V4-04: ROBOTIC TOTAL PELVIC EXENTERATION WITH INTRACORPOREAL SIGMOID CONDUIT AND COLOSTOMY: FIRST CLINICAL REPORT
Total pelvic exenteration may offer durable palliation in the setting of locally advanced pelvic cancer, but traditionally its morbidity has limited widespread use. We intend to demonstrate the feasibility of robotic total pelvic exenteration with completely intracorporeal sigmoid conduit and colostomy for locally advanced prostate cancer.
We present the case of a 73-year-old man with metastatic castrate-resistant prostate cancer after primary brachytherapy who suffered from progressive local symptoms due to an enlarging pelvic mass. Despite treatment with complete androgen blockade and docetaxel, he progressed locally with worsening pelvic pain, bladder outlet obstruction, bilateral hydronephrosis requiring nephrostomy tubes, and impending rectal obstruction. Despite stable bony metastases, death from bowel obstruction was imminent without intervention. After extensive discussion and counseling, the patient elected to proceed with total pelvic exenteration. Surgery was performed via 5 ports in the standard "W" configuration with the patient in lithotomy and steep Trendelenburg position.
The total robotic time was 5.4 hours. Estimated blood loss was 100 ml. There were no surgical complications. The sigmoid conduit and colostomy were harvested intracorporeally, and the specimen was extracted via the anus, avoiding the need for an open incision. The use of sigmoid colon for the conduit avoided a bowel anastomosis. The perioperative course was complicated by disseminated intravascular coagulation, a known complication of metastatic prostate cancer, which resolved with the transfusion of blood products and intensive care monitoring. Due to abnormal clotting associated with this pathological condition, the patient suffered an ischemic stroke perioperatively. Length of stay was 8 days. The patient was cognitively intact and had regained gross motor function on the affected side within 1 month of surgery.
Robotic total pelvic exenteration with intracorporeal sigmoid conduit is technically feasible. By minimizing surgical morbidity, this approach may allow more patients to benefit from local surgical palliation.