Advertisement

Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do?

Published:January 09, 2023DOI:https://doi.org/10.1016/j.ejso.2023.01.002

      Abstract

      Introduction

      In patients with locally advanced (LARC) or locally recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially offer a cure. The study aim was to compare PC and RC in PE patients in terms of oncological outcome, post-operative complications and quality-of-life (QoL).

      Materials & methods

      This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC cancer with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC.

      Results

      60 PC patients and 269 RC patients were included. Overall R0 resection was 84.3%. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (P = 0.008). Overall, 1-, 3- and 5-year OS was 90.8%, 68.1% and 58.6% after PC, and 88.7%, 62.2% and 49.5% after RC. Rates of urinary sepsis or urological leaks did not differ between groups, however, RC patients experienced significantly higher rates of perineal wound- and flap-related complications (39.8% vs 25.0%, P = 0.032).

      Conclusion

      PC as part of PE can be performed safely with good oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Steffens D.
        • Solomon M.J.
        • Young J.M.
        • Koh C.
        • Venchiarutti R.L.
        • Lee P.
        • et al.
        Cohort study of long-term survival and quality of life following pelvic exenteration.
        BJS Open. 2018; 22 (2): 328-335
        • The Pelvex Collaborative
        Surgical and survival outcomes following pelvic exenteration for locally advanced primary rectal cancer: results from an international collaboration.
        Ann Surg. 2019; 269: 315-332
        • The PelvEx Collaborative
        Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer.
        Br J Surg. 2018; 105: 650-657
        • Beyond TME Consensus
        Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes.
        Br J Surg. 2013; 100 (2013): 1009-1014
        • Kates M.
        • Gorin M.A.
        • Deibert C.M.
        • Pierorazio P.M.
        • Schoenberg M.P.
        • McKiernan J.M.
        • et al.
        In-hospital death and hospital acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States.
        Urol Oncol. 2014; 32 (53 e9-14)
        • Kondo A.
        • Sasaki T.
        • Kitaguchi D.
        • Tsukada Y.
        • Nishizawa Y.
        • Ito M.
        Resection of the urinary baldder for locally advanced colorectal cancer: a retrospective comparison of partial versus total cystectomy.
        BMC Surg. 2019; 19
        • Knoedler J.
        • Frank I.
        Organ sparing surgery in urology: partial cystectomy.
        Curr Opin Urol. 2015; 25: 111-115
        • Ebbing J.
        • Heckmann R.C.
        • Collins J.W.
        • Miller K.
        • et al.
        Oncological outcomes, quality of life outcomes and complications of partial cystectomy for selected cases of muscle-invasive bladder cancer.
        Sci Rep. 2018; 8: 8360
        • Brown K.G.
        • Solomon M.J.
        • Latif E.R.
        • et al.
        Urological complications after cystectomy as part of pelvic exenteration are higher than that after cystectomy for primary bladder malignancy.
        J Surg Oncol. 2017; 115 (2017): 307-311
        • Peacock O.
        • Waters P.S.
        • Kong J.C.
        • Warrier S.K.
        • Wakeman C.
        • Eglinton T.
        • et al.
        Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases.
        Tech Coloproctol. 2020 Feb; 24: 181-190
        • Aslim E.J.
        • Chew M.H.
        • Chew G.K.
        • Lee L.S.
        Urological outcomes following pelvic exenteration for advanced pelvic cancer are not inferior to those following radical cystectomy.
        ANZ J Surg. 2018; 88: 896-900
        • Kazi M.
        • Rohila J.
        • Kumar N.A.
        • Bankar S.
        • Engineer R.
        • Desouza A.
        Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes.
        Langenbeck's Arch Surg. 2021; 406: 329-337
        • Khan O.
        • Patsouras D.
        • Ravindraanandan M.
        • Abrar M.M.
        • Schizas A.
        • George M.
        • et al.
        Total Pelvic exenteration for locally advanced and recurrent rectal cancer; urological outcomes and adverse events.
        Eur Urol Focus. 2021; 7: 638-643
        • Winter D.C.
        • Walsh R.
        • Lee G.
        • Kiely D.
        • O'Riordain M.G.
        • O'Sullivan G.C.
