Using agile development methodology to develop a decision aid for complex rectal cancer.

Female urethral diverticulum carcinoma (UDC) is an exceptionally rare malignancy within the female urogenital system. The reported incidence of urethral diverticulum in females ranges from 0.02% to 6%, with malignant transformation occurring in an even smaller subset of cases. The extreme rarity of this condition has significantly constrained both basic research into its pathogenesis and the accumulation of clinical experience in its management. A 46-year-old Han Chinese female presented with a 2-year history of increased urinary frequency, urgency, and dysuria. Pelvic MRI with contrast enhancement revealed a well-defined neoplastic lesion measuring 4.9 × 4.9 × 5.1cm surrounding the urethra. Urethroscopic examination and radiological evaluation showed a urethral diverticulum suspicious for malignancy. Histopathological analysis of the biopsy specimen indicated papillary carcinoma. The patient underwent anterior pelvic exenteration, ileal conduit urinary diversion, and vaginal reconstruction. Postoperative pathological examination suggested high-grade urothelial carcinoma with glandular differentiation in the urethra, with evidence of invasion into the muscular layer of the bladder wall. UDC presents significant diagnostic challenges due to its nonspecific clinical manifestations and frequent delays in diagnosis, underscoring the importance of comprehensive physical examinations, including meticulous vaginal palpation, and advanced diagnostic procedures, such as cystoscopy with biopsy. The optimal treatment paradigm remains elusive, emphasizing the critical need for further clinical research, enhanced international collaboration, and the establishment of standardized treatment protocols to improve therapeutic outcomes for this rare and clinically challenging disease entity.

The treatment of locally advanced (LARC) and locally recurrent (LRRC) rectal cancers poses significant challenges due to the anatomical complexity and the aggressive nature of tumor invasion. The adoption of multidisciplinary team (MDT) treatment models has become key to improving patient outcomes. Within the MDT framework, advances in imaging and pathology facilitate accurate assessment of disease. In minimally invasive surgery, urinary system reconstruction and pelvic floor reconstruction techniques have significantly improved outcomes for patients undergoing surgery. MDT decision-making plays a particularly important role in the selection of neoadjuvant treatment strategies: The MDT must weigh up the benefits and risks while taking into account the patient's primary disease, as well as their physical and mental condition, and strictly adhere to the indications for pelvic exenteration (PE) surgery. For patients without mesorectal involvement, neoadjuvant chemotherapy alone has demonstrated comparable efficacy to neoadjuvant chemoradiotherapy while exhibiting lower toxicity, but its application in T4b patients requires further validation. In conclusion, the treatment of LARC/LRRC has entered the era of multidisciplinary precision, and the MDT model is the core mechanism for integrating technological innovation and evidence to continuously improve patients' survival and quality of life. The future direction of development under the MDT model focuses on the integration of imaging and liquid biopsy for precise stratification, the optimization of the cost of robotic surgery and the innovation of bioprosthetic materials, the clarification of the optimal preoperative plan through multicenter studies, and exploring immune-based/targeted combination strategies.

With the implementation of surgical techniques, such as total pelvic exenteration, and improvements in perioperative management, an increasing number of patients with locally recurrent rectal cancer (LRRC) are potential targets for curative surgery. Negative pathological margins (R0 resection) and favorable pathological complete response (pCR) have been identified as independent predictors of better oncological outcomes in LRRC. However, achieving R0 resection and optimal tumor regression remain primary concerns and significant challenges for colorectal surgeons. Based on the latest research both domestically and internationally, along with the clinical experience of authors' team, this article provides an overview to enhance the likelihood of achieving R0 resection and pCR from surgical strategies and perioperative therapies, aiming to offer a reference for colorectal surgeons specializing in locally recurrent rectal cancer.

