Pelvic Compartments and Imaging Considerations Beyond TME Surgery for Rectal Cancer Patients

• Abstract
• Introduction
• Pelvic Compartments
• Imaging Considerations for Beyond TME Surgeries
• Complications of Beyond TME Surgeries
• Conclusion
• References

Abstract

The rectum resides next to multiple important organs, muscles, nodes, nerves, and vessels. While operating in the mesorectal plane is sacrosanct for a successful rectal cancer surgery to obtain a negative circumferential resection margin and minimize local recurrence, advanced rectal tumors need to be operated beyond the standard surgical template. We discuss the various surgical options in such cases, and describe the imaging findings to consider helping the surgeon decide on the appropriate surgery.

Introduction

Advanced rectal cancers (T4 tumors) and locally recurrent rectal cancers (LRRC) require complex surgical management with extended, multi-visceral and exenterative resections beyond the conventional total mesorectal excision (TME) planes to achieve R0 resection. This poses a surgical challenge due to the complex anatomy and narrow confined borders of the pelvis and the close proximity of the rectum to other adjacent vital organs. Such extensive surgeries requiring en bloc removal of all involved pelvic organs result in significant morbidity and functional sequelae.[1] Thus, accurate preoperative staging is of great importance in selecting patients for beyond TME surgery and also to guide the resectability of such tumors. The most optimal modality for imaging the pelvis for rectal cancer is high-resolution magnetic resonance imaging (MRI). MRI is considered the gold standard and plays a vital role in the management of rectal cancer: for imaging prior to neoadjuvant therapies, as a prerequisite for surgical planning, and in patients on surveillance or watch-and-wait protocol. MRI is able to predict the pelvic compartment involvement in T4 tumors and LRRC tumors with high accuracy and low percentage of understaging.[2]

A good-quality dedicated MRI of the rectum is the prerequisite for ensuring accurate local assessment and surgical planning. The details of a quality MRI rectum study have been mentioned earlier in this volume. Contrast administration is not mandatory.[3]

Pelvic Compartments

The Beyond Total Mesorectal Excision (TME) Consensus Group devised an MRI classification system, the BTME Classification or the Royal Marsden Classification, which separates the pelvic compartments along various fascial boundaries.[1] It describes the topographic anatomy of the pelvis, relevant landmarks, and the surgical tumor dissection planes. It aids in defining the anatomical location of a tumor within one of seven proposed intrapelvic compartments, which in turn allows planning surgical resection and preemptively predicting technical difficulties.

The anterior peritoneal reflection corresponds to the peritoneum covering the rectouterine and uterovesical pouches in females and the rectovesical pouch in males. The anterior compartment is divided into anterior above peritoneal reflection and anterior below peritoneal reflection. The other compartments include the central, posterior, lateral, and inferior compartments and the anterior urogenital triangle ([Fig. 1] and [Fig. 2]).[4]

• i. The “anterior above peritoneal reflection” compartment includes the ureters, iliac vessels above the peritoneal reflection, sigmoid colon, small bowel, and lateral pelvic sidewall fascia (peritoneal surface). This compartment represents a transition zone between the abdominal cavity and the pelvic sidewall.

• ii. The “anterior below peritoneal reflection” compartment includes the genitourinary system, i.e., seminal vesicles; prostate in males; and uterus, vagina, ovaries in females; urinary bladder/vesico-ureteric junction; proximal urethra; and pubic symphysis.

• iii. The “central” compartment consists of the rectum/neo-rectum (intra/extraluminal), perirectal fat, or mesorectal recurrence.

• iv. The “inferior” compartment includes levator ani muscles, external sphincter complex, ischiorectal and ischioanal fossa, and perineal and gluteal subcutaneous and cutaneous tissues.

• v. The “posterior” compartment includes the coccyx, presacral fascia, retrosacral space, sacrum, sciatic nerve, sciatic notch, and the S1 and S2 nerve roots.

