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Keywords:

  • Robotic surgery;
  • pelvic exenteration;
  • rectal cancer

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

Aim

The aim of this study was to present the feasibility and surgical outcome of robotic en bloc resection of the rectum and with prostate and seminal vesicle invaded by rectal cancer.

Method

The details of three consecutive cases involving male patients in their forties, with locally invasive low rectal cancers are presented. The da Vinci robotic system was used by experienced colorectal and urological surgeons to perform en bloc resection of the rectum, prostate and seminal vesicles.

Results

In the first case, coloanal and vesico-urethral anastomoses were performed, and the second included an end colostomy and vesico-urethral anastomosis. The bladder and bulbar urethra were also removed en bloc in the third case, with robotic intracorporeal ileal conduit formation and end colostomy. There was no major complication postoperatively. In the second patient there was a minor leakage at the vesico-urethral anastomosis. The third was readmitted the following week with a urinary infection which settled with intravenous antibiotics. In the first case, the circumferential resection margin was microscopically positive but the patient is currently free of recurrence after 14 months. In the second and third cases, all margins were clear.

Conclusion

This the first report of the use of the da Vinci robotic system for pelvic exenteration in patients with locally advanced rectal cancer invading the prostate and seminal vesicles. The robot may have a potential role in selected patients requiring exenterative pelvic surgery particularly in men.

What does this paper add to the literature?

This paper details the first reported use of the da Vinci robot to achieve total pelvic exenteration for rectal cancer. This approach could herald a new frontier for locally advanced and recurrent pelvic malignancy by offering minimal invasive surgery.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

Approximately 10% of rectal cancers involve adjacent organs and require extensive surgery for complete resection [1]. In selected cases in which locally advanced rectal cancer is fixed to adjacent pelvic organs, en bloc resection is necessary to achieve tumour-free margins [2]. Completeness of resection is the key factor influencing overall survival, disease-free survival and local recurrence in advanced rectal cancer [3]. If advanced rectal cancer is located anteriorly, en bloc resection of the urogenital organs can result in an improved oncological outcome [2]. Even though laparoscopic surgery is becoming standard practice for rectal cancer in many centres, minimally invasive procedures are generally considered to have a minor role in extenterative surgery. Indeed, laparoscopic surgery has a limited role in extensive, complex surgery in part due to the unstable camera imaging, two-dimensional view, relative loss of dexterity, particularly in a narrow space, and the limited motion of instruments. In contrast, the da Vinci robotic system has potential advantages for a magnified three-dimensional view, enhanced ergonomics and elimination of tremor. This system has been widely adopted in urology for prostatectomy [4]. More recently, robotic surgery has been performed for treatment of rectal cancer. The safety and feasibility of this procedure for treating rectal cancer has been proven in both short- and medium-term outcomes [5, 6]. In selected cases, the combination of the robotic procedure seems to be feasible for the treatment of advanced rectal cancer that involves adjacent structures. We describe using the da Vinci system in three cases of rectal cancer with invasion of the male genital organs.

Patients

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

The first and second cases in this series were performed at Korea University Anam Hospital, Korea, involving a colorectal surgeon (SHK) and an urologist (JC) with extensive robotic experience of prostate cancer. This publication obtained approval (ED13080) from the hospital institutional review board. The third patient was operated on at the Royal Brisbane Hospital, Brisbane, Australia, involving a colorectal surgeon (ARLS) who had been mentored by a visiting expert (SHK) in his early robotic training, and an urologist (GC) with extensive robotic experience. This operation also received institutional administrative board approval.

