Contemporary outcomes of total pelvic exenteration in the treatment of colorectal cancer

PURPOSE: Total pelvic exenteration is performed infrequently in selected patients with locally advanced or recurrent colorectal cancer. We reviewed our contemporary experience with pelvic exenteration for colorectal cancer to identify selection criteria and prognostic factors for long-term survival. METHODS: Between 1991 and 2000, 55 patients (males, 29; median age, 62 years) undergoing total pelvic exenteration for colorectal cancer were identified from a prospective database. Clinicopathologic variables were evaluated as prognostic indicators of long-term survival by log-rank test and multivariate Cox regression. RESULTS: Indications for surgery were recurrent colorectal cancer in 71 percent and primary colorectal cancer in 29 percent. Of 39 patients with recurrent colorectal cancer, 85 percent had previous radiotherapy, and 64 percent had previous abdominoperineal resection. At the time of pelvic exenteration, 49 percent of patients received intraoperative radiation, and 20 percent required sacrectomy. Complete resection with negative margins was achieved in 73 percent. Perioperative mortality after pelvic exenteration was 5.5 percent, and complications included perineal wound infection (40 percent), pelvic abscess (20 percent), abdominal wound infection (18 percent), and cardiopulmonary events (18 percent). Median disease-specific survival for all patients was 48.9 (range, 3.2-105.6) months. Univariate analysis identified five factors associated with decreased survival: male gender, recurrent colorectal cancer, previous abdominoperineal resection, positive surgical margin, and administration of intraoperative radiation. On multivariate analysis, only previous abdominoperineal resection was an independent predictor of unfavorable outcome (P < 0.04). CONCLUSIONS: Total pelvic exenteration can be performed safely in highly selected patients with colorectal cancer and can result in significantly prolonged survival. Less satisfactory outcomes are observed in patients whose indication for pelvic exenteration is recurrent colorectal cancer after abdominoperineal resection.