• vi. “Lateral” compartment consists of internal and external iliac vessels, lateral pelvic lymph nodes, piriformis muscle, and obturator internus muscle.

• vii. The perineal body/perineal scar (if previous abdominoperineal resection of rectum done), vaginal introitus, distal urethra, and crus of penis constitute the “anterior urogenital triangle.”

This classification system has been validated by the work of Georgiou et al., who demonstrated excellent diagnostic performance.[5] They reported that patients with tumor within the “anterior above peritoneal reflection” compartment on MRI had a worse overall survival compared with patients in whom this compartment was not involved, and patients with a tumor within the “lateral” and “posterior” compartments, or those with tumor within three or more compartments also had a reduced disease-free survival. The usefulness of this classification system has also been proven on an anatomical basis by Stelzner et al., who confirmed that the seven-compartment–based MRI classification system provided crucial anatomical landmarks for facilitating pelvic exenterative surgery.[6]

Imaging Considerations for Beyond TME Surgeries

Resection in beyond TME surgeries is tailored, based on the preoperative imaging on MRI, taking into consideration the extent of tumor spread and the presence of EMVI or tumor deposits reaching the mesorectal fascia or lateral pelvic nodes.

The anterior peritoneal reflection (APR) separates the intra- and extraperitoneal portions of the rectum and is a well-defined anatomical landmark on laparotomy.[7] The identification of the APR and its relation with rectal cancers is essential for T staging. T4a or peritoneal invasion of rectal cancer is suspected on MRI when there is altered signal intensity, thickening, or nodularity of the APR, and not merely abutment of the peritoneum by tumor.[8] It has been found that less distention of the urinary bladder, an anteverted uterus with a closer distance between the uterus and anterior abdominal wall, thicker abdominal subcutaneous fat layers, and greater volume of peritoneal connective tissue, makes it easier to identify the APR on MRI.[9] In females, it is fixed to the round ligament, which is removed with the peritoneum and is also more firmly attached to the uterine body and cervix, whereas in males it is more easily detached along the rectovesical pouch.[2] The peritoneal reflection is usually lifted from the lower lateral abdominal wall and the upper pelvic sidewall at the time of surgery. Anterior dissection is tailored as per quadrant of involvement and involves resection of one plane beyond the tumor.

In males, Denonvilliers' fascia is an additional fascial layer between the anterior mesorectal fascia and the prostate. It is excised along with TME in cases with close or threatened anterior mesorectal fascia. However, in cases with suspicious prostatic involvement on MRI as evidenced by indistinct fat planes between the tumor and prostate, a prostatic shave (for equivocal or minimal involvement) or a bladder-sparing prostatectomy or total pelvic exenteration (TPE) is performed. For tumors showing frank involvement of the prostate without involvement of the bladder neck, that is, cases with a breach of prostatic capsule or alteration in the normal T2 hyperintense signal intensity of the peripheral zone, an abdominoperineal resection with en masse prostatectomy with or without a cysto-urethral anastomosis can be performed ([Fig. 3]). TPE is required for most extensive involvement of the prostate with tumor invasion of the entire gland and suspicious bladder base involvement[10] ([Fig. 4]). Involvement of the seminal vesicles requires seminal vesicle excision to achieve a negative circumferential resection margin ([Fig. 5]). It is important to note here that beyond TME surgeries may need to be performed not just for direct organ involvement, but also to achieve negative margins. Thus, a tumor abutting the left seminal vesicle without involvement may still need a TME plus left seminal vesicle excision to avoid a positive CRM (circumferential resection margin). Similarly, prostatic abutment without involvement may require Denonvilliers' fascia excision or prostatic shave to achieve negative margins. In females, involvement of the uterus, cervix, and variable lengths of vagina requires posterior exenteration, wherein these organs are removed en bloc along with the rectum ([Fig. 6]). Posterior vaginectomy with reconstruction of the posterior vaginal wall is performed for isolated vaginal involvement when the posterior fornix is spared ([Fig. 7]).