Patient I

A 47-year-old man presented with haematochezia and pelvic pain. He had been diagnosed with rectal cancer and ascending colon cancer 1 year prior to presenting at our institution. He underwent preoperative radiotherapy (RTx) with 44 Gy at a different institution. However, as the patient refused any possibility of permanent colostomy after the radiotherapy, the patient declined surgery and further treatment. The patient eventually presented to our department because of pelvic pain and obstructive defaecation symptom. An abdominopelvic computed tomography (CT) and pelvic magnetic resonance imaging (MRI) revealed that the ascending colon cancer and rectal cancer had progressed. In particular, the latter was shown to involve the prostate and left seminal vesicle (Fig. 1a,b). The ascending colon cancer had not invaded the surrounding organs. On digital rectal examination, the distal end of the rectal cancer was located at 3.5 cm from the anal verge and the tumour was fixed. The regional lymph nodes were enlarged, but there were no distant metastases on CT and MRI. The patient's body mass index (BMI) was 19.0 kg/m2 and his ASA (American Society of Anesthesiologists) score was 1. The patient still refused a permanent stoma. Sphincter-saving rectal surgery with combined prostatectomy and vesico-uretheral anastomosis was judged to be too difficult to finish the operation without any possibility of permanent stoma. A colorectal and urological surgeon decided to perform a hybrid robotic procedure including intersphincteric resection (ISR) and prostatectomy en bloc with a simultaneous laparoscopic right hemicolectomy.

image

Figure 1. Patient I. Pelvic MRI showing rectal cancer invading the prostate (a) and the left seminal vesicle (b). A side view (c) of the resected specimen (arrow, rectum; arrow head, prostate), and the final abdominal incisions and diverting ileostomy (d).

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After the induction of general anaesthesia, the patient was placed in a Trendelenburg position. A 12-mm camera port was placed above the umbilicus. The two 8-mm robotic trocars were located in positions which were 8 cm lateral to the midline and 15 cm above the pubis. Another 8-mm robotic trocar was placed around the left anterior superior iliac spine. Two ports for the assistant were inserted in the right side (5 and 12 mm). With 12 mmHg CO2 pneumoperitoneum, a transverse incision of the peritoneum was made to transect right and left umbilical ligaments. The endopelvic fascia was dissected, and after identification of the prostato-vesical junction the anterior bladder wall was incised. The posterior bladder neck was gradually dissected away from the prostate. Because the pedicle of the prostate was not clearly identified due to previous radiotherapy, prostatectomy was not pursued further. A hybrid intersphincteric resection for the rectal cancer was then commenced without the need for additional trocars. After low ligation of the inferior mesenteric artery (IMA), the left colon was mobilized robotically in a medial-to-lateral fashion and the rectal dissection was started. The posterior pelvic dissection was performed to the level of the pelvic floor. Anteriorly, the rectum was fixed around the colovesical pouch and careful dissection of the seminal vesicles and prostate was continued through the posterior portion of bladder neck.

After the pelvic dissection was completed, the robotic instruments were removed and transanal dissection was then performed in a usual fashion of intersphincteric resection obtaining at least a 1 cm distal margin grossly. After the entire en bloc specimen was freed from the surrounding tissues, a laparoscopic approach was then used to mobilize the splenic flexure and perform a right hemicolectomy. A 6 cm vertical mid-line incision was made including the camera port. The right colon was removed and an ileocolic anastomosis was performed extracorporeally. The en bloc specimen of the rectum and prostate was also retrieved through the same midline incision and the descending colon was divided. The mini-laparotomy was closed temporarily and re-insufflation was introduced. A vesico-urethral anastomosis was then performed robotically. The descending colon was pulled out through the anus and a side-to-end coloanal anastomosis was performed by interrupted hand-sewn sutures. Finally, a loop ileostomy was created in the area of the right lower quadrant port, and a closed suction drain was placed in the pelvic cavity.

Total operation time was 585 min and robotic console time was 355 min. The estimated blood loss was 700 ml. The gross specimen is shown in Fig. 1c. The pathology of the ascending colon cancer was pT3N0 and the number of harvested lymph nodes was 67. That of the rectum was ypT4bN0. The main tumour had directly invaded the prostate and left seminal vesicle. The circumferential margin was microscopically positive on the right postero-lateral side of the rectum. The number of harvested lymph nodes was 23. A day after the operation the patient was permitted oral fluids. Postoperative recovery was uneventful and there was no clinical leakage identified at the coloanal anastomosis. At postoperative day 21, cysto-urethrography showed no leakage at the vesico-urethral anastomosis and the urinary catheter was removed. The final incision and covering ileostomy are shown in Fig. 1d. The patient was discharged at 28 days postoperatively and treated with 12 cycles of FOLFOX 4 chemotherapy for 6 months. He has mild erectile dysfunction postoperatively, but is able to perform sexual intercourse. He currently has no recurrence at 14 months after the surgery.

