Journal of Minimally Invasive Surgery 2022; 25(4): 131-138
Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers
Mufaddal Kazi, Ashwin Desouza, Chaitali Nashikkar, Avanish Saklani
Division of Gastrointestinal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
Correspondence to: Avanish Saklani
Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges, Marg, Parel, Mumbai 400012, Maharashtra, India
Tel: +91-22-24177000, ext 7176
Fax: +91-22-24177000

This is the invited article for the study presented at the 2022 Conference of the Korean Society of Endo-Laparoscopic & Robotic Surgery Conference.
Received: July 26, 2022; Revised: September 8, 2022; Accepted: September 13, 2022; Published online: December 15, 2022.
© The Korean Society of Endo-Laparoscopic & Robotic Surgery.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose: Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database.
Methods: Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI).
Results: The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%–37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%–13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively.
Conclusion: MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.
Keywords: Rectal neoplasms, Locally advanced, Minimally invasive surgical procedures, Pelvic exenteration

Nearly 40% to 50% of rectal cancers are locally advanced at presentation [1], and about half of them would require extended or beyond total mesorectal excisions (TME) to achieve negative margins [2]. All trials that compared open against minimally invasive surgery (MIS) for rectal cancers, uniformly excluded such advanced rectal cancers [36]. Since the ACOSOG Z6051 and the ALaCaRT trials failed to demonstrate the non-inferiority of MIS in terms of composite pathological endpoint for rectal cancers without involvement of the mesorectal fascia [7,8], a randomized trial comparing MIS and open pelvic exenterations is not a foreseeable project. The oncological outcomes were not different in any of the trials [9,10]; yet, doubt remains regarding the safety of MIS in rectal cancers requiring adjacent organ resections.

Even though some high-volume exenteration units perform minimally invasive exenterations, the published data on the same is scarce. The PelvEx group performed a meta-analysis on the available comparative data of MIS against open exenterations with only 37 MIS exenterations from four pooled studies [11]. Despite the increase in operative time, there was a significant reduction in hospital stay and overall morbidity rate with MIS exenterations. However, since the MIS numbers were very small, drawing definite conclusions is difficult with regard to its safety. Besides, there was no report on oncological outcomes. The other significant comparative data comes from a single-center experience of 61 MIS exenterations [12], where R0 resection rate and 3-year survivals were similar. However, significant selection biases exist, and data on a larger number of patients is needed.

The present study aimed to define the safety of MIS exenterations based primarily on major morbidity rate and R1 resections. The threshold was defined by the standards set by the PelvEx group for exenterations in primary locally-advanced rectal cancers. A 30-day major complication rate (≥grade IIIA) of 37.8% and R1/2 resection rate of 15.6% were found among 1,291 exenterations [13], and these were used as benchmark values. Secondarily, disease-free (DFS) and overall survival (OS) would be assessed.


Study design, setting, and patients

The prospectively maintained data of pelvic exenterations from a single, tertiary colorectal cancer surgical unit was audited. Patients who operated between November 2015 and June 2022 for primary, locally-advanced rectal adenocarcinomas were included. Exclusions were the need for high sacral resection (S3 and above), lateral compartment resection (vascular resections, clearance of sciatic notch), recurrent rectal cancers, and non-adenocarcinoma histology (squamous cancer, gastrointestinal stromal tumors).

The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) and SAMPL (Statistical Analyses and Methods in the Published Literature) guidelines were followed for study reporting.


Rectal cancers were investigated with a colonoscopy, biopsy, magnetic resonance imaging (MRI) of the pelvis, and contrast-enhanced computed tomography of the chest and abdomen. Tumor location was measured on colonoscopy as the lower edge of the tumor from the anal verge. All patients were discussed in the multidisciplinary team (MDT) meeting for treatment planning. Preoperative radiation was delivered for all advanced tumors (≥T3 or ≥N1). The choice of radiation (long-course chemoradiation, 50 Gy in 25 fractions with concurrent capecitabine vs. short-course radiation, 25 Gy in five fractions) was at the discretion of the MDT. Similarly, the use of consolidation chemotherapy was also individualized. Response MRI was performed at least 6 weeks after completion of radiation.

Pelvic exenterations included the removal of one or more anterior urogenital organs en bloc with the rectum, either for margins or for disease infiltration [2]. Non-multivisceral resection or those requiring partial organ resections are categorized as extended TME and were not included. Thus, total pelvic exenterations [2], bladder sparing exenterations [14], and posterior pelvic exenterations were the operations performed [15], with or without sacral or perineal resections. The techniques for each of these are previously described, and all operations were performed by the same team of surgeons. The operative technique for the extirpative part of the procedure did not considerably change over the years. The choice for robotic or laparoscopic surgery was based on the availability of robotic theater rather than patient or tumor characteristics. Adjuvant chemotherapy and further follow-up were in accordance with the National comprehensive cancer network guidelines [16].


