Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity

Background Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. Methods Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. Results There were increases over time in rates of lateral and posterior compartment resections (P < 0.001), and bony pelvis (P = 0.002) and neurovascular (P < 0.001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0.005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved. Conclusion Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.