ObjectivesThis study aims to estimate the rate of recruitment of participants.DesignThis is a pilot, multicentre, double-blind, placebo-controlled, randomised controlled trial of oral oxycodone and sublingual placebo vs sublingual buprenorphine and oral placebo for postoperative pain management for 7 days after pelvic exenteration.SettingPatients will be recruited from three metropolitan quaternary referral centres that offer advanced gastrointestinal surgery in Australia.ParticipantsThe inclusion criteria will be patients over the age of 18 years undergoing pelvic exenteration surgery and exclusion criteria are previous adverse events related to the study drugs, currently requiring monoamine oxidase inhibitor medications and if epidural analgesia is planned in the perioperative period.InterventionsEnrolled patients will undergo pelvic exenteration surgery and be initiated postoperatively on patient-controlled analgesia. In the postoperative period, when clinically appropriate to take oral medications, patients will be commenced on trial analgesia for 7 days. Participants will be randomised to receive either oral active oxycodone 5–10 mg up to 3 hourly as required (with sublingual placebo) or sublingual active buprenorphine 200–400 mcg 3 hourly as required (with oral placebo).Main outcome measuresThe primary outcome measure is the rate of recruitment over a 6-month period. Secondary outcomes include an assessment of missing data, protocol adherence and acceptability of the trial to participants.Ethics and disseminationThe trial received ethics approval from Sydney Local Health District, Royal Prince Alfred Hospital Human Research Ethics Committee (No: X25-0128 & 2025/ETH01058). The results of the study will be disseminated by publication and presentation at local annual scientific meetings in Australia.Trial registration numberThe study protocol is prospectively registered at the Australian New Zealand Clinical Trials Registry (ANZCTR) (www.anzctr.org.au; ACTRN12625000901404).

Pelvic exenteration (PE) has evolved from a palliative "procedure of desperation" into a potentially curative operation for selected patients with locally advanced or recurrent pelvic malignancy. Christchurch Hospital has delivered PE for more than three decades and has been an active contributor to the international development of these procedures. Retrospective description of the Christchurch PE programme and its evolution since the mid‑1990s, contextualised against contemporary multicentre evidence, is provided. Service components evaluated include multidisciplinary governance, patient selection, operative strategies for posterior and lateral compartment disease (including sacrectomy), peri‑operative optimisation and survivorship pathways. Since 1995, Christchurch has undertaken over 520 multivisceral pelvic resections. Centralisation of complex patient care supports operative volume, consistency of team performance and benchmarking against international standards. Prospective audits with collaborative international research have strengthened the understanding of what drives good oncological outcomes (particularly the impact of R0 resection), as well as morbidity patterns in high‑risk sub-groups, feasibility of repeat PE and patient‑reported outcomes including quality of life. A centralised multidisciplinary programme can safely deliver ultra‑complex pelvic oncology surgery. Continued international collaboration and systematic capture of patient‑reported outcomes will define the next phase of PE service development.

Pelvic exenteration for cervical cancer - Oncologic outcome and long-term health-related quality of life, a mixed methods study.

The present study aims to evaluate the current data regarding the clinical outcomes of patients undergoing pelvic exenteration with major vascular resection and reconstruction. This study was conducted according to the PRISMA guidelines and the Cochrane handbook. Scholar databases were systematically screened. The last search date was March 2026. The primary endpoint was the overall complications rate. Secondary endpoints included specific postoperative complications, oncological outcomes of interest, and perioperative efficacy metrics. Random Effects (RE) models were reported. Overall, 6 studies and 69 patients were included in this study. Pooled complications rate was 57.9% (95% CI: 32.2%-83.6%, p = 0.003). Overall vessel thrombosis and reoperation rates were estimated to be 16.5% (p = 0.008) and 21.7% (p = 0.011). The reported reoperated cases included hemostasis n:13, stent placement n:3, thrombectomy n:2, fasciotomies n:2 and amputation n:1. R0 resection margin was achieved in 58.2% (p = 0.002) of patients. It was shown that in cases with a primary tumor R0 rate was 50% (p = 0.295), while in the recurrent malignancies this dropped to 42% (p = 0.364). Two patients had local relapse at 15 and 25 months while distal metastasis related mortality developed in two patients at 14 and 22 months after surgery. In total, the pooled local recurrence rate was 20% (p = 0.002). We estimated a significant overall morbidity burden with increased risk for loss of vascular patency and reoperation and suboptimal oncological outcomes. Despite this, cases with pelvic confined disease that require vascular reconstruction can still be amendable in curative surgery following multidisciplinary assessment.