Tumors involving the anterior compartment above the peritoneal reflection demonstrate worse overall survival.[11] Tumors extending into the anterior compartment that are fixed to the small bowel loops or colon need appropriate resection and anastomosis with diversion stomas. Involvement of the ureters requires ureterolysis with adequate length preservation for urinary diversion. Tumors involving the aortoiliac axis were historically labeled as irresectable. However, in the recent past in specialized centers, there have been reports of the feasibility and safety of extra-anatomic resections with major vascular reconstruction.

Standard of care for extensive anterior urogenital organ invasion is TPE, which removes all the pelvic organs with subsequent urinary reconstruction.[12] In cases with more extensive involvement, like infiltration of the root of penis and distal urethra, pubic bone and perineal urethral resections can also be performed ([Fig. 8]). Urinary reconstruction, however, carries its own set of complications and morbidity. So, it is preferred to perform partial cystectomy with or without bladder augmentation for diseases sparing the trigone of the urinary bladder.[13]

For inferior compartment tumors, defining the site and extent of involvement of the levator ani in terms of how high and how lateral is the involvement is important for the surgeon. It is important to report the presence of any fistula formation ([Fig. 9]). It is also important to identify the presence and location of any lymph nodes along the inferior pudendal vessels deep to the gluteal muscles. Radical inferior compartment excision with ischiorectal and extra-levator abdominoperineal excision is required for addressing inferior compartment invasion, for example, tumors going beyond the external sphincter into the ischiorectal fossa. All patients with skin loss are offered plastic reconstruction, such as unilateral or bilateral gluteal advancement flaps in a V–Y fashion for perineal and posterior vaginal wall reconstruction[14] ([Fig. 10]).

In cases of posterior compartment invasion, careful evaluation of the presacral fat as well as the sacrum is essential. Isolated posterior MRF involvement without extension into the presacral fat on imaging appears as T2 intermediate thickening and requires only excision of the presacral fascia.[15] Tumors showing obvious presacral fat invasion at or below the level of S3 ([Fig. 10]) are subjected to a low sacrectomy and coccygectomy without additional morbidity, as the nerve roots resected are the ones innervating the sphincters.[16] Tumors involving the presacral fat or sacrum above the level of S2 are difficult to resect, as a high sacrectomy would entail paraplegia, due to the nerve roots excised. High sacrectomy can be performed only in very select cases with special care taken of the sacral nerve roots and the thecal sac. For less extensive involvement of the high sacrum or tumors involving only the periosteum, periosteal shave or anterior cortical sacrectomy with bilateral nerve root preservation is done[17] ([Fig. 11]). Involvement of the lumbosacral plexus requires complete sacroiliac disarticulation and spinopelvic fixation.[18] Sciatic notch examination is done carefully in axial images, to identify direct disease extension, metastatic nodes, and/or tumor deposits. Bilateral sciatic nerve involvement is an absolute contraindication for any surgery. However, extension of the disease through the sciatic notch and high sacral involvement (above S2) are relative contraindications where the risk:benefit ratio needs to be weighed on an individual basis for patient-centric decision making[1] [12] ([Fig. 12]).

The most challenging pelvic compartment when it comes to extended surgeries is the lateral compartment, as it requires knowledge of complex neurovascular and musculoskeletal anatomy. For lateral MRF involved by direct tumor extension or extramural venous invasion (EMVI), a “vascular” approach is usually selected with delineation of the internal iliac artery, lateralization of the ipsilateral ureter and en masse resection of the extramesorectal pelvic fat done along the internal iliac artery beyond the TME planes.[19] If the tumor or nodes abut or cross the internal iliac vessels, an “extra- vascular” approach is selected with ligation of the internal iliac artery and vein, to allow a wider margin resection, and the lateral pelvic lymph nodes and fibrofatty tissue are removed en bloc with the internal iliac vasculature. Thus, it is important to map out the disease extension in the lateral compartment on MRI with respect to the internal iliac vessels. In cases of tumor reaching up to the obturator internus muscle, a radiologist must define the lumbosacral trunk and sacral nerve roots for the surgeon. This allows the surgeon to carefully divide the muscle and detach it from the pelvic side wall, while ensuring preservation of the sacral plexus and sciatic nerve.[20] Majority of these cases also involve the distal ureters, and when TPE is not planned, the distal portions are resected followed by reimplantation in the urinary bladder. When ureters cannot be well identified on MRI pelvis, an MR urography or a computed tomography (CT) intravenous urography may be performed. Such patients may also undergo preoperative DJ stenting to help delineate the ureter well intraoperatively. Involvement of common and external iliac vessels, which were once absolute contraindications for surgery, has also been attempted in recent times in specialized centers with similar survival outcomes.[21] Lateral pelvic bone resections, like resection of the ischium for inferolateral diseases and peri-acetabular resections, are also performed.