Patient and demographic characteristics recorded were age, sex, performance status on the Eastern Cooperative Oncology Group scale, comorbidities on the American Society of Anesthesiologists physical status classification, body mass index, preoperative hemoglobin, and albumin levels. Tumor-related factors noted were distance from anal verge, luminal occlusion, histologic subtype and differentiation, carcinoembryonic antigen levels, clinical T, N, and M stage, presence of extramural vascular invasion, and lateral pelvic nodes. Treatment variables entered were neoadjuvant radiation, chemotherapy, surgical approach (laparoscopic vs. robotic), surgery performed, lateral pelvic node dissection, sacral resection, perineal reconstructions, and the use of adjuvant chemotherapy.

Outcomes and safety thresholds

Postoperative and pathological outcomes were the short-term endpoints used. Operating duration, blood loss, and 30-day complications on the Clavien-Dindo classification [17] were recorded. Pathological factors were the Mandard tumor regression grade [18], pathological T and N stage, presence of lymphovascular and perineural invasion, and the status of circumferential resection margin (CRM). A positive CRM was considered when tumor was within 1 mm of the radial non-peritonealized resection surface.

Benchmark values for short-term outcomes of pelvic exenterations from the PelvEx data were used for deciding the safety thresholds [13]. A 30-day major complication rate (≥grade IIIA) of 37.8% and R1/2 resection rate of 15.6% were found for exenterations in locally-advanced rectal cancers [13]. Based on this, the upper limit of the 95% confidence interval (CI) for safety was set at 40% for major morbidity and 20% for R1 resections. Based on our previous data for MIS exenterations [12], a 30% major morbidity and 13% R1 resections were expected.

The number of patients required to demonstrate the safety with 95% CI would be 88 patients for morbidity and 101 for R1 resections. Thus, the inclusion of 124 patients in the study would suffice to meet the statistical thresholds.

Statistical methods

Data were recorded and analyzed using the IBM SPSS version 16 (IBM Corp., Armonk, NY, USA). For the various continuous variables, medians and interquartile ranges were calculated. Categorical variables were represented by numbers and proportions. Median follow-up was calculated by the reverse Kaplan-Meier method and survivals analysis was performed by the Kaplan-Meier curves.

OS was calculated from the date of operation to the date of death from any cause. Similarly, DFS was measured from the date of operation till recurrences or deaths. All patients were censored at their last follow-up.


Patients and intervention

One-hundred twenty-four patients underwent MIS exenterations during the study period (Fig. 1). The median age of our cohort was 47 years and 65.3% (81 patients) were male (Table 1). Poorly-differentiated tumors comprised on 29.8%, and 17 patients (13.7%) had signet ring cell histology. The majority were low rectal cancers (median distance from anal verge, 3 cm) and 12 patients (9.7%) in addition had curable distant metastasis.

Other than eight patients, all received preoperative radiation. Consolidation chemotherapy was given to 66 (53.2%). We performed a laparoscopic exenteration for 95 patients (76.6%) and the remainder had a robotic operation (Table 2). There were two conversions to open surgery (1.6%), both in laparoscopic exenterations. A total pelvic exenteration was carried out in 74 patients (59.7%), posterior exenteration in 36 (29.0%), and a bladder sparing exenteration in 14 (11.3%). Thirty-six patients had sphincter preservation and 56.5% had a lateral pelvic node dissection.


The major morbidity rate at 30-days (≥grade IIIA) was 28.2% (35 patients). The upper limit of 95% CI was 37%; thus, the safety threshold of 40% was not crossed. The pathological CRM involvement was noted in nine patients (7.3%) with a 95% CI of 3.4% to 13.4%. Once again, the set safety limit was not crossed (Table 3). No patient had a positive distal margin.

At a median follow-up of 15 months, 44 patients (35.5%) recurred (Table 4). Local recurrences (with or without systemic relapses) were seen in 10 patients (8.1%). The median DFS was 31 months and the 2-year DFS and OS were 53.7% and 85.2%, respectively (Fig. 2).


In the present series of 124 MIS exenterations for primary advanced rectal cancers, the predefined safety limits for major operative complications and R1 resections were not crossed. Thus, MIS exenterations appeared to have short-term safety comparable to international standards for open exenterations.

