Prospective case-control cohort analysis of two-day/two-stage pelvic exenteration surgery: Safety, feasibility, acceptability and medium-term outcomes.

Abstract

Pelvic exenteration (PE) is the only curative option for extensive pelvic cancers. Advances have facilitated increasingly complex resectional and reconstructive components, including per-operative oncological adjuncts such as intraoperative radiotherapy. Cumulatively, these components increase operative duration beyond what is feasible within a single conventional operating day. Two-day/two-stage PE addresses this, but little is known about this approach. This study aims to evaluate the feasibility, safety and medium-term outcomes of a two-day/two-stage PE. Consecutive patients (2010-2025) from a prospectively maintained high-volume PE unit database (n = 373) undergoing two-day/two-stage PE were compared against a matched control cohort of single-day cases lasting ≥15 h. EQ5D-5L and decision regret scores were longitudinally collected after 2021. Surgical, oncological and health-related quality-of-life outcomes were evaluated. Twenty-seven patients underwent two-day/two-stage PE, and 38 had one-day PE; more anal cancers were in the two-day/two-stage group (p = 0.012); median follow-up was 24.2 months. No 90-day mortalities occurred; 3-year overall survival was 54.4% for two-day/two-stage PE and 70.5% for one-day PE (p = 0.31); and R0-resection rates were 82% and 76%, respectively (p = 0.76). Major morbidity occurred in 56% and 47% (p = 0.62), with a median length of stay of 37 and 27 days (p = 0.07) and intensive care days of 5 and 3 (p = 0.08). 12-month EQ5D-5L utility scores were 0.79 and 0.81 (p = 0.96), with low 12-month decision regret in both groups (p = 0.15). Two-day/two-stage PE is safe and feasible, potentially representing the only option for highly selected patients needing high-complexity PE with multiple components. Although equivalent R0-resections were obtained, medium-term oncological outcomes were poorer in patients undergoing two-day/two-stage interventions.