or total pelvic exenteration. The detailed report proposed was as follows: en‐bloc high sacrectomy at the S1/2 junction by dissecting down in the subperiosteal plane from the sacral promontory for 38 mm before transecting the sacrum, taking care to preserve the right L5 nerve root but including the S1 nerve root in the resection. Along the right pelvic sidewall, the internal iliac artery should be ligated proximal to the origin of the SGA and excised with the specimen. The abdominal dissection should stop at the upper level of the sciatic notch to avoid breaching the structures which need to be resected as part of the ELSiE. From the prone position, on the right side all gluteal tissues should be mobilized off the posterior aspect of the SLAM and piriformis muscle to the tip of the ischial spine; after transection of the ischial spine, the distal aspect of the obturator internus muscle should be excised.
Table 3.3 Construction of the roadmap for R0 resection in patient 1.
| Category | Structures and assessment | Surgical considerations | Figures |
|---|---|---|---|
| Sacrum and presacral fascia | Presacral fluid collection surrounded by rim of fibrosis, starting 38 mm from sacral promontory | Subperiosteal dissection from promontory down to point of sacral transection 38 mm distally (S1/2 junction) | 3.1 |
| No discernible plain between presacral fibrosis and anterior sacral cortex | Full thickness sacrectomy | 3.1 | |
| Nerves | Right L5 nerve root free and separate from tumor No discernible plain between right S1 nerve root and tumor/fibrosis | Preservation of right L5 nerve root with resection of S1 nerve root leading to partial motor deficit | 3.2 |
| Sacropelvic ligaments and ischial spines | Right SLAM complex grossly involved by tumor including insertion into ischial spine | Right ELSiE taking the tip of the ischial spine | 3.3 |
| Muscles | Distal aspect of right obturator internus muscle undistinguishable from tumor/fibrosis | Resection of distal aspect of right obturator internus as part of ELSiE | |
| Right piriformis muscle grossly tethered by tumor/fibrosis | Resection of right piriformis as part of ELSiE | 3.4 | |
| Vessels | Tumor extending to origin of right SGA | Right internal iliac ligation proximal to SGA origin | 3.5 |
| Visceral structures | Primary rectal tumor tethering uterus and both ovaries Bladder not directly involved but completely denervated due to required S1/2 sacrectomy | Total pelvic exenteration preferable but bladder preservation possible (to be discussed with patient) | 3.6 |
| Ureters | Distal right ureter indistinguishable from tumor/fibrosis | If bladder to be preserved: Proximal division of right ureter at level of pelvic brim, distal division just proximal to the ureterovesical junction Right ureteric reimplantation | 3.7 |
Figure 3.1 Sagittal MRI showing presacral fluid collection surrounded by a thick rim of fibrosis abutting the anterior sacral cortex; the extent of subperiosteal dissection to the level of planned sacral transection is indicated.
This roadmap was strictly followed intraoperatively and a total pelvic exenteration with en‐bloc S1/2 sacrectomy and right ELSiE was performed, resulting in R0 resection and very limited impact on patient mobility.
Figure 3.2 (a) Axial MRI at the level of S1 nerve roots. (b) Right S1 nerve root clearly inseparable from edge of tumor.
Figure 3.3 (a) Axial MRI at the level of ischial spine. (b) Gross involvement of the right SLAM complex to its insertion at the tip of the right ischial spine by tumor compared to a normal left SLAM.
Figure 3.4 (a) Axial MRI at the level of the piriformis muscle. (b) The anterior edge of the left piriformis is smooth, but the right piriformis is clearly infiltrated by tumor.
Figure 3.5 (a) Axial MRI at the level of the SGA. (b) A “tongue” of tumor clearly extending toward the medial aspect of the right SGA.
Figure 3.6 Coronal MRI showing tethering of the uterus and rectum by tumor/fibrosis.
Figure 3.7 (a) Axial MRI at the level of the distal ureters. (b) The right ureter is clearly in direct contact with the edge of tumor/fibrosis; note the clear asymmetry in position of the ureters due to tethering by the tumor to the right of the midline.
Radiological Assessment of Metastatic Disease
Approximately 50% of patients with RRC will have metachronous metastatic disease at the time of diagnosis of pelvic recurrence [56]. CT examination of the chest, abdomen, and pelvis is the primary technique for identification of metastatic disease [43]. PET‐CT utilizing fluorodeoxyglucose (FDG) can occasionally be helpful in troubleshooting indeterminate lesions such as borderline enlarged para‐aortic or inguinal nodes or for detection of CT occult
