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Updated: Aug 15, 2025
Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer
Published on: February 12, 2022
Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers
Mufaddal Kazi1, Ashwin Desouza1, Chaitali Nashikkar1
1Division of Gastrointestinal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
Purpose:
Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database.
Methods:
Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI).
Results:
The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%-37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%-13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively.
Conclusion:
MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.
Insights
Minimally invasive surgery (MIS) for advanced rectal cancer requiring pelvic exenteration is safe, with acceptable complication rates and R0 resections. This approach shows promise for T4 rectal tumors previously excluded from MIS studies.
Area of Science:
- Surgical Oncology
- Rectal Cancer Management
- Minimally Invasive Surgery
Background:
- Minimally invasive surgery (MIS) has been largely excluded for T4 rectal tumors.
- Locally-advanced rectal cancers often necessitate complex procedures like pelvic exenteration.
Purpose of the Study:
- To evaluate the safety and feasibility of MIS for T4 rectal cancers requiring pelvic exenteration.
- To benchmark outcomes against established safety thresholds using data from the international PelvEx database.
Main Methods:
- Analysis of 124 consecutive MIS pelvic exenterations for T4 rectal cancer with urogenital invasion (Nov 2015-June 2022).
- Safety thresholds: <20% R1 resection rate and <40% major complication rate (≥grade IIIA).
- Procedures included laparoscopic and robotic approaches; majority were total pelvic exenterations.
Main Results:
- 124 MIS exenterations performed; 59.7% total pelvic exenterations.
- Major complications occurred in 28.2% (95% CI, 20.5%-37.0%); R1 resections in 7.3% (95% CI, 3.4%-13.4%).
- Safety thresholds were not exceeded. 2-year overall survival was 85.2%.
Conclusions:
- MIS pelvic exenteration is a safe and feasible option for locally-advanced T4 rectal cancers at experienced centers.
- The technique achieves acceptable morbidity and R0 resection rates.
- Further follow-up is needed to fully assess long-term cancer survival outcomes.