Pelvic exenteration (PE) is a complex, potentially curative option for locally advanced or recurrent pelvic malignancies in which achieving an R0 margin is paramount. This clinical review provides a pragmatic, anatomy-driven framework to optimize preoperative assessment and multidisciplinary planning. Using a compartment-based schema-central, anterior, posterior, and lateral-the article maps tumour spread to structures that determine technical feasibility and functional outcomes. For each compartment, surgical implications and reporting "pearls and pitfalls" are summarized to ensure radiological interpretation directly informs surgical decision-making. Special attention is given to differentiating tumour infiltration from post-treatment fibrosis, particularly following chemoradiotherapy, where diffusion-weighted MRI plays an important role in the attempt to differentiate residual disease from fibrosis and defining safe resection planes. The review outlines assessment of critical anatomical structures or variants that have implications for surgical planning or functional consequences for patients. In addition, reconstructive options and their imaging appearances are briefly discussed to aid postoperative assessment. Through detailed anatomical analysis and structured, compartment-based reporting, radiologists can enhance multidisciplinary communication, refine patient selection, anticipate morbidity, and ultimately increase the likelihood of achieving complete resection in pelvic exenteration.

Pelvic exenteration (PE) remains one of the most radical procedures in gynaecological oncology and is associated with substantial morbidity and long-term complications. We aimed to synthesise evidence on short and long-term QoL outcomes following PE for advanced or recurrent gynaecological malignancies. A systematic review was conducted using a prospectively registered protocol and reported in accordance with PRISMA guidelines. MEDLINE, Embase, PubMed and the Cochrane Library were searched from inception to October 2025. Eligible studies reported on one or more patient outcomes, including generic health QoL, sexual function, body image, menopausal symptoms and/or psychological distress. Risk of bias was assessed using ROBINS-I. Qualitative data synthesis was undertaken. A total of 23 studies comprising 1,655 patients were included, of whom 746 contributed QoL data. No randomised trials were identified. There were equal numbers of prospective and retrospective studies (11/23 each), and 17/23 studies carried a serious risk of bias. Global QoL trajectories were variable in the early postoperative period, with 2/9 studies reporting deterioration, 3/9 stability and 4/9 improvement within the first six months. Beyond six months, most studies (5/9) demonstrated stabilisation or recovery (3/9) of QoL. In contrast, domain-specific morbidity was common and persistent. Sexual function deteriorated in 11/14 studies, body image worsened in 8/12 studies (often associated with stoma formation) and psychological distress increased in all studies assessing this outcome. Dual stomas, infra/trans-levator resections and adjuvant radiotherapy were associated with poorer QoL, while vaginal reconstruction was associated with improved outcomes. PE may permit acceptable long-term global QoL in selected women; however, this is frequently achieved at the cost of sustained sexual, body image and psychological morbidity. Multidimensional QoL assessment should be integral to patient selection, counselling and survivorship care. There is an imminent need for future prospective studies with standardised longitudinal QoL.

Extended pelvic exenteration (EPE) is a key therapeutic strategy for locally advanced or recurrent rectal cancer. However, conventional postoperative assessments-including histopathology, serum tumor markers, and standard imaging-are limited by low sensitivity and a considerable temporal lag in detecting residual disease. Detection of molecular residual disease (MRD) via circulating tumor DNA (ctDNA) may provide a reliable biomarker to enable more precise postoperative management following EPE. This study evaluates the utility of ctDNA-based MRD assessment in determining molecular R0 resection status and in monitoring disease recurrence after pelvic exenteration for rectal cancer. Between May 2022 and October 2023, a real-world study was conducted involving 100 patients with locally advanced or recurrent rectal cancer without evidence of distant metastasis who underwent radical resection at Shanghai Changzheng Hospital. Peripheral blood samples were collected preoperatively, postoperatively, following adjuvant therapy, and at 3-month intervals thereafter. MRD status was assessed using a personalized, tumor-informed panel based on whole-exome sequencing of the primary tumor. The cohort comprised 52 male patients (52%), with a mean (standard deviation) age of 50.8 (13.24) years. While all patients achieved pathologically negative margins, the postoperative MRD positivity rate (MRD1) remained at 35%, increasing to 41% following adjuvant therapy (MRD2). Over a median follow-up of 745 days (95% confidence interval, 697-793days), the 1-year and 2-year disease-free survival (DFS) rates were 85.0% and 71.9%, respectively. Positivity at the MRD1 and MRD2 timepoints conferred an 8-fold and a 60-fold increased risk of recurrence, respectively, compared with MRD-negative status. Notably, MRD positivity detected tumor recurrence or metastasis significantly earlier than radiological confirmation, with a median lead time of 361 days (interquartile range, 158.5-468 days). ctDNA-based MRD detection demonstrates substantial clinical utility for recurrence surveillance and prognostic stratification. Postoperative MRD status provides a more accurate reflection of molecular R0 resection than conventional pathological margin assessment. Furthermore, MRD status upon completion of initial adjuvant therapy serves as an early indicator of therapeutic efficacy and a robust predictor of long-term prognosis.

