VM22 - Robotic total pelvic exenteration with transperineal urethral transection

ONGOING VIDEOS

Location: ASCRS Connect Lounge, Hall B1/B2, Ground Level

Video Presentation(s)

Mitsuru Yokota

Chief
Kurashiki Central Hospital, Department of general surgery
Kurashiki, Okayama, Japan

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

HM

Hiroya Matsuoka, n/a

doctor
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
KY

Kenji Yamaguchi, n/a

doctor
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
JM

Jun Muto, n/a

doctor
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
YN

Yoshio Nagahisa, n/a

doctor
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
YI

Yukio Inamura, n/a

doctor
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
KK

Kenji Kawada, n/a

chief
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
MO

Michio Okabe, n/a

chief
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
TM

Toshihiko Masui, n/a

director
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.
KK

Kazuyuki Kawamoto, n/a

vice president
Department of general surgery
Kurashiki, Okayama, Japan

Disclosure information not submitted.

All of the relevant financial relationships listed below have been mitigated.

Mitsuru Yokota, n/a: This individual has no financial relationships with ineligible companies.

Image or Table (Do Not add text here):

Purpose/Background: Total pelvic exenteration (TPE) is often necessary for the complete resection of advanced rectal cancer involving the prostate, sphincter urethrae muscle, or urethra. Although urethral transection is typically performed with the abdominal approach, the angles of the forceps and pubic symphysis hinder distal urethral transection, increasing the risk of positive margins depending on the tumor location.
This video aims to show the successful transperineal transection of urethra, ensuring negative resection margins in a patient undergoing robotic TPE.

Methods/Interventions: A 75-year-old man was diagnosed with advanced lower rectal cancer invading the prostate and the sphincter urethrae and bulbospongiosus muscles. Preoperative total neoadjuvant therapy planned for initiation after stoma construction was changed to capecitabine plus oxaliplatin (CapOX) following abscess formation secondary to tumor perforation. Robotic TPE was performed after seven courses of CapOX. Preoperative magnetic resonance imaging revealed the involvement of the bulbospongiosus muscle, raising the need to secure an anterior wall margin distal to the prostate. Thus, urethral transection from the perineal side was planned. A fluorescent ureteral stent by infrared illumination system inserted prior to the surgery revealed the urethral location during surgery, and the urethra-oriented procedure was performed from both the abdominal and perineal sides.

Results/Outcomes: The use of robotic multi-joint forceps allowed the dissection of the vessels along the main internal iliac vessels feeding pelvic organs and the levator ani muscles at the root. The deep dorsal vein complex was dissected after hemostasis with soft coagulation, which caused minimal bleeding. The luminescence of the urethra prevented accidental urethral dissection. The urethra covered by the bulbospongiosus muscle was transected and connected to the abdominal side along the pubic arch from the perineal side, allowing the combined resection of the corpus spongiosum penis. Consequently, urethral transection could be distally performed, securing an anterior wall margin distal to the prostate. Histopathologic assessment revealed the invasion of the bulbospongiosus muscle and corpus spongiosum penis. All resection margins were negative. The total bleeding volume was 295 mL, suggesting the benefit of the minimally invasive approach. The patient developed postoperative perineal wound infection, which was treated with conservative measures.

Conclusion/Discussion: Robotic TPE is a feasible, minimally invasive procedure with favorable outcomes. In patients with urethral invasion distal to the prostate, transperineal urethral transection achieves negative resection margins.