










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Prostate neoplasms, cystectomy, pelvic 
exenteration, prostatectomy, salvage therapy

None declared. Received on January 8, 2022 
Accepted on February 26, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(3):163–183

DOI: 10.48083/KGMI7850

163SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

REVIEW

The Role of Pelvic Exenteration in the Management 
of Locally Advanced Prostate Cancer

Ala’a Farkouh,1 Nassib Abou Heidar,2 Ryan W. Dobbs,3  Ibrahim Abu-Gheida,4 Muhammad Bulbul,2  
Mohammed Shahait1 

1 Department of Surgery, King Hussein Cancer Center, Amman, Jordan 2 American University of Beirut Medical Center, Beirut, Lebanon   
3 Cook County Health and Hospitals System, Chicago, United States 4 Burjeel Cancer Institute, Burjeel Medical City, United Arab Emirates

Abstract

Locally advanced prostate cancer poses a clinical challenge for physicians. Despite the established role of radiotherapy 
and androgen-deprivation therapy in these cases, some patients with locally advanced disease experience recurrent 
disease or persistent disease with debilitating local symptoms, such as intractable pain and urinary symptoms. In 
this narrative review, we sought to evaluate the role of exenterative surgery in the management of locally advanced 
prostate cancer. From our search, we found that total pelvic exenteration or cystoprostatectomy represents a viable 
therapeutic modality to manage prostate cancer directly invading the bladder, lower urinary tract symptoms, 
debilitating pain caused by locally advanced disease, and as salvage treatment after failure of primary treatment 
among other applications. Reports on minimally invasive pelvic exenteration for prostate cancer were also retrieved, 
as this represents a feasible and effective treatment option for experienced clinicians. Pelvic exenteration may be an 
effective tool for the treatment of locally advanced prostate cancer in the surgeon’s armamentarium; however, further 
studies are needed to establish its role in improving survival and overall patient outcomes.

Introduction

While there is no single definition of locally advanced prostate cancer (LAPca), it is generally understood to be disease 
extending beyond the prostatic capsule (T3 and T4 disease)[1–3]. The European Association of Urology (EAU) defines 
locally advanced prostate cancer as clinical cT3–cT4 or disease with positive lymph nodes (cN1)[1]. This issue has 
become particularly pertinent in recent years as a shift towards LAPca has been observed following the United States 
Preventative Task Force recommendation against routine prostate cancer screening in 2012[4].

Although there is no consensus among urologists, oncologists, and radiation oncologists on the management of 
LAPca, the survival benefit of radiotherapy (RT) combined with androgen-deprivation therapy (ADT) has been well 
established, and it has been consistently used for the treatment of LAPca[5,6]. The role of surgery in the treatment of 
this condition is more controversial but has been an area of intense investigation in recent years.

A meta-analysis demonstrated significant survival improvement with radical prostatectomy (RP) in LAPca, 
and when RP was combined with adjuvant radiotherapy, survival rates were comparable to those seen with RT and 
ADT[7]. The survival benefit of surgery for T4 disease in men aged < 50 years was described by Hsiao et al., who 
suggested that RP should be offered to men in that age group as part of a multimodal treatment approach[8].

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https://orcid.org/0000-0002-0362-9109
https://orcid.org/0000-0003-3811-5543
https://orcid.org/0000-0003-1397-7307
https://orcid.org/0000-0003-2609-5629


Kim et al. stressed the importance of local treatment 
of the primary tumor in T4 prostate cancer with surgery, 
RT, or a combination of both compared to systematic 
therapy with ADT or chemotherapy, and reported 5-year 
survival rates of 57.8% for local therapy versus 33.2% 
for systematic therapy[9]. Given the high rates of posi-
tive surgical margins, recurrence, and occult systemic 
metastasis in LAPca, a combination of surgery with 
either adjuvant or neoadjuvant RT has been described in 
the literature as having improved outcomes[10].

Bot hersome pelv ic sy mptoms a re f requent ly 
encountered in the management of patients LAPca. 
For instance, up to two-thirds of men diagnosed with 
castrate-sensitive prostate cancer (CSPC) experience 
pelvic symptoms, including perineal pain, lower urinary 
tract symptoms (LUTS), and urinary tract obstruc-
tion[11]. Men dying of prostate cancer experience a high 
incidence of urological complications[12]. Fifty percent 
of men dying of metastatic prostate cancer suffer from 
LUTS, 21% undergo lower urinary tract procedures, 
and 8% undergo upper urinary tract interventions[13]. 
In another report, 25% of prostate cancer patients who 
underwent palliative transurethral resection of the 
prostate required repeat TURP after a mean duration 
of 11 months[14]. LAPca can lead to chronic pelvic pain 
requiring opioid medications, as well as bladder outlet 
obstruction requiring catheterization or renal failure 
requiring urinary diversion or ureteral stenting. While 
these sequelae might not lead to increased cancer-spe-
cific mortality, they decrease the quality of life (QoL) of 
affected patients[15].

Pelvic exenteration is an extensive surgery that 
involves the removal of pelvic organs to treat pelvic 
malignancies[16]. It was first described by Brunschwig in 
1948 for the management of gynecological cancers[17]. 
Currently, pelvic exenteration is most commonly 
performed for gynecological and locally advanced rectal 
tumors[18]. Total pelvic exenteration involves removal 
of the bladder, reproductive organs, sigmoid colon, and 
rectum, and creation of diversions for urine and stool. 
Variations include anterior pelvic exenteration, which 
spares the rectosigmoid, and posterior pelvic exen-

teration, which spares the bladder[19]. Pelvic exenter-
ation has also been described in the management of 
other pelvic tumors such as bladder cancer and pelvic 
sarcomas[20,21].

In this review, we aim to evaluate the role of cysto-
prostatectomy and pelvic exenteration in patients with 
LAPca by highlighting the various indications, compli-
cations, and outcomes reported in published studies, 
and to identify gaps in the literature that may be a focus 
for future studies.

Methods
This review is structured as a narrative review in 
accordance with the scale for the assessment of narrative 
review (SANRA) criteria[22].

A comprehensive literature search was performed by 
2 authors using PubMed from 1980 to 2021. The search 
string used was ([prostate cancer] AND [pelvic exenter-
ation] OR [cystoprostatectomy] OR [cysto-prostatec-
tomy]). Filters included only English language papers, 
human subjects, and the following types of articles: case 
reports, classical articles, clinical studies, clinical trials, 
clinical trial protocols, clinical trials, comparative stud-
ies, controlled clinical trials, guidelines, journal arti-
cles, meta-analyses, multicenter studies, observational 
studies, practice guidelines, randomized controlled 
trials, reviews, and systematic review papers. The arti-
cles yielded from the final search were first screened by 
title, then abstract, and finally by full text. Articles on 
prostate sarcomas and non-adenocarcinoma tumors and 
articles on pelvic exenteration performed for non-pros-
tate pelvic tumors were excluded. Letters to the editor, 
opinions, abstracts, summaries, videos, and reports in 
non-English languages were excluded. Finally, a manual 
search was conducted from the selected articles and 
search engines.

The included articles were then evaluated to extract 
the following data: number of patients included, type 
of exenteration surgery, the indication for exenteration, 
neoadjuvant or adjuvant treatments, operative outcomes 
(blood loss, blood transfusions, length of surgery, hospi-
tal stay), complications (including 30-day morbidity and 
mortality when reported), R0 resection, follow-up and 
the reported long-term survival outcomes.

Results
Following our search criteria, 529 articles were extracted 
and screened by title; 473 papers were excluded.  
A total of 56 abstracts were screened, and 23 papers were 
excluded. Thirty-three full-text articles were reviewed, 
of which 4 were excluded. Five articles were retrieved by 
a manual search, yielding a total of 34 articles included 

Abbreviations 
ADT androgen-deprivation therapy
CRPC castrate-resistant prostate cancer
LAPca locally advanced prostate cancer
LUTS lower urinary tract symptoms
QoL quality of life
RP radical prostatectomy
RT radiotherapy

164 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

 REVIEW

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in our results. The article screening process, the numbers 
included and excluded, and the reasons for exclusion are 
summarized in Figure 1.

