Laparoscopic Anterior Pelvic Exenteration: A Technical Description

Abstract

Introduction: Anterior pelvic exenteration remains a main option for urologic and gynecologic cancers. Although classically performed through an open morbid approach, minimally invasive techniques have been arising. However, due to technical difficulties in this multistage complex procedure, it is still not widely performed when robotics is not available. Thus, we aim to demonstrate that our step-by-step and standardized laparoscopic technique is safe and feasible, even for locally advanced tumours, when keeping fascial plane dissection, anatomical landmarks identification, and procedure decomposition in simple and sequential moves, each one simplifying and assisting the next. Methods: Our key steps are: steep Trendelenburg; ureteral dissection and ligation with Hem-o-loks® with a reference suture; ovarian and uterine’ ligaments section; lateral dissection until endopelvic fascia exposure and vesicovaginal vessels ligation; posterior plane dissection, followed by anterior plane with careful urethra dissection; vaginal closure; lymph node dissection; mesosigmoid tunnelization for left ureter transposition, and ileal reference for urinary diversion. Results: The technique demonstrated was applied to a locally advanced neoplasm. Conclusion: We highlight the safety and efficacy of EPAL even in locally advanced and aggressive tumours, and that it is an achievable surgery when carried out maintaining dissection by planes, following anatomical landmarks, and broken down into simple and sequential steps, each one helping the success of the next.