It must be emphasized that decisions for beyond TME surgeries must be taken in the setting of a multidisciplinary tumor board discussion, based on the MRI and digital rectal examination findings and the patient's clinical status. A direct conversation between the surgeon and the radiologist helps in crystallizing a definitive roadmap for surgery and ensures that everyone is on the same page. While a routine MRI of the pelvis and contrast-enhanced CT (CECT) of the thorax and abdomen usually suffices for imaging workup, we also perform a PET/CT in patients who require a TPE to exclude occult metastasis. A summary of the beyond TME surgeries has been tabulated in [Table 1]. A structured template for reporting rectal cancers is provided as [Supplementary Material S1] (available in the online version only).

Complications of Beyond TME Surgeries

Imaging plays a central role in imaging postsurgical complications. Pelvic collections following TPE are common and are suitable for drainage via image-guided intervention. Migration of small bowel loops into the pelvis following pelvic exenteration is due to a phenomenon known as empty pelvis syndrome, leading to potential complications like bowel ileus or obstruction, wound or flap dehiscence, and enteric fistulae[22] ([Fig. 13A]). A spacer device like Bakri balloon placement has been performed following TPE to address empty pelvis syndrome, without significant adverse events[23] ([Fig. 13B]). A CECT is the investigation of choice in identifying pelvic collections ([Fig. 14]), the level of bowel obstruction ([Fig. 15]), as well as the presence and site of communication of enteric fistulae, if any ([Fig. 16]). Urinary reconstruction and conduit formation following TPE are also related to various complications. Early complications included uretero-ileal leaks, conduit-related complications, and acute pyelonephritis, whereas late complications included uretero-intestinal strictures. Overall, the conduit diversions are associated with a high urinary morbidity rate but low mortality rate[24] ([Fig. 17]). Anastomotic leaks after bowel anastomosis usually occur in the first few weeks in the postoperative period. Small, contained leaks present as a late complication and are often difficult to distinguish from postoperative abscesses on imaging. A CT scan with oral contrast is most useful in the identification of these bowel leaks. These are either managed conservatively or with reexploration and resection anastomosis.

Conclusion

Knowledge of the pelvic compartments and extent of the tumor and metastatic lymph nodes allows a radiologist to assist the surgeon in preoperative planning, which can greatly reduce any intraoperative surprises and allows successful achievement of negative surgical margins, lower postoperative morbidity, and better surgical outcomes.[25] Deconstructing the anatomy of the pelvic compartments and involvement of various pelvic organs by the tumor prior to exenterative surgeries allows the surgeon to be prepared for technical difficulties and also to counsel the patient appropriately. Multidisciplinary team approach is key to ensure active dialogue between the operating surgeon and the radiologist to allow an accurate image-based surgical plan.

Conflict of Interest

None declared.