Pelvic exenterations are a major undertaking, and operative complications are a culmination of various factors. The patient and tumor characteristics, the receipt of neoadjuvant therapies, and the extent of surgical resection and reconstruction, all contribute to the morbidity. By adopting minimally invasive surgical approaches, the intention is to introduce a modifiable factor that can reduce some of the complications. However, one must be critical of new procedures with a patient-centric approach at all times.

Our group has adopted MIS for pelvic exenterations for all advanced rectal cancers except for recurrent cancers, diseases requiring high sacrectomy or vascular resections, and for those with prior pelvic operations with anticipated bowel adhesions. Thus, comparing our MIS exenterations against open would entail an uncorrectable selection bias. Therefore, we chose to compare the international standards with benchmarked outcomes from the PelvEx database [13]. Selection bias was therefore minimized as all consecutive eligible patients underwent MIS without exclusions or missing data.

To address the morbidity associated with pelvic exenterations, various measures were taken for standardization of the procedure and postoperative care over time. All ureteroenteral anastomoses were stented with the delayed removal of stents to reduce the incidence of clinically significant urinary leaks [19]. Perineal closures were routinely performed with versatile gluteal fasciocutaneous advancement flaps to overcome wound breakdowns and infections [20]. Finally, empty pelvis syndrome was mitigated with the use of pelvic spacer balloons [21]. Besides the standardizations in reconstructive phase of exenterations, the use of MIS probably helps by reducing blood loss, abdominal surgical site infection, early return from ileus, and earlier discharge from hospital [12,22].

R0 resections are key to achieving successful oncological outcomes after exenterative procedures. Over 90% of the present cohort had margin negative resections, suggesting non-inferiority to the open operations in the PelvEx data [13]. The above figure is in spite of 30% poorly-differentiated or signet ring cell cancers that are known to have higher positive margins [23]. Only two patients were converted to open surgery from MIS; one for bleeding and the other for an inadvertent ureteric injury. Selection of patients and operator experience is key, since it is worthless to pursue MIS with the risk of positive margins. Vascular (external iliac and proximal) and bone resections (S3 and above), although possible via MIS in highly experienced units, are surrogates for a very advanced infiltrative disease into the pelvic side walls, and remain absolute indications for an open operation at our center.

The principal drawback of our study is the absence of a comparator arm. We, therefore, used the international benchmarks set as the historical comparator. The retrospective nature of the study, despite prospective data entry, is associated with some variables with missing data.

Overall, the number of events (for complications or R+ resections) was few, and meaningful regression analysis to identify predictors of safety was not possible. Finally, the short follow-up duration of our cohort does not allow comparisons of survival outcomes.

Notwithstanding the above shortcomings, our study has important strengths. The present study describes the outcomes of the largest cohort of MIS exenterations for locally-advanced rectal cancers. The cohort is homogenous, and all patients had complete data on the primary outcomes to be analyzed. Lastly, the safety threshold was based on the upper limit of 95% CIs; hence, our results have statistical validity.

Our findings may not be universally applicable. Before embarking on MIS exenterations, the operating team was very well experienced in standard rectal resections [24], lateral pelvic node dissections [25], and open exenterations [19]. Thus, experience and deconstruction of the complex procedure are key to the successful safe performance of MIS exenterations.

The adoption of MIS for advanced and T4 rectal cancers is growing, and the short-term safety is well-established. However, long-term oncological results are still lacking with available data showing similar outcomes [12]. Although randomized evidence would be ideal, generating such evidence for MIS exenterations is a less likely possibility. A more relevant question today might be to elucidate differences between the MIS approaches. Future research should look into the cost-benefit analysis, patient-reported outcomes, and the long-term benefits vis-à-vis the environmental sustainability between laparoscopic and robotic operations [26]. Finally learning curves of minimally invasive exenterations with recurrence as the outcome can be examined in future studies.

In conclusion, MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.


Ethical statements

The current study is a subgroup analysis of a prospective Institutional Review Board (IRB) approved study (No. 1478). Signed informed consent was obtained from each patient during treatment and surgery. The study protocol followed the ethical standards of the institutional research committee and the 1964 Helsinki Declaration and its later amendments. Separate IRB review exemption was also approved for the present analysis.

Authors’ contributions

Data curation: MK, AD, CN

Formal analysis, Visualization: MK

Investigation, Methodology: MK, AD, AS

Project administration: AD, CN, AS

Writing–original draft: MK

Writing–review & editing: MK, AD, AS

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.



Fig. 1. Patient selection. MIS, minimally invasive surgery.
Fig. 2. Survival curves. (A) Overall survival. (B) Disease-free survival.