To investigate trends in radical hysterectomy being performed by gynecologic oncology fellows in the United States. Summary statistics for Accreditation Council for Graduate Medical Education (ACGME) programs were obtained from the ACGME public reporting system. For each academic year spanning 2019-2020 through 2024-2025, the national mean procedure count was extracted for radical hysterectomy. Over the past 5 years, there has been a significant decline in the number of radical hysterectomies being performed by fellows in the United States. Gynecologic oncology training number in radical hysterectomy has declined. This decline has implications that extend to training in other radical pelvic operations, including lymphadenectomy, cytoreductive surgery, and exenteration.

Background/Objectives: We evaluated perioperative morbidity, recurrence patterns and survival outcomes following pelvic exenteration (PE) at a tertiary referral centre. Methods: A retrospective observational study was conducted in women undergoing PE from 2004 to 2024. We collected demographics, performance status (PS), comorbidities, body mass index (BMI), tumour histology, intraoperative details, postoperative morbidity (Clavien–Dindo classification), mortality, length of stay (LOS), recurrence patterns and cancer-related death. Descriptive statistics were performed alongside Kaplan–Meier survival analysis. Results: Forty-seven patients underwent PE; median PS was 0 [interquartile range (IQR) 0–0]. Median ages at diagnosis and surgery were 55 (IQR 49–66) and 60 (IQR 50–68) years, respectively, with a median follow-up of 26 months (IQR 12–64). Thirty-two procedures (68%) were performed for recurrent and N = 15 (32%) for primary disease. Histology included N = 17 endometrial (36%), N = 10 vulval (23%), ovarian (15%), N = 5 cervical (11%) and N = 7 vaginal (15%) cases. Eighteen patients (38%) underwent total PE, N = 15 (32%) anterior PE and N = 14 (30%) posterior PE. Median blood loss was 1.5 L (IQR 0.85–2.0) and median operative time was 391 mis (IQR 313–482). Median HDU stay was 4 days (IQR 2–5) and LOS was 17 days (IQR 13–31). One postoperative death occurred. Major complications (Clavien–Dindo ≥3) occurred in 15 patients (32%). Late complications occurred in n = 17 (36.2%) women. Nineteen patients (41%) remained recurrence-free; N = 4 (9%) developed local and N = 24 (51%) distant recurrence. Mean overall survival time post-surgery for curative intent PE (N = 46) was 94 months (95%CI = 57–131 months); for primary tumours this was 51.6 (95%CI = 31–72) vs. 99 (56.01–142) for recurrent disease (p > 0.05). Conclusions: Pelvic exenteration is associated with acceptable morbidity and mortality in carefully selected patients, offering excellent locoregional disease control.

Advances in chemotherapy have shifted the treatment paradigm for colorectal cancer from surgical intervention to medical treatment. We report the outcomes of laparotomy following total pelvic exenteration (TPE) and describe specific methods for preventing ileal conduit injury. Eighteen patients underwent a total of 29 laparotomies after TPE. Laparotomies were categorized into three types "Recurrence surgery", "Complication surgery (early complications and late complications)", and "Palliative surgery". Ileal conduit preservations were categorized into Category A (Retrograde catheterization), Category B (Internal stenting via nephrostomy), and Category C (Sustained stenting after TPE). Among the seven recurrence surgeries, four (57.1%) involved tumor resection with ostectomy and three (42.9%) involved tumor resection alone. Among the seven early complication surgeries, colostomy and drainage for peritonitis due to perforation was the most common procedure (3/7, 42.9%). Among the eight late complication surgeries, ileal conduit reconstruction was most common (3/8, 37.5%). Among the seven palliative surgeries, bypass surgery was the most frequent procedure (5/7, 71.4%). The distribution of ileal conduit preservation strategies differed significantly according to surgery type: recurrence surgery, Category A 28.6%, Category B 28.6%, none 42.8%; early complication surgery, Category C 100.0%; late complication surgery, Category A 37.5%, Category B 50.0%, none 12.5%; and palliative surgery, Category B 14.3%, Category C 14.3%, none 71.4% (p<0.0001). Laparotomy after TPE appears to be a feasible and acceptably safe option when performed with appropriate precautions, particularly with strategies aimed at preserving the ileal conduit.