• References

• 1 Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100 (08) 1009-1014
  CrossrefPubMedSearch in Google Scholar
• 2 Stelzner S, Kittner T, Schneider M. et al. Beyond total mesorectal excision (TME)-results of MRI-guided multivisceral resections in T4 rectal carcinoma and local recurrence. Cancers (Basel) 2023; 15 (22) 5328
  CrossrefPubMedSearch in Google Scholar
• 3 Vliegen RF, Beets GL, von Meyenfeldt MF. et al. Rectal cancer: MR imaging in local staging–is gadolinium-based contrast material helpful?. Radiology 2005; 234 (01) 179-188
  PubMedSearch in Google Scholar
• 4 Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally recurrent rectal cancer according to a standardized MRI classification system: a systematic review of the literature. J Clin Med 2022; 11 (12) 3511
  PubMedSearch in Google Scholar
• 5 Georgiou PA, Tekkis PP, Constantinides VA. et al. Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal cancer. Eur J Cancer 2013; 49 (01) 72-81
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  CrossrefPubMedSearch in Google Scholar
• 7 Dujovny N, Quiros RM, Saclarides TJ. Anorectal anatomy and embryology. Surg Oncol Clin N Am 2004; 13 (02) 277-293
  CrossrefPubMedSearch in Google Scholar
• 8 Lee S, Kassam Z, Baheti AD. et al. Rectal cancer lexicon 2023 revised and updated consensus statement from the Society of Abdominal Radiology Colorectal and Anal Cancer Disease-Focused Panel. Abdom Radiol (NY) 2023; 48 (09) 2792-2806
  CrossrefPubMedSearch in Google Scholar
• 9 Yiqun S, Tong T, Fangqi L. et al. Recognition of anterior peritoneal reflections and their relationship with rectal tumors using rectal magnetic resonance imaging. Medicine (Baltimore) 2016; 95 (09) e2889
  CrossrefPubMedSearch in Google Scholar
• 10 Raj Kumar B, Bankar S, Pandey D. et al. Abdominoperineal excision with prostatectomy in T4 rectal cancer - bladder-sparing robotic pelvic exenteration - a video vignette. Colorectal Dis 2020; 22 (11) 1786-1787
  PubMedSearch in Google Scholar
• 11 Shur JD, Qiu S, Johnston E. et al. Multimodality imaging to direct management of primary and recurrent rectal adenocarcinoma beyond the total mesorectal excision plane. Radiol Imaging Cancer 2024; 6 (02) e230077
  PubMedSearch in Google Scholar
• 12 Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406 (06) 1763-1774
  PubMedSearch in Google Scholar
• 13 Verma K, Engineer R, Ostwal V. et al. Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study. Colorectal Dis 2018; 20 (12) 1070-1077
  PubMedSearch in Google Scholar
• 14 Chavan RN, Saklani AP, Desouza AL. et al. V-Y gluteal advancement fasciocutaneous flap for reconstruction of perineal defects after surgery for anorectal cancers- a single-center experience. Indian J Surg Oncol 2021; 12 (02) 241-245
  PubMedSearch in Google Scholar
• 15 Kumar S, Rohila J, Sasi SP. et al. Robotic-assisted low anterior resection: beyond total mesorectal excision; a left vascular approach with presacral fascia excision - a video vignette. Colorectal Dis 2020; 22 (05) 595-596
  PubMedSearch in Google Scholar
• 16 Pareekutty NM, Balasubramanian S, Kadam S. et al. En bloc resection with partial sacrectomy helps to achieve R0 resection in locally advanced rectal cancer, experience from a tertiary cancer center. Indian J Surg Oncol 2019; 10 (01) 141-148
  PubMedSearch in Google Scholar
• 17 Evans MD, Harji DP, Sagar PM. et al. Partial anterior sacrectomy with nerve preservation to treat locally advanced rectal cancer. Colorectal Dis 2013; 15 (06) e336-e339
  PubMedSearch in Google Scholar
• 18 Colibaseanu DT, Dozois EJ, Mathis KL. et al. Extended sacropelvic resection for locally recurrent rectal cancer: can it be done safely and with good oncologic outcomes?. Dis Colon Rectum 2014; 57 (01) 47-55
  PubMedSearch in Google Scholar
• 19 Desouza A, Sugoor P, Sasi S, Rohila J, Saklani A. Robotic intersphincteric resection with right seminal vesicle excision via a right vascular approach using the Da Vinci Xi robotic system - a video vignette. Colorectal Dis 2019; 21 (04) 492-493
  PubMedSearch in Google Scholar
• 20 Pereira P, Ghouti L, Gaichet V. Extra-vascular dissection of the pelvic sidewall for advanced cancers of the pelvis. A technique to obtain wider lateral resection margins. J Visc Surg 2012; 149 (05) e307-e313
  PubMedSearch in Google Scholar
• 21 Abdelsattar ZM, Mathis KL, Colibaseanu DT. et al. Surgery for locally advanced recurrent colorectal cancer involving the aortoiliac axis: can we achieve R0 resection and long-term survival?. Dis Colon Rectum 2013; 56 (06) 711-716
  PubMedSearch in Google Scholar
• 22 Johnson YL, West MA, Gould LE. et al. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24 (01) 16-26
  PubMedSearch in Google Scholar
• 23 Kazi M, Desouza A, Bankar S. et al. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - a prospective safety and efficacy study for the Bakri balloon. Colorectal Dis 2023; 25 (04) 616-623
  PubMedSearch in Google Scholar
• 24 Kazi M, Rohila J, Kumar NA. et al. Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes. Langenbecks Arch Surg 2021; 406 (02) 329-337
  PubMedSearch in Google Scholar
• 25 PelvEx Collaborative. Surgical and survival outcomes following pelvic exenteration for locally advanced primary rectal cancer: results from an international collaboration. Ann Surg 2019; 269 (02) 315-321
  CrossrefPubMedSearch in Google Scholar

