EP2027 - Efficacy and safety of total pelvic exenteration for late complications of pelvic radiation injury

Purpose/Background: To investigate the therapeutic effect and safety of total pelvic exenteration (TPE) in the treatment of late complications of pelvic radiation injury.

Methods/Interventions: An observational study was conducted to include patients who underwent TPE at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2020 to May 2025 due to advanced complications of pelvic radiation injury. Inclusion criteria: (1) History of radiotherapy for pelvic malignancies; (2) late complications of pelvic radiation injury, accompanied by complex fistulas and multi-organ fistulas. Exclusion criteria: (1) preoperative or intraoperative diagnosis of tumor recurrence or metastasis; (2) incomplete clinical data. Relevant data from eligible patients, encompassing basic information, intraoperative conditions, postoperative complications, and follow-up information, were collected and systematically analyzed.

Results/Outcomes: A total of 35 patients were included, with a pelvic radiation dose of 67.8 ± 20.8 gy. The radiation-induced complications observed included 17 cases of rectovaginal-bladder fistula, 4 cases of recto-bladder fistula, 3 cases of ileo-bladder fistula, 2 cases of colobladder fistula, 4 cases of vagino-bladder fistula, 1 case of recto-bladder fistula combined with an ileal fistula, 1 case of rectovaginal fistula combined with an ileo-bladder fistula, 1 case of rectovaginal fistula combined with ureteral stricture, and 2 cases of intestinal obstruction combined with ureteral stricture. The average surgical duration was 570.3 ± 118.2 minutes, with a median blood loss of 500 (300, 1000) ml. 14 cases underwent modified Bacon reconstruction for digestive tract reconstruction, 8 cases underwent Parks, and 2 cases underwent Dixon. 27 cases underwent Bricker surgery for urinary reconstruction, and 2 cases underwent unilateral Bricker in conjunction with unilateral pyeloplasty. Pelvic floor reconstruction was mainly based on omental packing combined with biological patch reconstruction. The postoperative hospital stay averaged 20.0 ± 13.6 days, the time to resume feeding was 5 (3, 9) days, and the duration of drainage tube indwelling was 15 (13, 25) days. 14 patients experienced Clavien-Dindo III or higher perioperative complications, including surgical site infections in 11 cases, pelvic abscesses in 9 cases, pulmonary infections in 5 cases, intestinal obstructions in 3 cases, urinary system infections in 4 cases, and bladder fistulae in 2 cases. There were no instances of perioperative mortality. 10 patients were diagnosed with empty pelvic syndrome (EPS), of whom 5 did not undergo pelvic floor reconstruction. The median follow-up duration was 48 months, during which 8 patients passed away, including 5 due to tumor recurrence and metastasis, renal failure, and COVID-19. The causes of death for the remaining 3 patients were suspected to be postoperative complications, comprising two cases of abdominal infection and 1 case of intestinal obstruction. 15 patients achieved complete symptom relief, and the symptoms of the remaining surviving patients were alleviated compared to baseline.

Conclusion/Discussion: TPE is a crucial surgical method for treating late complications of pelvic radiation injury, which can effectively alleviate patient symptoms. Reasonable pelvic floor reconstruction can reduce the incidence of postoperative empty pelvis syndrome, and further follow-up is required to monitor the relief of patients' symptoms and improvement in quality of life.

Table1. Details of operations
Table2. Long-term outcome of patients after operations