In our review, pelvic exenteration for prostate cancer 
has been described in different settings based on 
different indications. The majority of retrospective 
studies reporting the indications, complications, and 
outcomes of pelvic exenteration for prostate cancer 
are summarized in Table 1[23–42]. Table 2[43–48] 
summarizes the reported cases of minimally invasive 
pelvic exenteration for prostate cancer, whether 
laparoscopic or robot-assisted.

Cystoprostatectomy for prostate cancer 
invading the bladder
Cystoprostatectomy can be performed to control 
LUTS in prostate cancer invading the bladder and 
has been described as a palliative treatment option for 
LUTS after failure of other treatments or as a primary 
treatment option for prostate cancer invading the 
bladder[49]. Leibovici et al. demonstrated that palliative 
cystoprostatectomy alleviated LUTS in 68% of patients 
with prostate cancer invading the bladder, whether 
primary or recurrent after radiotherapy, and reported 
significant relief of all local pain and LUTS, as well as 
the need for palliative lower urinary tract procedures 

Initial PubMed Search
after applying �lters

n = 529 articles

Screening articles 
by title

n = 56 articles remaining

Screening articles 
by abstract

n = 33 articles remaining

Full-text article 
screening

n = 29 articles remaining

Total number of articles 
included in narrative review

n = 34

Excluded articles (n = 4)

• Exenteration not done for 
 prostate cancer (n = 2)

• Prostate carcinosarcoma 
 case (n = 1)

• Summary article (n = 1)

Articles retrieved by manual
search from other articles 

or search engines n = 5

FIGURE 1. 

The flowchart summarizes the screening process for article inclusion in this narrative review. Numbers of articles 
screened at each phase, the reasons for exclusion, and the final number of articles included are demonstrated in  
the flowchart.

165SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

The Role of Pelvic Exenteration in the Management of Locally Advanced Prostate Cancer

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Mador  
et al. 
(1985)

7
Radical prostatectomy (4)
Cystoprostatectomy (3) 

Salvage surgery after 
local recurrence of 
prostate cancer after 
failure of radiotherapy 
with no metastasis (7)

– NR Mean 5.3 units Mean 4.9h Mean 10 days
30-day mortality 1/7
30-day morbidity 5/7
Late post-op 
complications 2/7

NR – –

6/7 patients alive at 
3–22 months post-op
1/7 developed metastasis  
1 year after CP

Moul  
et al.  
(1991)

22

Radical perineal  
prostatectomy (4)
Cystoprostatectomy with 
urinary diversion: ileal 
conduit (5),
Koch pouch (3)

Salvage surgery for 
recurrent prostate 
cancer after  
radiotherapy (12)

–

RPP: Mean 
800 ml 

CP: Mean 
3190 ml (CP)

RPP: NR 

CP: Mean  
6 units

RPP: Mean 
4h20min 

CP: Mean 
8h20min 

RPP: average  
23 days

CP: average  
21.7 days

RPP: 4/4 
reported post-op 
complications, 
including wound 
infection, urosepsis, 
urine leak
CP and Koch pouch: 
3/3 reported post-
op complications, 
including urinoma 
requiring urinary 
diversion, urosepsis, 
SBO, pneumonia
CP and ileal 
conduit: no reported 
complications

5/12 
(41.7%)

Mean  
49 months –

4/12 no evidence of disease 
recurrence at follow-up
5/12 only elevated PSA  
at follow-up

Failure rate of 
salvage surgery after 
radiotherapy is higher 
than standard radical 
prostatectomy for 
localized prostate 
cancer (control) but not 
statistically significant

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (8), 
Koch pouch (1)
Pelvic exenteration  
with colostomy and  
ileal conduit (1)

Locally advanced 
prostate cancer not 
amenable to standard 
radical prostatectomy 
(10) 

5 of 10 patients 
received 

neoadjuvant 
treatment

Mean  
2890 ml

Mean  
7.3 units

 

Mean  
8h

NR

6/10 reported  
post-op complications 
including 
haemorrhage  
requiring  
re-exploration,  
SBO, presacral 
abscess, Ileus,  
MI, rectal laceration 

3/10 
(30%)

Mean  
59 months –

6/10 developed metastasis 
and required ADT
1/10 no evidence of disease 
recurrence at follow-up
1/10 only elevated PSA at 
follow-up

CP had a significantly 
higher failure rate 
than standard radical 
prostatectomy controls

Zincke   
et al. 
(1992)

62

Radical prostatectomy (32)
Cystoprostatectomy with 
ileal conduit (23)
Total pelvic exenteration (7)

Salvage surgery after 
radiation failure, no 
distant metastasis in 
all patients at time of 
surgery (62)

22 patients (35%) 
received hormonal 
treatment before 

surgery

NR

RP: median 1.5 units, 
range 0–20

CP: median 1 unit, 
range 0–12

TPE: median 4 units, 
range 3–6

RP: median 3.1h, 
range 1.5–5

CP: median 4.7h, 
range3-7.5

TPE: median 
5.5h, range 

3.9–8

RP: median 11.5 
days, range 5–23

CP: median 12 
days, range6–34

TPE median 
20 days, range 

12–45

RP: 30-day morbidity 
10/32, 18/32 
developed late 
complications
CP: 30-day morbidity 
10/23, 8/23 
developed late 
complications
TPE: 6/7 developed 
complications with a 
total of 16 reported 
complications and 
some patients 
experiencing several 
complications

RP: 24/32 
(75%)

CP: 15/23 
(65%)

TPE: 4/7  
(53%)

–

17 patients 
(27%) received 

hormonal 
treatment after 

surgery

Overall 5-year survival  
rate: 68%

RP group had survival 
advantage and less 
recurrence compared to 
exenteration groups  
(higher residual  
cancer rates)

Among the RP group, 
those who received 
adjuvant hormonal 
therapy had significantly 
less progression than 
those who did not

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

166 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

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TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Mador  
et al. 
(1985)

7
Radical prostatectomy (4)
Cystoprostatectomy (3) 

Salvage surgery after 
local recurrence of 
prostate cancer after 
failure of radiotherapy 
with no metastasis (7)

– NR Mean 5.3 units Mean 4.9h Mean 10 days
30-day mortality 1/7
30-day morbidity 5/7
Late post-op 
complications 2/7

NR – –

6/7 patients alive at 
3–22 months post-op
1/7 developed metastasis  
1 year after CP

Moul  
et al.  
(1991)

22

Radical perineal  
prostatectomy (4)
Cystoprostatectomy with 
urinary diversion: ileal 
conduit (5),
Koch pouch (3)

Salvage surgery for 
recurrent prostate 
cancer after  
radiotherapy (12)

–

RPP: Mean 
800 ml 

CP: Mean 
3190 ml (CP)

RPP: NR 

CP: Mean  
6 units

RPP: Mean 
4h20min 

CP: Mean 
8h20min 

RPP: average  
23 days

CP: average  
21.7 days

RPP: 4/4 
reported post-op 
complications, 
including wound 
infection, urosepsis, 
urine leak
CP and Koch pouch: 
3/3 reported post-
op complications, 
including urinoma 
requiring urinary 
diversion, urosepsis, 
SBO, pneumonia
CP and ileal 
conduit: no reported 
complications

5/12 
(41.7%)

Mean  
49 months –

4/12 no evidence of disease 
recurrence at follow-up
5/12 only elevated PSA  
at follow-up

Failure rate of 
salvage surgery after 
radiotherapy is higher 
than standard radical 
prostatectomy for 
localized prostate 
cancer (control) but not 
statistically significant

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (8), 
Koch pouch (1)
Pelvic exenteration  
with colostomy and  
ileal conduit (1)

Locally advanced 
prostate cancer not 
amenable to standard 
radical prostatectomy 
(10) 

5 of 10 patients 
received 

neoadjuvant 
treatment

Mean  
2890 ml

Mean  
7.3 units

 

Mean  
8h

NR

6/10 reported  
post-op complications 
including 
haemorrhage  
requiring  
re-exploration,  
SBO, presacral 
abscess, Ileus,  
MI, rectal laceration 

3/10 
(30%)

Mean  
59 months –

6/10 developed metastasis 
and required ADT
1/10 no evidence of disease 
recurrence at follow-up
1/10 only elevated PSA at 
follow-up

CP had a significantly 
higher failure rate 
than standard radical 
prostatectomy controls

Zincke   
et al. 
(1992)

62

Radical prostatectomy (32)
Cystoprostatectomy with 
ileal conduit (23)
Total pelvic exenteration (7)

