Total Pelvic Exenteration with Presacral Fascia and Pelvic Musculature Excision for Pelvic Recurrence of Rectal Cancer.

Background: Local relapse has not been eradicated even in the era of total mesorectum excision.^1,2 Although various approaches have been attempted, R0 resection remains the only potentially curative treatment.^3,4 PATIENT AND METHODS: A 45-year-old woman with a history of laparoscopic abdominoperineal resection was diagnosed with pelvic recurrence 7 months ago. Then, she received chemoradiotherapy. Magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) showed pelvic recurrences at the surface of the right piriformis and obturator internus, posterior vaginal wall, and presacral fascia. The patient also had bilateral hydronephrosis. No distant metastasis was found. First, the lateral pelvic lymph nodes were removed. Then, the internal iliac arteries and veins were transected. Next, the fibrotic ureters were isolated and cut. Then, presacral fascia at the S4 and S5 levels was excised. Anteriorly, the urethra and vagina were transected. Lastly, the suspected pelvic recurrent lesions were resected en bloc with partial right piriformis, obturator internus, and gluteus maximus through a combined abdominal and perineal approach. Greater omental pedicle flap was transplanted into the pelvic cavity and pelvic floor was reconstructed.

Results: The operative time was 600 min, and blood loss was 400 ml. Postoperative course was uneventful, and the patient was discharged 14 days after surgery. Pathology report showed a moderately differentiated rectal adenocarcinoma invading the vagina, presacral fascia, and pelvic musculature. All margins were negative.

Conclusions: As demonstrated by this case, image-guided total pelvic exenteration with presacral fascia and sidewall musculature excision provides an opportunity to cure pelvic recurrence of rectal cancer.⁵.