Patient II

A 42-year-old man presented with haematochezia and difficult defaecation. On digital rectal examination, the distal end of the rectal cancer involved the anal canal and the tumour was fixed. An abdominopelvic CT and pelvic MRI showed that the rectal cancer invaded the prostate, anal sphincter, levator ani muscle and extension to right perianal/ischiorectal space (Fig. 2a,b). The regional lymph nodes were enlarged, but there were no distant metastases. The patient received short-course radiotherapy with 25 Gy over 5 days preoperatively. His BMI was 27.0 kg/m2 and his ASA score was 1. Robotic abdominopelvic resection with en bloc prostatectomy including the seminal vesicles was planned. Ligation of the inferior mesenteric vessels and left colonic mobilization was performed laparoscopically, followed by robotic pelvic surgery.

image

Figure 2. Patient II. Pelvic MRI showing rectal cancer invading the prostate (a) and extending to the right ischiorectal fossa (b). The perineal operative views just before (c) and after (d) specimen retrieval are shown (u, urethral catheter; b, bladder). Side view of the resected specimen (e) (R, rectum; P, prostate; S, seminal vesicle).

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In contrast to Case I, rectal dissection was performed first. After mobilizing the rectum posteriorly and then on each side and anteriorly, the urologist resected part of the bladder and the prostate and seminal vesicles. During the perineal phase, the skin, pelvic muscle including the sphincter, levator ani muscle and extension to the right perianal/ischiorectal space were resected as an extended abdominoperineal resection. After retrieval of the specimen via the perineal defect, a vesico-urethral anastomosis was performed by an open technique through the perineal wound. The perineal defect was primarily repaired without mesh. The perineal operative views just prior to and after the specimen retrieval are shown in Fig. 2c,d. The resected specimen is seen in Fig. 2e.

Total operative time was 550 min and robotic console time was 128 min. The estimated blood loss was 600 ml. The pathological stage was ypT4bN2b. Seven of 52 lymph nodes were positive for metastatic tumour. The circumferential and distal margins were all free from carcinoma. A day after the operation the patient was permitted oral fluids. At postoperative day 14, urinary leakage occurred through a small defect in the perineal wound and cysto-urethrography confirmed leakage at the vesico-urethral anastomosis. Suprapubic cystostomy was performed then removed 2 months later after a voiding cysto-urethrogram confirmed no leakage. The patient is currently on adjuvant FOLFOX 4 chemotherapy.

Patient III

This patient was a 41-year-old man diagnosed with low rectal cancer (cT4N2M0) invading the prostate, seminal vesicles and urethra with multiple enlarged mesorectal nodes up to the origin of the inferior mesenteric artery (Fig. 3a). The patient had tenesmus, rectal bleeding and pain on sitting. There was also weight loss of 20 kg over the past 12 months with a BMI of 18 kg/m2 at the time of surgery. Clinical examination confirmed a near circumferential low rectal tumour approximately 2 cm above the anal verge. The patient was treated with long-course neoadjuvant chemoradiation. Eight weeks after its completion, he was admitted on the day of surgery for robotic pelvic exenteration.

image

Figure 3. Patient III. Pelvic MRI showing a locally advanced low rectal cancer (a). The final abdominal incisions and colostomy and urostomy are shown (b).

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A seven-port transperitoneal approach was used with initial mobilization of the sigmoid colon and division of the inferior mesenteric vessels. There was a large node measuring 3 cm overlying the left common iliac vein. Bilateral obturator lymph node dissection was performed. The ureters were identified and clipped distally, followed by mobilization of the mesorectum down to the level of the coccyx posteriorly and laterally. The vesicle pedicles were divided and an en bloc prostatectomy was performed. The dorsal vein of the penis was divided and the membranous urethra mobilized anteriorly. The robot was undocked to allow wide perineal resection of the bulbar urethra and extralevator dissection of the anorectum. The specimen was then removed via the perineal defect which was then closed with bioabsorbable mesh (Biodesign™; Cook Medical, Bloomington, Indiana, USA). The robot was then redocked for intracorporeal formation of an ileal conduit and end colostomy. Total operation time was 480 min and the robotic console time was 230 min. Estimated blood loss was 300 ml.