Address for correspondence

Publication History

Article published online:
05 June 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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• References

• 1 Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100 (08) 1009-1014
  CrossrefPubMedSearch in Google Scholar
• 2 Stelzner S, Kittner T, Schneider M. et al. Beyond total mesorectal excision (TME)-results of MRI-guided multivisceral resections in T4 rectal carcinoma and local recurrence. Cancers (Basel) 2023; 15 (22) 5328
  CrossrefPubMedSearch in Google Scholar
• 3 Vliegen RF, Beets GL, von Meyenfeldt MF. et al. Rectal cancer: MR imaging in local staging–is gadolinium-based contrast material helpful?. Radiology 2005; 234 (01) 179-188
  PubMedSearch in Google Scholar
• 4 Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally recurrent rectal cancer according to a standardized MRI classification system: a systematic review of the literature. J Clin Med 2022; 11 (12) 3511
  PubMedSearch in Google Scholar
• 5 Georgiou PA, Tekkis PP, Constantinides VA. et al. Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal cancer. Eur J Cancer 2013; 49 (01) 72-81
  CrossrefPubMedSearch in Google Scholar
• 6 Stelzner S, Heinze T, Heimke M. et al. Beyond total mesorectal excision: compartment-based anatomy of the pelvis revisited for exenterative pelvic surgery. Ann Surg 2023; 278 (01) e58-e67
  CrossrefPubMedSearch in Google Scholar
• 7 Dujovny N, Quiros RM, Saclarides TJ. Anorectal anatomy and embryology. Surg Oncol Clin N Am 2004; 13 (02) 277-293
  CrossrefPubMedSearch in Google Scholar
• 8 Lee S, Kassam Z, Baheti AD. et al. Rectal cancer lexicon 2023 revised and updated consensus statement from the Society of Abdominal Radiology Colorectal and Anal Cancer Disease-Focused Panel. Abdom Radiol (NY) 2023; 48 (09) 2792-2806
  CrossrefPubMedSearch in Google Scholar
• 9 Yiqun S, Tong T, Fangqi L. et al. Recognition of anterior peritoneal reflections and their relationship with rectal tumors using rectal magnetic resonance imaging. Medicine (Baltimore) 2016; 95 (09) e2889
  CrossrefPubMedSearch in Google Scholar
• 10 Raj Kumar B, Bankar S, Pandey D. et al. Abdominoperineal excision with prostatectomy in T4 rectal cancer - bladder-sparing robotic pelvic exenteration - a video vignette. Colorectal Dis 2020; 22 (11) 1786-1787
  PubMedSearch in Google Scholar
• 11 Shur JD, Qiu S, Johnston E. et al. Multimodality imaging to direct management of primary and recurrent rectal adenocarcinoma beyond the total mesorectal excision plane. Radiol Imaging Cancer 2024; 6 (02) e230077
  PubMedSearch in Google Scholar
• 12 Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406 (06) 1763-1774
  PubMedSearch in Google Scholar
• 13 Verma K, Engineer R, Ostwal V. et al. Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study. Colorectal Dis 2018; 20 (12) 1070-1077