Salvage surgery after 
radiation failure, no 
distant metastasis in 
all patients at time of 
surgery (62)

22 patients (35%) 
received hormonal 
treatment before 

surgery

NR

RP: median 1.5 units, 
range 0–20

CP: median 1 unit, 
range 0–12

TPE: median 4 units, 
range 3–6

RP: median 3.1h, 
range 1.5–5

CP: median 4.7h, 
range3-7.5

TPE: median 
5.5h, range 

3.9–8

RP: median 11.5 
days, range 5–23

CP: median 12 
days, range6–34

TPE median 
20 days, range 

12–45

RP: 30-day morbidity 
10/32, 18/32 
developed late 
complications
CP: 30-day morbidity 
10/23, 8/23 
developed late 
complications
TPE: 6/7 developed 
complications with a 
total of 16 reported 
complications and 
some patients 
experiencing several 
complications

RP: 24/32 
(75%)

CP: 15/23 
(65%)

TPE: 4/7  
(53%)

–

17 patients 
(27%) received 

hormonal 
treatment after 

surgery

Overall 5-year survival  
rate: 68%

RP group had survival 
advantage and less 
recurrence compared to 
exenteration groups  
(higher residual  
cancer rates)

Among the RP group, 
those who received 
adjuvant hormonal 
therapy had significantly 
less progression than 
those who did not

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

continued on page 168

167SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

The Role of Pelvic Exenteration in the Management of Locally Advanced Prostate Cancer

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Ahlering  
et al. 
(1992)

34

Prostatectomy (10)
Cystoprostatectomy  
with urinary diversion (22): 
ileal conduit (8), continent 
cutaneous diversions (14)
Cystoprostatectomy and 
LAR (1)
Total pelvic exenteration (1)

Salvage surgery after 
failure of radiotherapy 
and no distant 
metastasis (34)

– NR NR NR

RP: mean 7.6 
days, range 6–12

Exenteration: 
mean 11 days, 

range 7–16 

2 patients of the 
cystoprostatectomy 
group developed 
complications (ileus 
and SBO, requiring 
exploration and 
adhesolysis)

NR
Mean 109 

months post 
radiotherapy

27/34 (79%) 
received 

perioperative 
adjuvant 
hormonal 
therapy

24/34 alive without disease 
2 have elevated PSA

10/34 developed recurrence  
7 of whom died from disease

Pontes  
et al. 
(1993)

43
Prostatectomy (35)
Cystoprostatectomy (8)

Salvage surgery  
after failure of 
radiotherapy (43)

26 received 
hormonal surgery 
before or after 
surgery

CP: NR CP: NR CP: NR CP: NR

CP: 2 rectal 
perforations intra-op 
repaired primarily and 
1 death from PE 

No significant late 
morbidity reported for 
those who underwent 
CP

13/43 
(30.2%)

Range 1–10 
years

26 received 
hormonal 

surgery before 
or after surgery

6/9 died from metastasis
34 were alive:
• 10/34 no evidence of 

disease
• 15/34 elevated PSA
• 4/34 too early to evaluate
• 5/34 has metastasis

No influence of hormonal 
therapy on survival was 
seen

Lerner  
et al. 
(1995)

132

Radical prostatectomy  
(79–90%)
Cystoprostatectomy  
(38–29%)
Total pelvic exenteration 
(5–4%)
PLND alone (10–7%) 

Salvage surgery 
after failure of local 
radiotherapy and no 
distant metastasis, 
low co-morbidity and 
10-year life expectancy 
(132)

– NR

RP: median 1 unit, 
range 0–22

CP: median 2 units, 
range 0–22

TPE: median 9.5 units, 
range 7–97

PLND: median 1 unit, 
range 0–2

NR

RP: median 8 
days, range 2–44

CP: median  
12 days, range 

8–34

TPE: median 
20 days, range 

12–45

PLND: median  
8 days, range 

5–15

RP: 35 (44%) 
complications 
reported

CP: 12 (31.6%) 
complications 
reported

TPE: 6 complications 
reported (some 
patients experienced 
more than one)

PLND: 4 (40%) 
complications 
reported

NR –

80 (61%) 
received 
adjuvant 

perioperative 
hormonal 
therapy

Generally, overall survival 
and cause-specific survival 
was significantly higher for 
the RP group compared to 
the exenteration groups (due 
to a higher proportion of 
patients with organ-confined 
disease as well as a higher 
proportion of non-aneuploid 
cancer in the RP group)

Adjuvant hormonal 
therapy was associated 
with higher progression-
free survival in patients 
with non-aneuploid 
tumors

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

after surgery[42]. Similarly, Sato et al. reported effective 
control of LUTS in all patients who under went 
cystoprostatectomy as a primary treatment for LAPca 
and found no significant difference in QoL or overall 
survival compared with RP in those without bladder 
neck involvement; in fact, for patients who underwent 
cystoprostatectomy, the 10-year disease-free survival 
rate was 82%[39]. A recent report by Yuan et al. described 
cystoprostatectomy as a therapeutic option that provides 
symptom control and has favorable outcomes in terms 

of survival and patient QoL[33]. They included 27 
patients with prostate cancer invading the bladder 
who had not received neoadjuvant treatment and 
had no distant metastases. All the patients underwent 
open or laparoscopic cystoprostatectomy with urinary 
diversion (ileal conduit or cutaneous ureterostomy) and 
extended pelvic lymph node dissection. All patients had 
LUTS before surgery, and all reported relief of urinary 
symptoms after the procedure. QoL was also assessed 
using the Functional Assessment of Cancer Therapy-

, Cont’d 

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Prostate (FACT-P) questionnaire, with the total score 
improving significantly at 6 months and one year after 
surgery compared with the preoperative score. Survival 
outcomes were also reported with a 3-year prostate 
cancer-free survival of 77.8%, as all patients received 
adjuvant ADT, with 9 patients also receiving RT and 3 
receiving chemotherapy. These survival outcomes are 
comparable to those reported by Kumazawa et al., who 
described a similar population of patients, among whom 
11 (64.7%) received neoadjuvant ADT and all received 

adjuvant ADT and were found to have a 5-year cancer-
specific survival of 87.1%[41].

Cystoprostatectomy as a salvage option after 
failure of other therapies 
Several authors have published the outcomes of salvage 
surgery after failure of RT for LAPca with no distant 
metastasis[23,26–28,32,34]. Cystoprostatectomy rather 
than prostatectomy was performed to alleviate LUTS, 
severe local symptoms, and complications after RT 

TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Ahlering  
et al. 
(1992)

34

Prostatectomy (10)
Cystoprostatectomy  
with urinary diversion (22): 
ileal conduit (8), continent 
cutaneous diversions (14)
Cystoprostatectomy and 
LAR (1)
Total pelvic exenteration (1)

Salvage surgery after 
failure of radiotherapy 
and no distant 
metastasis (34)

– NR NR NR

RP: mean 7.6 
days, range 6–12

Exenteration: 
mean 11 days, 

range 7–16 

2 patients of the 
cystoprostatectomy 
group developed 
complications (ileus 
and SBO, requiring 
exploration and 
adhesolysis)

NR
Mean 109 

months post 
radiotherapy

27/34 (79%) 
received 

perioperative 
adjuvant 
hormonal 
therapy

24/34 alive without disease 
2 have elevated PSA

10/34 developed recurrence  
7 of whom died from disease

Pontes  
et al. 
(1993)

43
Prostatectomy (35)
Cystoprostatectomy (8)

Salvage surgery  
after failure of 
radiotherapy (43)

26 received 
hormonal surgery 
before or after 
surgery

CP: NR CP: NR CP: NR CP: NR

CP: 2 rectal 
perforations intra-op 
repaired primarily and 
1 death from PE 

No significant late 
morbidity reported for 
those who underwent 
CP

13/43 
(30.2%)

Range 1–10 
years

26 received 
hormonal 

surgery before 
or after surgery

6/9 died from metastasis
34 were alive:
• 10/34 no evidence of 

disease
• 15/34 elevated PSA
• 4/34 too early to evaluate
• 5/34 has metastasis

No influence of hormonal 
therapy on survival was 
seen

Lerner  
et al. 
(1995)

132

Radical prostatectomy  
(79–90%)
Cystoprostatectomy  
(38–29%)
Total pelvic exenteration 
(5–4%)
PLND alone (10–7%) 

