2025/05/31 by Hongjie Yang, Peishi Jiang, Jiafei Liu +3 · 1 voice
Medicine · #Colorectal Cancer Surgical Treatments #Colorectal and Anal Carcinomas #Gastric Cancer Management and Outcomes
paper · pdf · doi:10.1093/bjs/znaf114
openalex publication_date 2025/05/31 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
Pelvic exenteration (PE) is a therapeutic option for patients with cervical cancer who have undergone concurrent chemoradiotherapy (CCRT) but subsequently developed local recurrence in the central pelvis1. Anterior PE (APE) is technically challenging for patients after CCRT for several reasons: destruction of the biological space due to tissue oedema and fibrosis after CCRT makes separation of the rectovaginal space difficult; the pelvic organs are restricted by their blood vessels, nerves, and peripheral ligaments, which form a natural axis that hinders surgical field exposure; poor elasticity of the pelvic tissue after CCRT exacerbates difficulty in surgical field exposure; and vaginal atrophy or fistulae establishment limits the utility of a uterine manipulator. To overcome these difficulties, the authors propose a modified approach for APE that involves rectal sparing on the basis of the mobilization of the total pelvic organs. Specifically, the total pelvic organs are first dissociated as a whole, thereby mobilizing them, after which the rectum is removed. The current video illustrates the case of a 69-year-old female patient who was diagnosed with local recurrent cervical cancer and an established enterovesico-uteral fistula 7 years after CCRT (Fig. 1). The operation began with the separation of the retro-rectal space, since spaces along the parietal fascia were often clear even after CCRT. The separation of the lateral and anterior rectal spaces was then performed along the posterior rectal space. The operation then shifted to the separation of the lateral spaces of the total pelvic organs to dissect the vascularis and nerves of the total pelvic organs. The space between the ureterohypogastric nerve fascia and the vesicohypogastric fascia (VHGF) was dissected, after which the space between the VHGF and the parietal fascia superior to the internal obturator muscle was separated2,3. The vascular supply, nerve distribution, and ligamental tissue were then isolated together, which are thereafter collectively referred to as the ‘vascular nerve pedicle’ of the total pelvic organs (Fig. 2). After transecting the bilateral vascular nerve pedicles, the total pelvic organs were freed from the pelvic side wall. Then, with the separation of the Space of Retzius and transection of the urethra, the total pelvic organs were freed completely, changing the natural axis of the total pelvic organs. After confirming the lower margin of the tumour by vaginal digital examination, the vagina was transected using a disposable endo linear cutter stapler (Sinolinks, Changzhou, China), and the anterior pelvic organs were removed en bloc (Fig. 3) without using a uterine manipulator (Video 1). Abdominal magnetic resonance image of a 69-year-old woman who was diagnosed with local recurrence of cervical cancer with establishment of an enterovesico-uteral fistula 7 years after concurrent chemoradiotherapy The entero-uteral fistula (red arrow), entero-vesical fistula (white arrow), and gas bubble in the bladder (blue arrow) can be observed. R, rectum; B, bladder; U, uterus. Surgical procedure of the proposed approach for laparoscopic anterior pelvic exenteration (APE) characterized as rectal sparing on the basis of the mobilization of the total pelvic organs. a Pelvic view before APE The associated small intestine was transected. b Dissection of the lateral rectal spaces along the separated retro-rectal space. c Dissection of the rectovaginal space was restricted by the natural axis of the pelvic organs. d Isolation of the left vascular supply, nerve distribution, and ligamental tissue, collectively referred to as the ‘vascular nerve pedicle’. e The isolation of the right vascular nerve pedicle. f Rectovaginal space becoming superficial after transection of the bilateral vascular nerve pedicles. g Transection of the vagina with a linear cutter stapler. h The ultimate surgical field and the stumps of the urethra, vagina, and bilateral vascular nerve pedicles. V, vagina; U, uterus; Ur, ureter; B, bladder; R, rectum; IIA, internal iliac artery; OVs, ovarian vessels; UHGNF, ureterohypogastric nerve fascia. En bloc specimen of anterior pelvic exenteration a Anterior view; b posterior view; c anterior view of the fistula after dissecting the bladder. The advantages of this approach are as follows: prioritizing the separation of the retro-rectal space could facilitate the uncovering of the desired lateral and anterior rectal space; by freeing the total pelvic organs, their anatomical angles could be manipulated, making the surgical field superficial; and avoiding the use of a uterine manipulator satisfies the concept of ‘no-touch’ tumour technique. This research was funded by the Tianjin Key Medical Discipline (Specialty) Construction Project (No.: TJYXZDXK-044A) and the hospital level scientific research fund of Tianjin Union Medical Center (No.: 2022GCXK004). Hongjie Yang (Writing—original draft, Writing—review & editing), Peishi Jiang (Conceptualization, Writing—review & editing), Jiafei Liu (Writing—review & editing), Yuanda Zhou (Data curation, Writing—review & editing), Pengpeng Qu (Writing—review & editing), and Yi Sun (Project administration, Writing—review & editing) The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Supplementary material is available at BJS online. The data that support the findings of this study are available from the corresponding author upon reasonable request.