Neoadjuvant treatment response and oncologic outcomes after pelvic exenteration for locally advanced rectal cancer.

The utility of cardiopulmonary exercise testing (CPET) in predicting perioperative outcomes for patients undergoing complex rectal cancer surgery.

Women with vulvar cancer are considerably older than those with other gynaecological malignancies, raising concerns about the tolerability of radical surgery. Yet, for locally advanced or recurrent disease, pelvic exenteration may be the only curative option. Robust evidence to guide decision-making in this population is lacking. This multicentre observational cohort study used data from the COREPEX registry including women who underwent anterior or total pelvic exenteration between 2005 and 2023 across 20 European tertiary referral centres. The primary outcome was overall survival (OS); secondary outcomes were progression-free survival (PFS) and major postoperative complications. Associations were assessed using multivariable Cox and binomial regression models adjusted for relevant covariates. Among 861 women, 79 (9.2%) had vulvar cancer. Median follow-up was 49 months for OS and 40 months for PFS. Women with vulvar cancer were older and more often overweight. Five-year OS was 32% (95% CI, 19-46) in vulvar cancer versus 29% (95% CI, 25-34) in other cancers, adjusted HR 1.05 (95% CI, 0.75-1.46). Five-year PFS was 34% versus 29%, adjusted HR 0.96 (95% CI, 0.69-1.34). Major complications occurred in 33% vs 29%, adjusted RR 1.12 (95% CI, 0.77-1.58). Lymph node metastases, positive margins, and recurrent or persistent disease independently predicted poorer survival. Despite their older age, women with vulvar cancer had survival and morbidity comparable to those with other gynaecological malignancies. These findings support pelvic exenteration as a curative option for selected women with vulvar cancer when complete resection is feasible.

Advancements in the multidisciplinary management of locally advanced and recurrent rectal cancer, as well as advanced pelvic malignancies, have significantly improved oncological outcomes. Pelvic exenteration is a complex procedure involving en bloc resection of the involved organs with the aim of achieving a microscopic negative margin (R0)1. Since 2012, the Royal Brisbane and Women's Hospital (RBWH) has been performing pelvic exenteration surgery and is now the statewide referral centre in Queensland. This study aims to present our oncological and surgical outcomes since establishment. This is a retrospective cohort study utilising data collected from medical records of patients who underwent pelvic exenteration at the RBWH between 1 January 2012 and 31 August 2023. Ethics approval was obtained from the Metro North Hospital and Health Service Human Research Ethics Committee (HREC 102257). A total of 139 patients underwent pelvic exenteration surgery over the 11-year period. 117 of those were total exenteration, 22 were partial. The indications were locally advanced rectal cancer (56.8%), locally recurrent rectal cancer (22.3%), other primary or recurrent malignancy or benign, (10.8%, 7.9%, 2.2% respectively). The proportion of patients with an R0 resection was 90.4%. The overall survival (using Kaplan-Meier analysis) at 1, 2 and 5 years was 89.9%, 82.0%, and 62.9%, respectively. Disease-free survival at 1, 2 and 5 years was 76.1%, 67.0% and 59.2%. Disease-specific survival at 1, 2 and 5 years was 92.7%, 83.8% and 66.8%. Our results were comparable to national data and PelvEx Collaborative group data and demonstrate that pelvic exenteration surgery can be safely performed in a lower volume centre with equivalent outcomes to higher volume centres.

Post-operative mobilisation and mobility outcomes after pelvic exenteration surgery for colorectal cancer.

The Inflammatory Biomarkers Prognostic Index (IBPI) obtained from standard preoperative blood tests predicts postoperative complications in patients undergoing pelvic exenteration for locally recurrent rectal cancer.