Salvage surgery 
after failure of local 
radiotherapy and no 
distant metastasis, 
low co-morbidity and 
10-year life expectancy 
(132)

– NR

RP: median 1 unit, 
range 0–22

CP: median 2 units, 
range 0–22

TPE: median 9.5 units, 
range 7–97

PLND: median 1 unit, 
range 0–2

NR

RP: median 8 
days, range 2–44

CP: median  
12 days, range 

8–34

TPE: median 
20 days, range 

12–45

PLND: median  
8 days, range 

5–15

RP: 35 (44%) 
complications 
reported

CP: 12 (31.6%) 
complications 
reported

TPE: 6 complications 
reported (some 
patients experienced 
more than one)

PLND: 4 (40%) 
complications 
reported

NR –

80 (61%) 
received 
adjuvant 

perioperative 
hormonal 
therapy

Generally, overall survival 
and cause-specific survival 
was significantly higher for 
the RP group compared to 
the exenteration groups (due 
to a higher proportion of 
patients with organ-confined 
disease as well as a higher 
proportion of non-aneuploid 
cancer in the RP group)

Adjuvant hormonal 
therapy was associated 
with higher progression-
free survival in patients 
with non-aneuploid 
tumors

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

continued on page 170

169SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

The Role of Pelvic Exenteration in the Management of Locally Advanced Prostate Cancer

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Gheiler   
et al. 
(1997) 

8

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (5),  
orthotopic neobladder (3)

Radio-recurrent  
prostate cancer with:  
severe fibrosis  
of bladder neck (2)  
small fibrotic bladder 
with severe  
incontinence (1)  
synchronous bladder 
TCC (2) severe 
incontinence due 
to injury of external 
urinary sphincter  
suspected invasion of 
prostate cancer into 
bladder neck

-

Ileal 
conduit: 

mean  
1030 ml 

Neobladder: 
mean  

800 ml 

Ileal conduit:  
mean 1.2 units 
Neobladder:  
mean 1 unit 

NR

Ileal conduit: 
mean 10.6 days

Neobladder: 
mean 12.7 days

Ileal conduit: 1/5 
complications 
(incisional hernia, 
required operative 
repair)

Neobladder: 30-day 
morbidity 2/3 

 (ileus, pyelonephritis), 
no late complications 
reported

Ileal conduit: 
3/5 (60%)

Neobladder: 
1/3 (33.3%)

– –

Ileal conduit: 
1/5 developed metastasis 
and died
1/5 developed PSA rise after 
12 months 
2/5 had no detectable  
PSA rise 
1/5 received orchiectomy 
as he had PSA rise before 
surgery 
Neobladder: 3/3 patients 
developed PSA increase at 
an average 22 months after 
surgery

Bochner  
et al. 
(1998)a

6

Cystoprostatectomy and 
orthotopic neobladder (3)
Total pelvic exenteration  
with orthotopic  
neobladder  (3)

Recurrent prostate 
cancer after 
radiotherapy (4)
Rectoprostatic fistula 
after radiotherapy (2)

–
Mean  

840 mLa
NR NR

Mean 
9.9 days, 

range 8-13)a

30-day morbidity  
3/18 (1 ileus and 
2 pouch-related 
complications)a

3/18 pouch-related 
late complications 
reported, with  
2 requiring repeat 
interventionsa

NR
Median 28 
monthsa

–

67% reported good  
daytime continence and 
57% reported good night 
time continencea 

Izawa  
et al. 
(2000)

6

Cystoprostatectomy  
with en bloc pubic 
symphysectomy (3)
Cystoprostatectomy (1)
Prostatectomy with  
bladder neck closure and 
continent catheterizable 
stoma (2)

Severe complications 
from salvage 
cryotherapy after 
failure of primary 
therapy for prostate 
cancer (6); including:  
Gross hematuria, 
urinary incontinence, 
prostatopubic fistula, 
bladder outlet 
obstruction and osteitis 
pubis

– NR NR
Mean 547 

minutes, range 
288–748

NR

2/6 reported 
complications 
(incisional hernia, 
wound infection) 

NR
Mean 59 
months, 

range 54-67
–

5/6 were alive at last follow-
up (death was not related to 
prostate cancer)

At last follow-up 3/6 
remained disease-free with 
no detectable PSA levels

Sato et al. 
(2003) 

15

Cystoprostatectomy 
with urinary diversion: 
ileal conduit (5), rectal 
bladder (8), Koch pouch (1), 
ureterocutaneostomy (1)

Prostate cancer  
invading the urinary 
bladder (15)

Surgical patients 
received 
neoadjuvant 
and/or adjuvant 
hormonal therapy

NR NR NR NR NR NR –

Surgical patients 
received 
neoadjuvant 
and/or adjuvant 
hormonal 
therapy

Disease specific survival: 
82% at 10 years (vs. 100% 
for prostatectomy vs. 74% 
for hormonal therapy)

PSA relapse-free survival: 
51% at 5 years (vs. 65% for 
prostatectomy vs. 38% for 
hormonal therapy)

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

, Cont’d 

170 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Gheiler   
et al. 
(1997) 

8

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (5),  
orthotopic neobladder (3)

Radio-recurrent  
prostate cancer with:  
severe fibrosis  
of bladder neck (2)  
small fibrotic bladder 
with severe  
incontinence (1)  
synchronous bladder 
TCC (2) severe 
incontinence due 
to injury of external 
urinary sphincter  
suspected invasion of 
prostate cancer into 
bladder neck

-

Ileal 
conduit: 

mean  
1030 ml 

Neobladder: 
mean  

800 ml 

Ileal conduit:  
mean 1.2 units 
Neobladder:  
mean 1 unit 

NR

Ileal conduit: 
mean 10.6 days

Neobladder: 
mean 12.7 days

Ileal conduit: 1/5 
complications 
(incisional hernia, 
required operative 
repair)

Neobladder: 30-day 
morbidity 2/3 

 (ileus, pyelonephritis), 
no late complications 
reported

Ileal conduit: 
3/5 (60%)

Neobladder: 
1/3 (33.3%)

– –

Ileal conduit: 
1/5 developed metastasis 
and died
1/5 developed PSA rise after 
12 months 
2/5 had no detectable  
PSA rise 
1/5 received orchiectomy 
as he had PSA rise before 
surgery 
Neobladder: 3/3 patients 
developed PSA increase at 
an average 22 months after 
surgery

Bochner  
et al. 
(1998)a

6

Cystoprostatectomy and 
orthotopic neobladder (3)
Total pelvic exenteration  
with orthotopic  
neobladder  (3)

Recurrent prostate 
cancer after 
radiotherapy (4)
Rectoprostatic fistula 
after radiotherapy (2)

–
Mean  

840 mLa
NR NR

Mean 
9.9 days, 

range 8-13)a

30-day morbidity  
3/18 (1 ileus and 
2 pouch-related 
complications)a

3/18 pouch-related 
late complications 
reported, with  
2 requiring repeat 
interventionsa

NR
Median 28 
monthsa

–

67% reported good  
daytime continence and 
57% reported good night 
time continencea 

Izawa  
et al. 
(2000)

6

Cystoprostatectomy  
with en bloc pubic 
symphysectomy (3)
Cystoprostatectomy (1)
Prostatectomy with  
bladder neck closure and 
continent catheterizable 
stoma (2)

Severe complications 
from salvage 
cryotherapy after 
failure of primary 
therapy for prostate 
cancer (6); including:  
Gross hematuria, 
urinary incontinence, 
prostatopubic fistula, 
bladder outlet 
obstruction and osteitis 
pubis

– NR NR
Mean 547 

minutes, range 
288–748

NR

2/6 reported 
complications 
(incisional hernia, 
wound infection) 

NR
Mean 59 
months, 

range 54-67
–

5/6 were alive at last follow-
up (death was not related to 
prostate cancer)

At last follow-up 3/6 
remained disease-free with 
no detectable PSA levels

Sato et al. 
(2003) 

15

Cystoprostatectomy 
with urinary diversion: 
ileal conduit (5), rectal 
bladder (8), Koch pouch (1), 
ureterocutaneostomy (1)

Prostate cancer  
invading the urinary 
bladder (15)

