis with complex reconstruction, and may be associated with significant postoperative morbidity. This thesis aimed to investigate rates of postoperative complications and oncological outcomes of patients who underwent radical pelvic surgery at the pelvic exenteration unit at Royal Prince Alfred Hospital, Sydney, since the unit was established in 1994. The major findings presented in chapter 2 are that the rate of urinary conduit-associated complications, especially urinary leaks and sepsis, are higher after pelvic exenteration than after cystectomy alone for primary bladder malignancy. Several factors may contribute to the higher rate of urological morbidity, including a history of pelvic irradiation, major intraoperative blood loss, cardiac disease, diabetes mellitus, as well as the type of urinary reconstruction. Chapter 3 found that en bloc lateral pelvic compartment excision allows complete oncological resection in 69% of patients undergoing planned curative surgery with acceptable postoperative morbidity (major and minor complication rates were 28% and 79%, respectively) and demonstrated that en bloc excision and reconstruction of the common or external iliac vessels is feasible, with no intraoperative or 30-day mortality, 96% overall graft patency at 1 year and 0% limb loss in a group of 21 patients. Chapter 4 described two novel techniques developed at the RPA exenteration unit (spiral saphenous vein graft for reconstruction of major pelvic vessels and segmental sacrectomy for tumours with high sacral involvement) in an attempt to reduce postoperative morbidity. There remain unanswered questions around the repeated use of radiation and intraoperative brachytherapy, postoperative chemotherapy, synchronous metastatectomy, repeat exenteration for re-recurrent rectal cancer and the future role of laparoscopic and robotic surgery in exenteration.