Baseline characteristics

Characteristic Data
No. of patients 124
Age (yr) 47 (37–56)
Male 81 (65.3)
Female 43 (34.7)
Rectum 117 (94.4)
Rectosigmoid 7 (5.6)
Performance status, ECOG scale
0 17 (13.7)
1 89 (71.7)
2 12 (9.7)
3 6 (4.8)
Comorbidities, ASA PS classification
I 77 (62.1)
II 44 (35.5)
III 3 (2.4)
Body mass index (kg/m2) 21.82 (19.29–24.09)
Preoperative hemoglobin (g/dL) 11.4 (10.1–12.7)
Preoperative albumin (g/dl) 3.9 (3.4–4.1)
Distance from anal verge (cm) 3 (1–6)
Preoperative diversion 36 (29.0%)
Histologic differentiation
Well-moderate 87 (70.2)
Poorly-differentiated 37 (29.8)
Signet ring cell cancer 17 (13.7)
CEA (ng/mL) 6.05 (3.07–23)
Lateral pelvic nodes 41 (33.1)
Preoperative T stage
T3 18 (14.5)
T4 106 (85.5)
Clinical node positive 118 (95.2)
Extramural vascular invasion (n = 63) 19 (30.2)
M1 stage 12 (9.7)
Site of M1 (n = 12)
Liver 6 (50.0)
Peritoneum 3 (25.0)
Extra-pelvic nodes 2 (16.7)
Lung 1 (8.3)

Values are presented as number only, median (interquartile range), or number (%).

ECOG, Eastern Cooperative Oncology Group; ASA PS, American Society of Anesthesiologists physical status.

Treatment, operative, and postoperative characteristics

Characteristic Data (n = 124)
Preoperative radiation
No 8 (6.5)
Long course chemoradiation 84 (67.7)
Short course chemotherapy 33 (26.6)
Preoperative chemotherapy 66 (53.2)
Total pelvic exenteration 74 (59.7)
Posterior exenteration 36 (29.0)
Bladder sparing exenteration 14 (11.3)
Surgical approach
Laparoscopic 95 (76.6)
Robotic 29 (23.4)
Sphincter preservation 36 (29.0)
Lateral pelvic node dissection 70 (56.5)
Urinary reconstruction
Ileal conduit 72 (58.1)
Sigmoid conduit 4 (3.2)
Supra-pubic catheter 14 (11.3)
Ureteric reimplantation 1 (0.8)
Not applicable 47 (37.9)
Perineal reconstruction (n = 95) 66 (69.5)
Sacrectomy 5 (4.0)
Surgical duration (min) 520 (420–650)
Blood loss (mL) 700 (480–1,300)
Hospital stay (mL) 11 (8–15)
Clavien-Dindo complications
0 48 (38.7)
I 12 (9.7)
II 29 (23.4)
IIIA 14 (11.3)
IIIB 17 (13.7)
IV 1 (0.8)
V 3 (2.4)
Complications, ASA PS grade ≥IIIA; 95% CI 35 (28.2); 20.5%–37.0%
Urinary (n = 91) 13 (14.3)
Bowel (n = 36) 5 (13.9)
Surgical site infection 27 (21.8)
Small bowel obstruction 13 (10.5)

Values are presented as number (%) and median range unless otherwise specified.

ASA PS, American Society of Anesthesiologist physical status; CI, confidence interval.

Pathological and oncological outcomes

Variable Data (n = 124)
Pathological T stage
T0 17 (13.7)
T1/2 9 (7.3)
T3 42 (33.9)
T4 56 (45.2)
Pathological N stage
0 74 (59.7)
1 35 (28.2)
2 15 (12.1)
Nodal yield 15.5 (0–66)
Extranodal extension 17 (13.7)
Lymphovascular invasion 24 (19.4)
Perineural invasion 23 (18.5)
Tumor regression grade (n = 113)
1 17 (15.0)
2 24 (21.2)
3 32 (28.3)
4 32 (28.3)
5 8 (7.1)
Pathological complete response (n = 116) 12 (10.3)
Positive CRM (R1 resection); 95% CI 9 (7.3); 3.4%–13.4%
Adjuvant chemotherapy 87 (70.1)

Values are presented as number (%) and median (range) unless otherwise specified.

CRM, circumferential resection margin.

