VM99 - Stepwise Approach for 
Robotic Total Pelvic Exenteration in T4b Rectal Cancer

Purpose/Background: The supralevator total pelvic exenteration is the procedure for en-bloc resection of the rectum, prostate gland, and urinary bladder with sphincter preserving. Its concept was used for rectal mass that cannot be resected in a normal TME (Total Mesorectal Excision) plane due to its local invasion of the bladder or prostate gland. Nowadays, robotic colorectal surgery is increasingly used because it provides better outcomes in patient recovery and decreases post-operative pain, however, its technique is still quite challenging due to the complex anatomy of the pelvic region. This video will provide a stepwise approach for robotic total pelvic exenteration.

Methods/Interventions: This video demonstrates a robotic supralevator total pelvic exenteration in a 58-year-old male, who presented with locally advanced mid-rectal cancer that invaded the bladder trigone, prostate gland, and seminal vesicles. After total neoadjuvant treatment, the patient was undergoing robotic supralevator total pelvic exenteration. The procedure starts with medial to lateral approach and IMA/IMV (Inferior Mesenteric Artery/Vein) management. We harvest all the nodal tissue around the root of the IMA and left colic artery, and then follow by low ligation technique. The IMV was divided at the same level as the IMA. Then the posterior dissection proceeded till the pelvic floor was met. For the lateral dissection, we clearly identify the ureter and external iliac vessels. Next, we dissect along the uretero-hypogastric fascia and the internal iliac artery, in this step, we can identify the lateral compartment structures; obturator neurovascular bundles, and external iliac vein, which were preserved. All the medial branches of the internal iliac artery can be divided and ligated. After the division of Vas deferens, the anterior dissection was performed into the retropubic space of Retzius, we stopped the dissection when met the dorsal venous complex. The ureter with its vascular cuff was carefully dissected and divided near the bladder. After full rectal mobilization, we made a low midline incision to control the dorsal venous complex and cut the ureter and the prostate gland. The rectum was transected, and the tumor was removed in an en-bloc fashion. Lastly, we create the end-to-end colorectal anastomosis with a circular stapler and the uretero-ileal anastomosis by hand-sewn technique.

Results/Outcomes: The final pathologic report showed residual moderately differentiated adenocarcinoma, ypT4bN1a, and negative all resection margin. There were no peri-operative complications.

Conclusion/Discussion: The robotic supralevator total pelvic exenteration is feasible and safe for the T4b locally advanced rectal cancer which provides good oncological outcomes.