A systematic review of minimally invasive approaches to pelvic exenteration

Florence Shekleton, Deena Harji, Ben Griffiths

Background
Minimally invasive surgical techniques have revolutionised the practice of colorectal surgery. Laparoscopic surgery has led the way followed by the development of robotic-assisted surgery as an alternative approach.  Pelvic exenteration is one of the most technically demanding operations reserved for locally advanced and recurrent pelvic malignancy.

Aims
To assess the feasibility of performing minimally invasive (MIS) exenterative surgery and its short term outcomes.

Methods
Literature searches were performed in MEDLINE (via OvidSP) (1966 – August 2017), EMBASE (via OvidSP) and the Cochrane Library. Searches were performed using key words for pelvic exenteration and minimally invasive surgery. For studies with a comparative arm an exploratory meta-analysis was undertaken. The odds ratio using 95 per cent confidence intervals (CI) were calculated for binary data and the standardised mean difference (SMD) with a 95 per cent CI were calculated for continuous data variables.

Results
17 studies were included, comprising 417 patients; 221 (52.9%) laparoscopic, 42 (10.0%) robotic, and 154 (36.9%) open. Operative time was significantly longer in the MIS group compared to the open group (p<0.001). There were no significant differences in margin status. Blood loss was reduced in the MIS Group (SMD -1.35, p<0.01). There were no differences in margin status or post-operative morbidity between the two groups. Length of stay was significantly shorter in the MIS group (SMD -5.77, p = 0.03). 

Conclusions
Minimally invasive pelvic exenteration is safe and feasible, with comparable early clinical outcomes to open surgery.