Oncological outcomes

Variable Data (n = 124)
Follow-up (mo) 15 (10.74–19.76)
Recurrences 44 (35.5)
Pattern of recurrences
Local 8 (6.5)
Distant 32 (25.8)
Peritoneal 10 (8.1)
Sites of distant relapse (n = 32)
Lung 18 (14.5)
Liver 15 (12.1)
Nodal 11 (8.9)
Bone 4 (3.2)
Deaths 17 (13.7)
Disease-free survival (mo) 31 (17.25–47.74)
2 yr 53.7%
Overall survival Not reached
2 yr 85.2%

Values are presented as median (95% confidence interval) or number (%) unless otherwise specified.

  1. Patil PS, Saklani A, Gambhire P, et al. Colorectal cancer in India: an audit from a tertiary center in a low prevalence area. Indian J Surg Oncol 2017;8:484-490.
    Pubmed KoreaMed CrossRef
  2. Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021;406:1763-1774.
    Pubmed CrossRef
  3. Bonjer HJ, Deijen CL, Abis GA, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324-1332.
    Pubmed CrossRef
  4. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007;246:655-624.
    Pubmed CrossRef
  5. Green BL, Marshall HC, Collinson F, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 2013;100:75-82.
    Pubmed CrossRef
  6. Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014;15:767-774.
    Pubmed CrossRef
  7. Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 2015;314:1346-1355.
    Pubmed KoreaMed CrossRef
  8. Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 2015;314:1356-1363.
    Pubmed CrossRef
  9. Stevenson AR, Solomon MJ, Brown CS, et al. Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Ann Surg 2019;269:596-602.
    Pubmed CrossRef
  10. Fleshman J, Branda ME, Sargent DJ, et al. Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg 2019;269:589-595.
    Pubmed KoreaMed CrossRef
  11. PelvEx Collaborative. Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc 2018;32:4707-4715.
    Pubmed CrossRef
  12. Kazi M, Kumar NA, Rohila J, et al. Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes. BJS Open 2021;5:zrab074.
    Pubmed KoreaMed CrossRef
  13. PelvEx Collaborative. Surgical and survival outcomes following pelvic exenteration for locally advanced primary rectal cancer: results from an international collaboration. Ann Surg 2019;269:315-321.
    Pubmed CrossRef
  14. Jaganmurugan R, Kazi M, Sukumar V, et al. Bladder preserving robotic pelvic exenteration for locally advanced rectal cancer-technique and short-term outcomes. J Surg Oncol 2022;125:493-497.
    Pubmed CrossRef
  15. Pokharkar A, Bankar S, Rohila J, Jaiswal D, deSouza A, Saklani A. Laparoscopic posterior pelvic exenteration (complete and supralevator) for locally advanced adenocarcinoma of the rectum in females: surgical technique and short-term outcomes. J Laparoendosc Adv Surg Tech A 2020;30:558-563.
    Pubmed CrossRef
  16. Benson AB, Venook AP, Al-Hawary MM, et al. Rectal cancer, version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018;16:874-901.
    Pubmed CrossRef
  17. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.
    Pubmed KoreaMed CrossRef
  18. Mandard AM, Dalibard F, Mandard JC, et al. Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma: clinicopathologic correlations. Cancer 1994;73:2680-2686.
    Pubmed CrossRef
  19. 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;406:329-337.
    Pubmed CrossRef
  20. 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;12:241-245.
    Pubmed KoreaMed CrossRef
  21. Bankar S, Desouza A, Paliwal V, et al. Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration. Colorectal Dis 2020;22:2322-2325.
    Pubmed CrossRef
  22. déAngelis N, Landi F, Vitali GC, et al. Multicentre propensity score-matched analysis of laparoscopic versus open surgery for T4 rectal cancer. Surg Endosc 2017;31:3106-3121.
    Pubmed CrossRef
  23. Kazi M, Jain D, Padhy AS, et al. Optimal neoadjuvant strategy for signet ring cell carcinoma of the rectum-Is TNT the solution? J Surg Oncol 2021;124:1417-1430.
    Pubmed CrossRef
  24. Kazi M, Sukumar V, Bankar S, Kapadia R, Desouza A, Saklani A. Learning curves for minimally invasive total mesorectal excision beyond the competency phase: a risk-adjusted cumulative sum analysis of 1000 rectal resections. Colorectal Dis 2022 Jul 15 [Epub]. DOI: 10.1111/codi.16266.
    Pubmed CrossRef
  25. Sukumar V, Kazi M, Gori J, et al. Learning curve analysis for lateral pelvic lymph node dissection in rectal cancers: outcomes improve with experience. Eur J Surg Oncol 2022;48:1110-1116.
    Pubmed CrossRef
  26. Papadopoulou A, Kumar NS, Vanhoestenberghe A, Francis NK. Environmental sustainability in robotic and laparoscopic surgery: systematic review. Br J Surg 2022;109:921-932.
    Pubmed CrossRef

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