Florida Surgeons Perform Robotic-Assisted Total Pelvic Exenteration

Surgeons with Cleveland Clinic in Florida have performed the regional health system’s first case ofrobotic-assisted total pelvic exenteration (RA-TPE), a last resort treatment for the management of certain advanced primary and recurrent pelvic cancers.

The surgery was performed at Cleveland Clinic Weston Hospital by board-certified urologic oncologist Alberto Pieretti, MD, and Giovanna da Silva, MD, a board-certified colorectal surgeon.

“Pelvic exenteration is among the most complex and invasive surgeries,” states Dr. Pieretti. “As with so many other pelvic surgeries, such as prostatectomies and cystectomies, we have found that a robotic approach can provide many important advantages.”

Three resections in one

The milestone case involved a 71-year-old patient who was previously treated for prostate cancer with brachytherapy and years later developed a rectal cancer that invaded the prostate. In early May, the team at Weston Hospital used a fully robotic approach to remove the patient’s sigmoid colon, rectum, anus, bladder, urethra, prostate and seminal vesicles, and to create urinary and bowel diversions.

“Instead of having an incision that runs from below the sternum to the pubic bone, the patient had a few 8 mm ports and one incision of less than 4 cm for organ extraction,” describes Dr. Pieretti. “Some of the benefits from this approach included less blood loss, reduced pain and use of narcotics, and early mobility.”

Following one night in the ICU, the patient was moved to a cardiac monitoring unit where he was out of bed and drinking clear liquids the day after surgery. To date the patient has experienced no postoperative complications. “He is ambulating and eating, and is continuing to recover from the extreme surgery,” adds Dr. Pieretti.

Last resort treatment

Pelvic exenteration (PE) was initially used in the 1940s as a palliative treatment for gynecologic cancers. Today, the rarely used procedure is a curative treatment for patients with resectable disease. Just a few thousand patients a year undergo the radical surgery in the United States, according to an analysis of the Nationwide Inpatient Sample database.

While a TPE involves removal of the bladder, rectum and reproductive organs, anterior pelvic exenteration spares the rectum and posterior pelvic exenteration preserves the bladder. Most of these invasive surgeries are performed via laparotomy and are associated with high morbidity and mortality.

A systematic review of 23 studies on open PE showed a median complication rate of 57% (ranging from 37% to 100%) and a median 30-day mortality rate of 2.2% (ranging from 0 to 25%). Known complications of PE include anastomotic leaks, abscesses, fistulas, and urologic injury, among others.

“Part of the challenge is that most patients undergoing a pelvic exenteration have had prior surgery and radiation therapy, so we are dealing with fibrotic tissues and disrupted tissue planes,” explains Dr. Pieretti. “An added hindrance is operating in the narrow space of the pelvis. But robotic technology has helped overcome many of these difficulties.”

A robotic advantage

The first case of robot-assisted laparoscopic pelvic exenteration for the treatment of recurrent cervical cancer was reported in 2009. Five years later a case of robot-assisted PE for the treatment of locally advanced rectal cancer was published.

In the years following, several case reports and small studies have demonstrated the safety and effectiveness of RA-TPE for the treatment of various pelvic malignancies. This includes a narrative review of robotic-assisted PE for locally advanced rectal cancer published in 2021, and a clinical practice review published last year on RA-TPE for patients with urological malignancies.

“There is a large body of research demonstrating the advantages of robotic techniques across many surgical fields in terms of improved access and visualization,” says Dr. Da Silva. “The combination of magnified 3D vision and the enhanced dexterity achieved with articulating wristed robotic instruments allows us to perform more accurate dissections, which is particularly beneficial in the enclosed space of the pelvis.”

Dr. Da Silva performs robotic-assisted surgery for most cases of colorectal cancers. She points out that negative margins are the most important factor in postoperative survival. Currently, however, there is limited oncological outcome data and no long-term follow-up data on robot-assisted TPE in the literature.

Other pelvic surgeries

Last year Dr. Da Silva also adopted a robotic-assisted approach with natural orifice specimen extraction (NOTES technique) for left-sided colorectal resections for benign disease, such as diverticulitis. “This is a technique that allows the specimen to be extracted through the rectum, avoiding an incision in the abdomen and reducing postoperative pain, the risk of infection, hernia and other complications, especially among patients with obesity,” she explains.

Dr. Pieretti notes that the ability to perform RA-TPE followed years of experience using robotic technology to perform other pelvic surgeries, including robotic-assisted radical prostatectomy (RARP), robotic-assisted radical cystectomy (RARC), and more recently, robotic-assisted salvage radical cystectomy (RA-SRC).

Robotic-assisted urological surgeries, in particular, have shown superior perioperative and postoperative outcomes compared to open surgeries. Authors of the aforementioned clinical practice review cited several studies demonstrating equivalent or superior oncological outcomes of RARP over open or laparoscopic radical prostatectomy, as well as advantages in perioperative safety, continence and erectile dysfunction recovery.

In addition, a literature review published in 2023 found RARC to be associated with comparable oncological outcomes, reduced blood loss and transfusion rates, shorter hospital stays, less risk for complications, and fewer hospital readmissions when compared to open radical cystectomy. Today about 40% of radical cystectomies are performed robotically, according to an analysis of the National Cancer Database.

“About 95% of my practice consists of robotic-assisted surgery,” says Dr. Pieretti. “The only reason I would do an open cystectomy, for example, is if the patient had a history of abdominal surgeries or access to the abdomen could be too challenging, but that’s rarely the case.”

Complex salvage procedures

Dr. Pieretti also performs most cases of salvage radical cystectomy, another challenging procedure associated with significant morbidity, using a robotic approach. “Even though robotic-assisted surgeries typically take longer, patients go home sooner, recover faster and return to their daily lives sooner, which is a benefit that can’t be ignored,” he says.

One Cleveland Clinic patient, a 72-year-old female, had surgery to treat lung cancer in 2023 and then developed another primary cancer in her bladder. She declined having a cystectomy and underwent radiation therapy. Her bladder became nonfunctional and the cancer returned, leaving the patient with a very low quality of life.

“We did a robotic salvage cystectomy, keeping the incisions small and removing the bladder through the patient’s vagina,” reports Dr. Pieretti. “At an 8-month postop visit, she was a completely different person and her quality of life was much improved.”

Currently, only a few surgeons in each state perform RARC and even fewer perform RA-SCR. “Typically, salvage cystectomies are performed by surgeons with advanced training and in high-volume centers like Weston Hospital,” says Dr. Pieretti, noting his colleague Facundo Davaro, MD, at Cleveland Clinic Martin Health, also performs RARC.