        Local involvement of the urinary bladder in primary colorectal cancer: outcome with en-bloc resection.
        Ann Surg Oncol. 2007; 14: 69-73
        • Luo H.L.
        • Tsai K.L.
        • Lin S.E.
        • Chiang P.H.
        Outcome of urinary bladder recurrence after partial cystectomy for en bloc urinary bladder adherent colorectal cancer resection.
        Int J Colorectal Dis. 2013; 28: 631-635
        • Li J.C.
        • Chong C.C.
        • Ng S.S.
        • Yiu R.Y.
        • Lee J.F.
        • Leung K.L.
        En bloc urinary bladder resection for locally advanced colorectal cancer: a 17-year experience.
        Int J Colorectal Dis. 2011; 26: 1169-1176
        • Gao F.
        • Cao Y.F.
        • Chen L.S.
        • Zhang S.
        • Tang Z.J.
        • Liang J.L.
        Outcome of surgical management of the bladder in advanced colorectal cancer.
        Int J Colorectal Dis. 2007; 22: 21-24
        • Carne P.W.
        • Frye J.N.
        • Kennedy-Smith A.
        • et al.
        Local invasion of the bladder with colorectal cancers: surgical management and patterns of local recurrence.
        Dis Colon Rectum. 2004; 47: 44-47
        • Stief C.G.
        • Jonas U.
        • Raab R.
        Long-term follow-up after surgery for advanced colorectal carcinoma involving the urogenital tract.
        Eur Urol. 2002; 41: 546-550
        • Yoshida T.
        • Shida D.
        • Taniguchi H.
        • Tsukamoto S.
        • Kanemitsu Y.
        Long-term outcomes following partial versus complete cystectomy in advanced colorectal cancer with regarding to the extent of bladder invasion.
        Ann Surg Oncol. 2019; 26: 1569-1576
        • Denost Q.
        • Solomon M.
        • Tuech J.J.
        • Ghouti L.
        • Cotte E.
        • Panis Y.
        • et al.
        International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis.
        Br J Surg. 2020 Dec; 107: 1846-1854
        • Bhangu A.
        • Ali S.M.
        • Darzi A.
        • Brown G.
        • Tekkis P.
        Meta-analysis of survival based on resection margin status following surgery for recurrent rectal cancer.
        Colorectal Dis. 2012; 14: 1457-1466
        • Young J.M.
        • Badgery-Parker T.
        • Masya L.M.
        • King M.
        • Koh C.
        • Lynch A.C.
        • et al.
        Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy.
        Br J Surg. 2014; 101: 277-287
        • Antonescu I.
        • Carli F.
        • Mayo N.E.
        • Feldman L.S.
        Validation ofthe SF-36 as a measure of postoperative recovery after colorectal surgery.
        Surg Endosc. 2014; 28: 3168-3178
        • Ward W.L.
        • Hahn E.A.
        • Mo F.
        • Hernandez L.
        • Tulsky D.S.
        • Cella D.
        Reliability and validity of the functional assessment of cancer therapy-colorectal (FACT-C) quality of life instrument.
        Qual Life Res. 1999; 8: 181-195
        • Gessler S.
        • Low J.
        • Daniells E.
        • et al.
        Screening for distress in cancer patients: is the distress thermometer a valid measure in the UK and does it measure change over time? A prospective validation study.
        Psycho Oncol. 2008; 17: 538-547
        • van den Heijkant F.
        • Vermeer T.A.
        • Vrijhof E.
        • Nieuwenhuijzen G.A.P.
        • Koldewijn E.L.
        • Rutten H.J.T.
        Psoas hitch ureteral reimplantation after surgery for locally advanced and locally recurrent colorectal cancer: complications and oncological outcome.
        Eur J Surg Oncol. 2017; 43: 1869-1875
        • Gosens J.E.M.
        • Klaassen R.A.
        • Tan-Go I.
        • Rutten H.J.T.
        • Martijn H.
        • van den Brule A.J.C.
        • et al.
        Circumferential margin involvement is the crucial prognostic factor after multimodality treatment in patients with locally advanced rectal carcinoma.
        Clin Cancer Res. 2007; 13: 6617-6623
        • Van Gijn W.
        • Marijnen C.A.M.
        • Nagtegaal I.D.
        • Meershoek-Klein Kranenbarg E.
        • Putter H.
        • Wiggers T.
        • et al.
        Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial.
        Lancet Oncol. 2011; 12: 575-582
        • Quyn A.J.
        • Austin K.K.S.
        • Young J.M.
        • Badgery-Parker T.
        • Masya L.M.
        • Roberts R.
        • et al.
        Outcomes of pelvic exenteration for locally advanced primary rectal cancer: overall survival and quality of life.
        EJSO. 2016; 42: 823-828