VM77 - Robotic Anterior Extramesorectal Excision for Rectal Cancer

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Purpose/Background: The role of the minimally invasive approach for rectal cancers breaching the visceral fascia with involvement of the beyond TME plane is not well established. Open surgery on the other hand, with its narrow operating field and poor illumination often leads to the surgeon performing a supra radical procedure such as an exenteration, with its attendant morbidity, in lieu of a more tailored robot assisted operation-which ensures a negative radial margin, whilst optimising function. The robotic platform, as we showcase in our presentation, is ideally suited for radical beyond TME approaches, especially in the narrow male pelvis, for anteriorly placed tumours, with maximal preservation of function.

Methods/Interventions: The index patient is a 48 year old male diagnosed with a poorly differentiated adenocarcinoma involving the mid rectum, with pretherapy MRI documenting locally advanced disease, with mesorectal fascia involvement, extramural vascular invasion and multiple meosrectal nodes. He underwent neoadjuvant short course radiotherapy followed by systemic chemotherapy. Reassessment imaging revealed a partial response with a circumferential mid rectal tumour with involvement of the prostate. He was counselled and consented for a robotic extramesorectal excision, with consent for an exenteration if a negative anterior margin could not be obtained. A specific consent for loss of sexual function was obtained. The patient underwent a robotic anterior extramesorectal excision with a stapled coloanal anastomosis, uneventfully. This is an unconventional procedure wherein the anterior plane of resection, includes the vas deferens, seminal vesicles and a coronal sleeve of the prostate, ensuring a negative margin, whilst preserving bladder and urethral integrity.

Results/Outcomes: The total operative time was 400 minutes and estimated blood loss was 300ml. The patient recovered without incident and was discharged on postoperative day 7. The surgical pathology report revealed a pathologic complete response, which came as a surprise. His urethral catheter was removed 2 weeks from surgery and he had normal voiding function; and remains free of disease 23 months from surgery.

Conclusion/Discussion: The robotic approach has tremendous potential for unconventional beyond TME resections for rectal cancer, especially in the narrow confines of the male pelvis and enables the surgeon to achieve an oncologically sound, margin negative resection while retaining near normal bladder function.