Extended resection and pelvic exenteration in distal third rectal cancer

Approximately 10% of all low rectal cancer needs surgical resection extended to other pelvic structures. Indication for extended resection should be given according to a precise systemic and local preoperative staging. Magnetic Resonance Imaging is the most important instrument utilized by the Multidisciplinary Team to decide therapeutic strategy according to the surgical risk. The status of the pathological circumferential resection margin is the most important prognostic factor determining local recurrence risk and oncological outcome and for this reason it should be considered pivotal in the decision of the strategy of treatment. When extended resection is performed, the presence of an expert colorectal surgeon is mandatory, often coordinating a group of specialists including urologist, plastic surgeon, vascular surgeon and orthopaedist when sacrectomy is necessary. The most frequent extended resection in women with low rectal cancer is the partial resection of vagina. In men, the infiltration of the prostate could be treated with partial prostatectomy, total prostatectomy with bladder preservation or pelvic exenteration, total or posterior, when the bladder is infiltrated. Rectal cancer infiltration of the pelvic sidewalls or of the sacrum is less frequent and obliges to perform a total pelvic exenteration including sometimes the hypogastric vessel or extended to the sacrum.