Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2020; 12(4): 190-196
Published online Apr 27, 2020. doi: 10.4240/wjgs.v12.i4.190
Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series
Nathaniel H Heah, Kar Yong Wong
Nathaniel H Heah, Department of Urology, Tan Tock Seng Hospital, Singapore 308433, Singapore
Kar Yong Wong, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
Author contributions: Wong KY and Heah NH all designed and performed research, analysed data, and wrote the paper.
Institutional review board statement: The study was reviewed and approved by National Healthcare Group Domain Specific Review Board. NHG DSRB Ref: 2018/01054.
Informed consent statement: Patients were not required to give informed consent to the study because analysis used anonymous data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors have no conflicts of interests to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Kar Yong Wong, FRCS (Ed), FRCS (Gen Surg), MBChB, Surgeon, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. kar_yong_wong@ttsh.com.sg
Received: December 20, 2019
Peer-review started: December 20, 2019
First decision: January 6, 2020
Revised: March 12, 2020
Accepted: March 22, 2020
Article in press: March 22, 2020
Published online: April 27, 2020
Research background

Locally advanced rectal cancers can involve adjacent organs. In male, rectal cancers frequently involves seminal vesicles and prostate. Complete en-bloc removal of rectal cancer and adjacent organs with clear margin is key to successful oncological surgery, and this commonly requires a total pelvic exenteration with removal of urological and intestinal organ. Such extensive surgeries are usually performed via open technique. Majority of patients have a prolonged hospital stay due to wound pain and a decreased quality of life because of presence of permanent stomas.

Research motivation

Robotic surgery may have a role in introducing minimal invasive surgery to pelvic exenteration surgery for locally advanced rectal cancer. Robotic surgery allows anastomosis of bladder and urethra in the deep pelvis and can potentially reduce the rate of permanent stoma formation for patient in the future requiring total pelvic exenteration surgery.

Research objectives

To explore and demonstrate the benefits of robotic surgery as a form of minimal invasive surgery in total pelvic exenteration. To show the feasibility of minimally invasive surgery bladder preservation prostatectomy with total mesorectal excision. Patients are able to avoid a permanent ileal conduit and also maintain continuity of bowel when anal sphincter is spared.

Research methods

Ethics approval was sought for this study. The data for 3 patients were included in the analysis and statistics including mean and paired t-tests for dependent variables with Stata 13.0 software. Parameters gathered included patient demographics, tumour characteristics such as distance from anal verge, peri-operative data including estimated blood loss and peri-operative haemoglobin, and margin status.

Research results

Our research showed that robot assisted bladder sparing pelvic exenteration is feasible. Although the safety and oncological outcomes for the procedure appears to be acceptable, more research and data is needed to confirm this early finding.

Research conclusions

In conclusion, this pilot study of 3 patients using a novel technique of robot assisted bladder sparing pelvic exenterations is both feasible and safe. The advent of the DaVinci Robot allows complex pelvic surgery to be performed in a minimally invasive manner and the advantages of such an approach is clear, and performing such complex surgeries are pushing the boundaries of minimally invasive surgery. However, this is a small series and further data is needed to confirm the safety and oncological outcomes of this technique. Until then, patients need to be carefully selected before undergoing such a complex and challenging surgery from the minimally invasive approach.

Research perspectives

Future research in this field will involve not just confirmation of the findings from this initial case series, but also the extent and limitations of the DaVinci Robot system. 3D vision and increased magnification in the pelvis are crucial to ensuring clear margin status as well as good functional outcomes for the patients. Complex reconstructive surgery such as bowel anastomoses and urethrovesical anastomoses highlight the advantages of the DaVinci Robot system but direct comparison between robot assisted laparoscopic cases and open cases may prove to be challenging due to the rare and unique nature of these patients and their locally advanced disease.