Surgical patients 
received 
neoadjuvant 
and/or adjuvant 
hormonal therapy

NR NR NR NR NR NR –

Surgical patients 
received 
neoadjuvant 
and/or adjuvant 
hormonal 
therapy

Disease specific survival: 
82% at 10 years (vs. 100% 
for prostatectomy vs. 74% 
for hormonal therapy)

PSA relapse-free survival: 
51% at 5 years (vs. 65% for 
prostatectomy vs. 38% for 
hormonal therapy)

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

continued on page 172

171SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

The Role of Pelvic Exenteration in the Management of Locally Advanced Prostate Cancer

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Kumazawa 
et al. 
(2009)

17

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (7),  
rectal neobladder (9),  
Koch pouch (1) 

Prostate cancer 
invading the urinary 
bladder without distant 
metastasis (17)

11 received 
neoadjuvant 
hormonal  
therapy

NR NR NR NR

11/17 (64.7%) 
reported perioperative 
complications as 
follows:
Wound infection:  
3 (17.6%)
Prolonged ileus:  
6 (35.3%)
Pelvic abscess:  
1 (5.9%)
Acute pyelonephritis: 
1 (5.9%)

NR -

All received 
adjuvant 
hormonal 
therapy

Projected 5-year PSA 
recurrence-free 
survival rate: 62.2%

5-year cause-specific 
survival: 87.1% 
 (no significant difference 
between pN0 and pN1)

Guo 
et al. 
(2009)

18 Total pelvic exenteration

Recurrent prostate 
cancer invading 
the rectum causing 
intractable perineal  
pain after failure of 
initial therapy (18)

– NR NR NR NR NR
8/18  

(44.4%)
–

All received 
adjuvant 
hormonal 
therapy and 
17/18 received 
adjuvant 
chemotherapy

9/18 (50%) died at a mean  
18 months after surgery 
(range 2–69 months)

9/18 (50%) alive at a mean  
15 months after surgery 
(range 3–34 months), but  
4 developed metastasis

Spahn  
et al. 
 (2017)b

62 Cystoprostatectomy  

cT4 prostate cancer  
with bladder invasion 
as part of multimodal 
treatment (62)

–
b

NR NR NR NR NR
29  

(46.8%)
Mean  

2.9 years
–

b

Clinical recurrence in 69.4% 
of patients at a median of  
35 months 

Estimated prostate cancer-
specific survival: 44.5% at  
5 years and 39.7% at 7 years

Estimated overall survival: 
39.8% at 5 years and  
32.4% at 7 years

Seminal vesicle invasion 
was found to be a strong 
predictor of cancer-
specific survival

Yuan  
et al.  
(2019)

27

Cystoprostatectomy  
with urinary diversion  
(ileal conduit or  
cutaneous  
ureterostomy)

Upfront surgery  
for prostate cancer 
invading the urinary 
bladder (27)

None NR NR
Mean  

258.8 mins
NR

9/27 (33.3%) 
patients developed 
complications, 
including 
hydronephrosis, 
wound infection, 
DVT, uremia, ileus, 
arterioureteral fistula, 
classified as follows:
Clavien-Dindo grade 1: 
5 (18.5%) patients
Clavien-Dindo grade 2: 
2 (7.4%) patients
Clavien-Dindo grade 3: 
2 (7.4%) patients

25/27 
(92.6%)

Mean  
46.1 months, 
range 20–80

All received 
adjuvant 
hormonal 
therapy, some 
also received 
adjuvant 
radiation or 
chemotherapy

Overall survival: 100% at  
1 year, 88.9% at 3 years
Clinical progression-free 
survival: 
100% at 1  year, 
77.8% at 3 years
Biochemical progression-
free survival: 
92.6% at 1 year, 
62.9% at 3 years

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

, Cont’d 

172 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Kumazawa 
et al. 
(2009)

17

Cystoprostatectomy  
with urinary diversion:  
ileal conduit (7),  
rectal neobladder (9),  
Koch pouch (1) 

Prostate cancer 
invading the urinary 
bladder without distant 
metastasis (17)

11 received 
neoadjuvant 
hormonal  
therapy

NR NR NR NR

11/17 (64.7%) 
reported perioperative 
complications as 
follows:
Wound infection:  
3 (17.6%)
Prolonged ileus:  
6 (35.3%)
Pelvic abscess:  
1 (5.9%)
Acute pyelonephritis: 
1 (5.9%)

NR -

All received 
adjuvant 
hormonal 
therapy

Projected 5-year PSA 
recurrence-free 
survival rate: 62.2%

5-year cause-specific 
survival: 87.1% 
 (no significant difference 
between pN0 and pN1)

Guo 
et al. 
(2009)

18 Total pelvic exenteration

Recurrent prostate 
cancer invading 
the rectum causing 
intractable perineal  
pain after failure of 
initial therapy (18)

– NR NR NR NR NR
8/18  

(44.4%)
–

All received 
adjuvant 
hormonal 
therapy and 
17/18 received 
adjuvant 
chemotherapy

9/18 (50%) died at a mean  
18 months after surgery 
(range 2–69 months)

9/18 (50%) alive at a mean  
15 months after surgery 
(range 3–34 months), but  
4 developed metastasis

Spahn  
et al. 
 (2017)b

62 Cystoprostatectomy  

cT4 prostate cancer  
with bladder invasion 
as part of multimodal 
treatment (62)

–
b

NR NR NR NR NR
29  

(46.8%)
Mean  

2.9 years
–

b

Clinical recurrence in 69.4% 
of patients at a median of  
35 months 

Estimated prostate cancer-
specific survival: 44.5% at  
5 years and 39.7% at 7 years

Estimated overall survival: 
39.8% at 5 years and  
32.4% at 7 years

Seminal vesicle invasion 
was found to be a strong 
predictor of cancer-
specific survival

Yuan  
et al.  
(2019)

27

Cystoprostatectomy  
with urinary diversion  
(ileal conduit or  
cutaneous  
ureterostomy)

Upfront surgery  
for prostate cancer 
invading the urinary 
bladder (27)

None NR NR
Mean  

258.8 mins
NR

9/27 (33.3%) 
patients developed 
complications, 
including 
hydronephrosis, 
wound infection, 
DVT, uremia, ileus, 
arterioureteral fistula, 
classified as follows:
Clavien-Dindo grade 1: 
5 (18.5%) patients
Clavien-Dindo grade 2: 
2 (7.4%) patients
Clavien-Dindo grade 3: 
2 (7.4%) patients

25/27 
(92.6%)

Mean  
46.1 months, 
range 20–80

All received 
adjuvant 
hormonal 
therapy, some 
also received 
adjuvant 
radiation or 
chemotherapy

Overall survival: 100% at  
1 year, 88.9% at 3 years
Clinical progression-free 
survival: 
100% at 1  year, 
77.8% at 3 years
Biochemical progression-
free survival: 
92.6% at 1 year, 
62.9% at 3 years

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

continued on page 174

173SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

The Role of Pelvic Exenteration in the Management of Locally Advanced Prostate Cancer

http://SIUJ.org


TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Heidenreich 
et al. 
(2020) 

103

Radical prostatectomy  
(9, 8.7%)
Cystoprostatectomy  
(71, 68.8%)
Total (23, 22.4%)

Locally advanced CRPC 
(84) or CSPC (19) with 
symptomatic infiltration 
into bladder, rectum 
or pelvic floor despite 
previous therapy

- NR

14.6% required 
transfusions from date 
of admission till 90 days 
after surgery

Mean  
271 minutes, 

range 210–292

Mean 18.3 days, 
range 10–34

Reported 
complications 
classified as follows:
Clavien-Dindo grade 2: 
30.6% of patients  
Clavien-Dindo grade 3: 
11.3% of patients
Clavien-Dindo grade 4: 
8.1% of patients

71/103 
(68.9%)

Mean  
3.04 years

–

Symptom-free survival: 
89.2% at 1 year,  
64.1% at 3 years

Overall survival:  
92.2% at 1 year,  
43.7% at 3 years

Surcel   
et al.  
(2020) 

25

Cystoprostatectomy (23)
Total pelvic exenteration (2)
Urinary diversion: 
ileal conduit (18), 
ureterocutaneostomy (6), 
Mainz Pouch (1)

Palliation of cT4 
prostate cancer with 
local invasion and local 
symptoms in a majority 
of patients, regardless 
of distant metastasis 
(25)

13 (52%) upfront 
surgery and 12 
(48%) after ADT

NR NR NR NR

11/25 (44%) 
patients developed 
perioperative 
complications, 
classified as follows: 
• Clavien-Dindo 

grades 1-3a: 7 
(28%) patients

• Clavien-Dindo 
grades 3b-4: 4 
(16%) patients 
(required surgical 
revision: 1 
colostomy, 1 
complicated 
lymphocele, 2 ileus 
due to adhesions)

12/25 
(48%)

Median 
follow-up 

15 months, 
range 3–41

–

11/25 (44%) were alive 
at follow-up 8/25 died of 
prostate cancer 6/25 died  
of other causes

Median overall survival:  
15 months

No significant difference  
in survival between the 
group who received 
preoperative ADT and  
the group that did not

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

or if RP was not surgically feasible. Data on primary 
therapy, adjuvant therapy, and survival outcomes have 
not been consistently reported among studies with vast 
heterogeneity. The studies are presented in Table 1.