  PubMedSearch in Google Scholar
• 14 Chavan RN, Saklani AP, Desouza AL. et al. V-Y gluteal advancement fasciocutaneous flap for reconstruction of perineal defects after surgery for anorectal cancers- a single-center experience. Indian J Surg Oncol 2021; 12 (02) 241-245
  PubMedSearch in Google Scholar
• 15 Kumar S, Rohila J, Sasi SP. et al. Robotic-assisted low anterior resection: beyond total mesorectal excision; a left vascular approach with presacral fascia excision - a video vignette. Colorectal Dis 2020; 22 (05) 595-596
  PubMedSearch in Google Scholar
• 16 Pareekutty NM, Balasubramanian S, Kadam S. et al. En bloc resection with partial sacrectomy helps to achieve R0 resection in locally advanced rectal cancer, experience from a tertiary cancer center. Indian J Surg Oncol 2019; 10 (01) 141-148
  PubMedSearch in Google Scholar
• 17 Evans MD, Harji DP, Sagar PM. et al. Partial anterior sacrectomy with nerve preservation to treat locally advanced rectal cancer. Colorectal Dis 2013; 15 (06) e336-e339
  PubMedSearch in Google Scholar
• 18 Colibaseanu DT, Dozois EJ, Mathis KL. et al. Extended sacropelvic resection for locally recurrent rectal cancer: can it be done safely and with good oncologic outcomes?. Dis Colon Rectum 2014; 57 (01) 47-55
  PubMedSearch in Google Scholar
• 19 Desouza A, Sugoor P, Sasi S, Rohila J, Saklani A. Robotic intersphincteric resection with right seminal vesicle excision via a right vascular approach using the Da Vinci Xi robotic system - a video vignette. Colorectal Dis 2019; 21 (04) 492-493
  PubMedSearch in Google Scholar
• 20 Pereira P, Ghouti L, Gaichet V. Extra-vascular dissection of the pelvic sidewall for advanced cancers of the pelvis. A technique to obtain wider lateral resection margins. J Visc Surg 2012; 149 (05) e307-e313
  PubMedSearch in Google Scholar
• 21 Abdelsattar ZM, Mathis KL, Colibaseanu DT. et al. Surgery for locally advanced recurrent colorectal cancer involving the aortoiliac axis: can we achieve R0 resection and long-term survival?. Dis Colon Rectum 2013; 56 (06) 711-716
  PubMedSearch in Google Scholar
• 22 Johnson YL, West MA, Gould LE. et al. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24 (01) 16-26
  PubMedSearch in Google Scholar
• 23 Kazi M, Desouza A, Bankar S. et al. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - a prospective safety and efficacy study for the Bakri balloon. Colorectal Dis 2023; 25 (04) 616-623
  PubMedSearch in Google Scholar
• 24 Kazi M, Rohila J, Kumar NA. et al. Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes. Langenbecks Arch Surg 2021; 406 (02) 329-337
  PubMedSearch in Google Scholar
• 25 PelvEx Collaborative. Surgical and survival outcomes following pelvic exenteration for locally advanced primary rectal cancer: results from an international collaboration. Ann Surg 2019; 269 (02) 315-321
  CrossrefPubMedSearch in Google Scholar

• Supplementary Material