Beyond Total Mesorectal Excision

Abstract

Objective: Magnetic resonance imaging–based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. Background: Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. Materials and Methods: Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. Results: All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. Conclusions: A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging–defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.

Optimal surgical techniques for curative resection of the rectal cancer

“…The study systematically approached the subject using seven compartments defined by magnetic resonance imaging, identifying crucial anatomical landmarks and key structures that facilitate pelvic exenterative surgery. [35] These compartments include the peritoneal reflection compartment, anterior compartments (above and below for both males and females), central compartment, lateral compartment, posterior compartment, and inferior compartment. It is important to note that beyond TME surgery is typically performed by highly specialized teams who possess a thorough understanding of pelvic compartments and the options and limitations of extended surgical procedures.…”

“…Extenterative surgery represents the sole method for obtaining a tumor-free margin, extending beyond the principles of TME. The work of Stelzner et al [35] presented a pelvic compartment classification based on 13 formalin-fixed pelvis specimens. The study systematically approached the subject using seven compartments defined by magnetic resonance imaging, identifying crucial anatomical landmarks and key structures that facilitate pelvic exenterative surgery.…”

Robotic-Assisted Pelvic Exenteration for Cervical Cancer: A Systematic Review and Novel Insights into Compartment-Based Imaging

“…For locoregional assessment, pelvic magnetic resonance imaging (MRI) has been the preferred imaging technique to determine the tumor size and invasion of surrounding tissues. Recently, MRI-based subdivision of the pelvis into seven compartments has been introduced for planning pelvic exenterations in colorectal cancer patients, reporting high sensitivity for locoregional tumor invasion [22,23]. Positron emission tomography-computed tomography (PET-CT) is the commonly used imaging modality for evaluating the presence of distant metastases.…”

“…In 2023, in Annals of Surgery, the compartment-based anatomy for colorectal cancer was revisited on the basis of MRI studies of 13 pelvic specimens from body donors, of which 6 females, and the anatomical landmarks for each compartment were described in detail [22]. Given that the original and revisited central compartment description for colorectal cancer contains the rectum and mesorectum as well as the pelvic autonomic nerves, the central compartment for persistent or recurrent cervical cancer should contain instead the uterus and cervix with its parametrium, the vagina with its paracolpium, the proximal round ligaments and the uterine/vaginal vessels.…”

Beyond Total Mesorectal Excision (TME)—Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence

“…Georgiou et al established an MRI staging system based on seven pelvic compartments and reported excellent results with respect to diagnostic performance [11]. Meanwhile, the usefulness of the proposed pelvic compartmentation was confirmed on an anatomical base [12].…”