Exenteration surgery to control local 
symptoms 
Direct invasion of prostate cancer into the surrounding 
tissues in locally advanced disease may result in 
symptoms such as significant perineal pain, LUTS, 
and urinary tract obstruction[50]. Pelvic exenteration 
has been described for prostate cancer with rectal and 
perineal invasion, causing severe symptoms that are 
unresponsive to RT[51]. Kamat et al. described the 
efficacy of total pelvic exenteration in the complete relief 
of perineal pain not responding to narcotics in 14 men 

with prostate cancer invading the rectum and having 
failed ADT and RT with an average symptom-free 
interval of 14 months in 11 men[40]. Pelvic exenteration 
can alleviate symptomatic local recurrence of prostate 
cancer after RP, which is not possible with ADT and RT. 
In a small series, Leibovici et al. reported that 4 patients 
underwent total pelvic exenteration and 1 patient 
underwent wide tumor resection after RP, concluding 
that salvage pelvic exenteration is feasible in well-
selected patients[25]. Guo et al. reported the outcomes of 
total pelvic exenteration after recurrent prostate cancer 
invading the rectum causing severe intractable perineal 
pain[36]. On the other hand, Surcel et al. performed 
cystoprostatectomy or pelvic exenteration for cT4 
prostate cancer with severe local symptoms, regardless 
of previous treatment or distant metastasis[30].

, Cont’d 

174 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

 REVIEW

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Role of exenteration in castrate-resistant 
prostate cancer 
Many patients with castrate-resistant prostate cancer 
(CRPC) experience local symptoms, such as hematuria, 
upper tract obstruction, or rectal invasion. Although the 
changes in the landscape of CRPC treatment have led to 
improvements in the overall survival of these patients 
from multimodal treatment and advancements in 
systemic therapeutics, local symptoms still pose a burden 
to affected patients and are projected to increase in 
incidence given the improved life expectancy of patients 
with CRPC[52,53]. In fact, approximately half of CRPC 
patients experience cancer-related local symptoms 
in their final year of life, with up to 25% requiring 
upper or lower urinary tract surgical interventions 

for palliation[52,53]. As described earlier, invasion 
of the bladder or rectum may necessitate anterior or 
total pelvic exenteration even in patients with CRPC; 
however, patients should be good surgical candidates 
with an expected survival of over 1 year[52,53]. Recently, 
Heidenreich et al. reviewed 103 patients with LAPca, 
of whom 84 had castrate-resistant prostate cancer and 
underwent pelvic exenteration for symptom relief[37]. 
Overall, 78.6% of patients were able to obtain complete 
relief of symptoms in their remaining lifetime. A 
total of 41.7% of men reported gross hematuria before 
surgery, whereas none reported hematuria after pelvic 
exenteration. A total of 55.3% of patients had upper 
urinary tract obstruction before surgery managed by 
endoluminal stenting or percutaneous nephrostomy, 
all of which were removed postoperatively, with only 

TABLE 1. 

Summary of studies on pelvic exenteration (anterior or total) for locally advanced prostate cancer 

Author 
(Year)

Total 
number of  
patients

Exenteration type 
(number)

Indication (number)
Neoadjuvant 

treatment
Blood loss PRBC transfusion  Surgery time Hospital stay  

Reported 
complications

R0  
resection

Follow-up 
Secondary 
treatment

Reported outcomes

Heidenreich 
et al. 
(2020) 

103

Radical prostatectomy  
(9, 8.7%)
Cystoprostatectomy  
(71, 68.8%)
Total (23, 22.4%)

Locally advanced CRPC 
(84) or CSPC (19) with 
symptomatic infiltration 
into bladder, rectum 
or pelvic floor despite 
previous therapy

- NR

14.6% required 
transfusions from date 
of admission till 90 days 
after surgery

Mean  
271 minutes, 

range 210–292

Mean 18.3 days, 
range 10–34

Reported 
complications 
classified as follows:
Clavien-Dindo grade 2: 
30.6% of patients  
Clavien-Dindo grade 3: 
11.3% of patients
Clavien-Dindo grade 4: 
8.1% of patients

71/103 
(68.9%)

Mean  
3.04 years

–

Symptom-free survival: 
89.2% at 1 year,  
64.1% at 3 years

Overall survival:  
92.2% at 1 year,  
43.7% at 3 years

Surcel   
et al.  
(2020) 

25

Cystoprostatectomy (23)
Total pelvic exenteration (2)
Urinary diversion: 
ileal conduit (18), 
ureterocutaneostomy (6), 
Mainz Pouch (1)

Palliation of cT4 
prostate cancer with 
local invasion and local 
symptoms in a majority 
of patients, regardless 
of distant metastasis 
(25)

13 (52%) upfront 
surgery and 12 
(48%) after ADT

NR NR NR NR

11/25 (44%) 
patients developed 
perioperative 
complications, 
classified as follows: 
• Clavien-Dindo 

grades 1-3a: 7 
(28%) patients

• Clavien-Dindo 
grades 3b-4: 4 
(16%) patients 
(required surgical 
revision: 1 
colostomy, 1 
complicated 
lymphocele, 2 ileus 
due to adhesions)

12/25 
(48%)

Median 
follow-up 

15 months, 
range 3–41

–

11/25 (44%) were alive 
at follow-up 8/25 died of 
prostate cancer 6/25 died  
of other causes

Median overall survival:  
15 months

No significant difference  
in survival between the 
group who received 
preoperative ADT and  
the group that did not

a Data reported on a total of 18 patients: 6 prostate and 12 bladder cancer  b Neoadjuvant and adjuvant treatments different between different institutions

PRBC: packed red blood cells; NR: not reported; postop: postoperative; CP: cystoprostatectomy; RPP: radical perineal prostatectomy; PSA: prostate specific  
antigen; SBO: small bowel obstruction; MI: myocardial infarction; ADT: androgen deprivation therapy; RP: radical prostatectomy;

TPE: total pelvic exenteration; LAR: low anterior resection; intra-op: intra-operative; PE: pulmonary embolus; PLND: pelvic lymph node dissection;  
TCC: transitional cell carcinoma; UTI: urinary tract infection; DVT: deep vein thrombosis.

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TABLE 2. 

Reported cases of minimally invasive pelvic exenteration for prostate cancer,  

Author 
(Year)

Number of 
patients

Exenteration surgery Indication Blood loss PRBC transfusion
Surgery 

time
Hospital 

stay
Reported 

complications
R0 resection Follow-up Reported outcomes

Yang  
et al. 
(2015)

1

Laparoscopic total pelvic 
exenteration with cutaneous 
ureterostomy 
and sigmoidostomy

Recurrent prostate sarcoma 
causing difficult defecation

600 mL NR 415 min 10 days
No early 
complications 
UTI after 6 months

R0 achieved 12 months Died of recurrence

Castillo  
et al.
(2015)a

1

Robotic pelvic exenteration, 
bilateral EPLND, en-bloc 
excision of bladder and 
rectum, urinary and fecal 
diversion using double-barrel 
wet colostomy

CRPC after radical 
prostatectomy + salvage 
radiation followed by ADT, 
presenting with rectal 
recurrence.

600 mL NR 249 min 7 days NR NR 24 months
6 weeks later: decreased PSA = 1.39 
Then treated with ADT and chemotherapy
2 years later: good quality of life, PSA = 2.37

Winters  
et al.  
(2015)

3

Robotic total pelvic 
exenteration with  
laparoscopic rectus  
flap

Local recurrence of 
high-risk prostate cancer 
with a large malignant 
rectourethral fistula - 
biopsy revealed recurrent 
prostate cancer extending 
to the rectal side of this 
fistula.