The histology confirmed a locally invasive poorly differentiated carcinoma of the rectum with no tumour response to neoadjuvant therapy. The circumferential and distal margins were all clear of tumour. However, there were tumour cells present at the large node where it had been dissected clear of the iliac vein. Four of 12 nodes were positive for metastatic tumour. Postoperatively the patient made a rapid recovery and was discharged home on the eighth postoperative day. The final incision and stoma are shown in Fig. 3b.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

Pelvic exenteration is a multivisceral resection performed for treating locally advanced pelvic malignancies and was first described by Brunschwig [7] in 1948. Even though perioperative morbidity and mortality are high, total pelvic exenteration is a curative strategy for locally advanced or locally recurrent rectal cancer conferring potential survival gain and locoregional control [8-11]. En bloc resection of the rectum and prostate is also an acceptable option in selected patients who would otherwise require total pelvic exenteration [12, 13]. These operations are largely performed by open surgery, but with the advancement of minimally invasive surgery, pelvic exenteration of gynaecological and urological malignancies can be performed laparoscopically [14-16]. Puntambekar et al. [14] reported the feasibility and oncological safety of laparoscopic anterior pelvic exenteration performed in 16 female patients. Martínez et al.[16] demonstrated in a cohort study with 43 patients with gynaecological malignancy that laparoscopic pelvic exenteration led to less blood loss and lower transfusion requirements than an open procedure, without compromising oncological safety.

In the field of rectal cancer, however, particularly in men, laparoscopic pelvic exenteration is more difficult because it usually requires deeper pelvic dissection than for gynaecological or urological malignancies and needs a low rectal anastomosis and/or an anastomosis between the bladder and urethra when necessary. Because of these technical difficulties, there are very few case reports of laparoscopic pelvic exenteration for rectal cancer [15, 17]. Patel et al. [15] reported two cases of salvage laparoscopic total pelvic exenteration with intra-operative blood loss of 1200 ml and an operation time of 5.5 h. Puntambekar et al. [17] also reported a case of laparoscopic posterior pelvic exenteration in a female patient with rectal cancer, although en bloc resection of rectal cancer with a female genital organ is likely to be less difficult, even laparoscopically, that when it invades a male genital organ.

Recently, robotic surgery has begun to be used for pelvic exenteration to facilitate this complex procedure and achieve a better surgical outcome. All robotic case reports available in PubMed [searched by terms ‘robotic(s)’ and ‘exenteration’] have been for gynaecological [18-20] and urological [21, 22] malignancy in women. There is only one report of a patient with recurrent endometrial cancer involving the rectum treated by total pelvic exenteration [20]. To the best of our knowledge, the present report is the first case series of robotic pelvic exenteration for primary rectal cancer with local invasion into an adjacent pelvic organ. In the report of Patel et al. [15], which is itself one of the very few examples of laparoscopic pelvic exenteration of a rectal cancer involving a male genital organ, the authors removed the bladder as well even though the rectal cancer only invaded the prostate.

Intra-operative blood loss is usually considerable in pelvic exenterative surgery which includes the male genital organs. Patel et al. [15] reported blood loss of 1200 ml; in the present report blood loss ranged from 300 to 700 ml. The surgical margins were free in two of the cases and the patient with a positive margin refused to have a stoma forcing the surgeon to perform a sphincter-sparing procedure. Fortunately, he is currently free of tumour recurrence after 14 months.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

The robotic approach can be applied to pelvic exenteration. It enables the surgeon to perform extensive surgery in a minimally invasive manner. In selected patients, this may be help to maximize the patient's quality of life and facilitate fast recovery. To our knowledge, this is the first report in which the da Vinci robotic system has been successfully used for pelvic exenteration in patients with a locally advanced rectal cancer invading the male genital organs.

Author contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References

All authors were involved in the operations, initial concept and design of the study. JW Shin, SG Kang and M Hara collected and analyzed the data. JW Shin, SH Kim and ARL Stevenson wrote the draft article. J Cheon, SH Kang, JM Kwak and G Coughlin reviewed and critically revised the draft. JW Shin and SH Kim prepared the manuscript for submission. All authors reviewed and approved the final manuscript.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients
  5. Discussion
  6. Conclusion
  7. Author contributions
  8. Conflicts of interest
  9. References
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