800 mL 2 units 660 min
7 days,  
1 day in 

ICU

30-day morbidity: 
1/3 (33.3%) – 
patient developed 
pelvic abscess and 
pyelonephritis

2/3  
(66.6%) –

All back to daily activities within 4–6 weeks

Prostate cancer treated 
with brachytherapy 
presented 6 years later 
with cT4 high-grade, 
squamous differentiated 
urothelial carcinoma 
involving the bladder neck, 
prostate, and perirectal 
tissues

500 mL 1 unit 600 min
8 days,  
1 day in 

ICU

T4N2M0 rectal 
adenocarcinoma treated 
with chemotherapy, 
followed by EBRT with 
persistent mass involving 
the prostate, seminal 
vesicles, and bladder

350 mL NR 570 min
7 days,  
1 day in 

ICU

Maurice  
et al. 
(2017)

1

Robotic total pelvic  
exenteration with 
intracorporeal sigmoid conduit 
and colostomy

Metastatic CRPC 
with failed primary 
brachytherapy but good 
systemic response to 
chemotherapy and ADT. 
PSA continued to rise with 
an enlarging prostatic 
pelvic mass causing 
progressive local symptoms  

NR NR
324 min 

(total robotic 
time)

8 days

DIC (resolved by 
blood products), 
TIA (no permanent 
disability)

NR
–

Died after 5 months due to metastatic 
disease but complete palliation of symptoms 
was achieved

a First reported case of robotic pelvic exenteration

UTI: urinary tract infection; EPLND: extended pelvic lymph node dissection; CRPR: castrate-resistant prostate cancer; ADT: androgen deprivation therapy;  
PSA: prostate-specific antigen; NR: not reported; PRBC: packed red blood cells; ICU: intensive care unit; EBRT: external beam radiotherapy; 

DIC: disseminated intravascular coagulation; TIA: transient ischemic attack; LAR: low anterior resection; TPN: total parenteral nutrition;  
APR: abdomino-perineal resection.

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TABLE 2. 

Reported cases of minimally invasive pelvic exenteration for prostate cancer,  

Author 
(Year)

Number of 
patients

Exenteration surgery Indication Blood loss PRBC transfusion
Surgery 

time
Hospital 

stay
Reported 

complications
R0 resection Follow-up Reported outcomes

Yang  
et al. 
(2015)

1

Laparoscopic total pelvic 
exenteration with cutaneous 
ureterostomy 
and sigmoidostomy

Recurrent prostate sarcoma 
causing difficult defecation

600 mL NR 415 min 10 days
No early 
complications 
UTI after 6 months

R0 achieved 12 months Died of recurrence

Castillo  
et al.
(2015)a

1

Robotic pelvic exenteration, 
bilateral EPLND, en-bloc 
excision of bladder and 
rectum, urinary and fecal 
diversion using double-barrel 
wet colostomy

CRPC after radical 
prostatectomy + salvage 
radiation followed by ADT, 
presenting with rectal 
recurrence.

600 mL NR 249 min 7 days NR NR 24 months
6 weeks later: decreased PSA = 1.39 
Then treated with ADT and chemotherapy
2 years later: good quality of life, PSA = 2.37

Winters  
et al.  
(2015)

3

Robotic total pelvic 
exenteration with  
laparoscopic rectus  
flap

Local recurrence of 
high-risk prostate cancer 
with a large malignant 
rectourethral fistula - 
biopsy revealed recurrent 
prostate cancer extending 
to the rectal side of this 
fistula.

800 mL 2 units 660 min
7 days,  
1 day in 

ICU

30-day morbidity: 
1/3 (33.3%) – 
patient developed 
pelvic abscess and 
pyelonephritis

2/3  
(66.6%) –

All back to daily activities within 4–6 weeks

Prostate cancer treated 
with brachytherapy 
presented 6 years later 
with cT4 high-grade, 
squamous differentiated 
urothelial carcinoma 
involving the bladder neck, 
prostate, and perirectal 
tissues

500 mL 1 unit 600 min
8 days,  
1 day in 

ICU

T4N2M0 rectal 
adenocarcinoma treated 
with chemotherapy, 
followed by EBRT with 
persistent mass involving 
the prostate, seminal 
vesicles, and bladder

350 mL NR 570 min
7 days,  
1 day in 

ICU

Maurice  
et al. 
(2017)

1

Robotic total pelvic  
exenteration with 
intracorporeal sigmoid conduit 
and colostomy

Metastatic CRPC 
with failed primary 
brachytherapy but good 
systemic response to 
chemotherapy and ADT. 
PSA continued to rise with 
an enlarging prostatic 
pelvic mass causing 
progressive local symptoms  

NR NR
324 min 

(total robotic 
time)

8 days

DIC (resolved by 
blood products), 
TIA (no permanent 
disability)

NR
–

Died after 5 months due to metastatic 
disease but complete palliation of symptoms 
was achieved

a First reported case of robotic pelvic exenteration

UTI: urinary tract infection; EPLND: extended pelvic lymph node dissection; CRPR: castrate-resistant prostate cancer; ADT: androgen deprivation therapy;  
PSA: prostate-specific antigen; NR: not reported; PRBC: packed red blood cells; ICU: intensive care unit; EBRT: external beam radiotherapy; 

DIC: disseminated intravascular coagulation; TIA: transient ischemic attack; LAR: low anterior resection; TPN: total parenteral nutrition;  
APR: abdomino-perineal resection.

continued on page 178

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TABLE 2. 

Reported cases of minimally invasive pelvic exenteration for prostate cancer,  

Author 
(Year)

Number of 
patients

Exenteration surgery Indication Blood loss PRBC transfusion
Surgery 

time
Hospital 

stay
Reported 

complications
R0 resection Follow-up Reported outcomes

Smith  
et al.  
(2020)

2

Robotic LAR + en-bloc  
prostatectomy

Locally advanced 
extracapsular prostate 
cancer after brachytherapy

 NR 2 units 480 min
15 days,  
1 day in 

ICU

Ileus (required 
TPN), atrial 
fibrillation

R0 achieved

12 months No recurrence for both at 12 months follow-up
Robotic APR + en-bloc 
cystoprostatectomy + ileal 
conduit

Locally advanced 
extracapsular prostate 
cancer after EBRT with 
synchronous T1 rectal 
cancer

 NR 2 units 360 min
11 days,  
1 day in 

ICU
NR R0 achieved

Peng  
et al. 
(2020)

1 Robotic pelvic exenteration

Prostate cancer with 
extracapsular extension 
that had persistent 
abutment of rectal wall and 
pelvic floor involvement 
after chemoradiation

NR NR NR NR NR R0 achieved – –

a First reported case of robotic pelvic exenteration

UTI: urinary tract infection; EPLND: extended pelvic lymph node dissection; CRPR: castrate-resistant prostate cancer; ADT: androgen deprivation therapy;  
PSA: prostate-specific antigen; NR: not reported; PRBC: packed red blood cells; ICU: intensive care unit; EBRT: external beam radiotherapy; 

DIC: disseminated intravascular coagulation; TIA: transient ischemic attack; LAR: low anterior resection; TPN: total parenteral nutrition;  
APR: abdomino-perineal resection.

5.8% of patients requiring stenting later. The surgical 
procedures and patient outcomes are summarized in 
Table 1.

Other reported indications for pelvic 
exenteration in prostate cancer
Cystoprostatectomy has been described in t he 
management of synchronous prostate and rectal 
cancer[54,55] and synchronous prostate and bladder 
cancer[56], as well as in the management of severe 
complications of salvage cryotherapy for prostate 
cancer[38].

Discussion
Pelvic exenteration, whether total or anterior, has been 
performed for LAPca, including CRPC, and has been 
described for the following indications: prostate cancer 
invading the bladder; salvage surgery after failure 
of other treatments; control of local symptoms; and 
synchronous prostate, bladder, or rectal tumors. In 
addition to the potential survival benefits associated 
with surgical treatment, pelvic exenteration may provide 
additional symptomatic benefits that investigators have 
evaluated in several studies.

The main limitation in assessing the impact of pelvic 
exenteration in LAPca is the heterogeneity and limita-
tions of the published studies. The majority of the 

studies have had small sample sizes and varied patient 
characteristics. Data on previous therapies, neo-ad-
juvant treatments, and adjuvant treatments have not 
been consistently reported and have insufficient details. 
Different survival parameters and follow-up durations 
have been reported. Surgical procedures and techniques 
were different between studies; for example, differ-
ent types of urinary diversion were used with all being 
feasible, but no data reported on the superiority of one 
over the other. Not all studies have reported operative 
outcomes, including the need for blood transfusions and 
length of hospitalization. Reporting of complications 
was not standardized among studies, with few using 
the Clavien-Dindo classification. Comparisons made 
within the studies were also heterogeneous. For exam-
ple, Gheiler et al.[35] compared all outcomes after cysto-
prostatectomy based on the type of urinary diversion 
used; Zincke et al.[34] and Lerner at al.[26] compared the 
outcomes between different types of surgery performed 
as salvage treatment after radiotherapy; and Ward et 
al.[32] reported the difference in need for blood trans-
fusions and early complication rates in patients under-
going cystoprostatectomy based on the year of their 
surgery. Finally, there are scarce reports on the outcomes 
of long-term follow-up, including the need for further 
urological interventions, number of readmissions, and 
objective assessment of QoL.

, Cont’d 

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Pelvic exenteration represents a major surgery that 
can lead to significant morbidity and that may harbor 
a perioperative mortality risk. The major complication 
rates reported in the literature range between 44% to 
55%. The impact of minimally invasive surgery for pelvic 
exenteration in prostate cancer is still unclear, given the 
small number of cases reported. Although there are no 
clear outcomes, a minimally invasive approach is possi-
ble, with few reported complications.

Most authors concluded that exenteration may be 
feasible for well-selected patients despite the increased 
operative risk. Therefore, the decision to proceed should 
be tailored according to patient comorbidities, projected 
life expectancy, impact of symptoms on QoL, and avail-
ability of experienced surgeons to perform these complex 
operations.

LAPca management remains a clinical challenge 
despite advances in systemic therapies over the past 
decade[57,58]. Even though systemic agents as well as 
traditional ADT have been successful in decreasing 
the progression and improving the survival of patients 
with advanced prostate cancer, they may not palliate or 
address the symptoms associated with the direct inva-
sion of LAPca. Pelvic exenteration, on the other hand, 
may not be curative in locally advanced disease but may 
be associated with a durable disease response, particu-
larly in combination with systemic treatments.

The rationale for the use of cytoreductive surgery 
involves multiple postulations. Decreasing the bulk of 
the disease would render systemic therapy more effec-
tive, since the same dosage is used against a smaller 
number of malignant cells. Another theory is that surgi-
cal debulking decreases the number of cells that can 
undergo somatic mutations and become castrate-resis-
tant in cases of prostate cancer[59,60]. Another rationale 
is extrapolation from the concept of index lesions in 
prostate cancer and clonality, which is the scientific basis 
of prostate focal therapy[61]. Exenteration would treat 
the index lesion, which would eventually lead to metas-
tasis and castration resistance.

The evidence for cytoreductive surgery in metastatic 
prostate cancer is not as robust but is an area of interest 
for many investigators. A study using the SEER database 
showed that such patients who underwent local ther-
apy had a survival benefit over those who did not receive 
local therapy[62]. Another national cancer database study 
showed that cytoreductive prostatectomy and primary 
radiotherapy provide an overall survival benefit in meta-
static prostate cancer[63]. However, these were retrospec-
tive database studies and did not provide robust evidence 
to change current practice guidelines or currently available 
systemic treatment options. Recently, the STAMPEDE  
trial has shown a survival benefit of local radiation therapy 
in low-volume metastatic prostate cancer[64].

TABLE 2. 

Reported cases of minimally invasive pelvic exenteration for prostate cancer,  

Author 
(Year)

Number of 
patients

Exenteration surgery Indication Blood loss PRBC transfusion
Surgery 

time
Hospital 

stay
Reported 

complications
R0 resection Follow-up Reported outcomes

Smith  
et al.  
(2020)

2

Robotic LAR + en-bloc  
prostatectomy

Locally advanced 
extracapsular prostate 
cancer after brachytherapy

 NR 2 units 480 min
15 days,  
1 day in 

ICU

Ileus (required 
TPN), atrial 
fibrillation

R0 achieved

12 months No recurrence for both at 12 months follow-up
Robotic APR + en-bloc 
cystoprostatectomy + ileal 
conduit

Locally advanced 
extracapsular prostate 
cancer after EBRT with 
synchronous T1 rectal 
cancer

 NR 2 units 360 min
11 days,  
1 day in 

ICU
NR R0 achieved

Peng  
et al. 
(2020)

1 Robotic pelvic exenteration

Prostate cancer with 
extracapsular extension 
that had persistent 
abutment of rectal wall and 
pelvic floor involvement 
after chemoradiation

NR NR NR NR NR R0 achieved – –

a First reported case of robotic pelvic exenteration

UTI: urinary tract infection; EPLND: extended pelvic lymph node dissection; CRPR: castrate-resistant prostate cancer; ADT: androgen deprivation therapy;  
PSA: prostate-specific antigen; NR: not reported; PRBC: packed red blood cells; ICU: intensive care unit; EBRT: external beam radiotherapy; 

DIC: disseminated intravascular coagulation; TIA: transient ischemic attack; LAR: low anterior resection; TPN: total parenteral nutrition;  
APR: abdomino-perineal resection.

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While pelvic exenteration may provide an onco-
logic benefit for locally advanced or metastatic prostate 
cancer, a more compelling reason for surgical interven-
tion is the control of local symptoms. However, there 
is no standardized quantifiable QoL indicator because 
symptomatology is variable given the heterogeneous 
nature of this disease and its classification. Future stud-
ies using validated QoL questionnaires would help to 
address these questions in these patients[65].

Recently, with the introduction of theranostics and 
the emerging widespread adoption of functional imag-
ing studies such as positron emission tomography using 
prostate-specific membrane antigen (PET-PSMA), vari-
ations in clinical management are expected[66]. These 
would include surgical planning in cases of advanced 
disease requiring exenteration.

The improvement in the perioperative and postop-
erative outcomes of salvage robot-assisted radical pros-
tatectomy might open the door for better utilization of 
neoadjuvant RT for LAPca[67,68]. The role of neoadju-
vant RT is well established for several different types of 
malignancies and is considered the standard of care for 
some patients[69,70]. The rationale for its preoperative 
use in cases of prostate cancer is that RT induces long-
term growth arrest in prostate cancer cells rather than 
acute apoptosis[71]. These cells would still be positive 
if present at the resection margin; however, a positive 
margin after neoadjuvant radiation therapy might indi-
cate the presence of sterilized cancer cells that later die 
due to necrosis[71].

The role of neoadjuvant RT in prostate cancer has 
not been well studied, and neoadjuvant RT is not part 

of the standard of care for the management of patients 
with prostate cancer. Carlson et al. reported their 
results on 18 patients who received neoadjuvant RT 
doses ranging from to 40 to 70 Gy followed by radical 
prostatectomy 1 to 2 months afterwards, with minimal 
postoperative morbidity and 67% of patients metas-
tasis-free at 5 years[72]. Several phase I and phase II 
trials of neoadjuvant RT followed by radical prosta-
tectomy have confirmed the safety of the surgery with 
minimal side effects and improvement in biochemical 
progression-free survival[73]. This approach should be 
investigated in patients with LAPca who might be good 
candidates for pelvic exenteration.

Conclusion
Pelvic exenteration can be offered to patients with 
LAPca, whether for cure or for palliation of local 
symptoms; however, it is not a widely used management 
option. Retrospective data indicated that pelvic 
exenteration may help alleviate local pain and LUTS and 
improve patient QoL. However, the oncological benefits 
of such procedures have not been well established. 
Furthermore, this extensive surgical treatment option 
is associated with high complication rates. There is an 
urgent need for prospective multicenter studies that use 
a standardized methodology to report complications, 
incorporate patient-reported outcomes, and examine 
novel endpoints such as the need for adjunct upper 
and lower urinary tract procedures and the need for 
hospitalization for complications related to the primary 
tumor. These studies will help define the future role of 
pelvic exenteration as a treatment modality for LAPca. 

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