Three decades of pelvic exenteration at Christchurch Hospital: the evolution of an exenteration service

Pelvic exenteration (PE), first described by Brunschwig in 1948, was initially associated with high peri‑operative mortality, prolonged hospitalisation, major functional consequences and poor long-term outcomes.¹ For decades it was regarded as a mutilating operation offered only when all other options had failed. Over the last 30 years, however, PE has been transformed by advances in imaging, anaesthesia, critical care, peri‑operative optimisation and reconstruction, together with the maturation of multidisciplinary team (MDT) governance.²

Modern rectal cancer treatment (including total mesorectal excision and neoadjuvant therapy) has reduced local recurrence rates, yet locally recurrent rectal cancer (LRRC) remains clinically significant, often presenting with pain, bleeding, fistulation or obstruction.³ Historically, LRRC was almost uniformly fatal; the emergence of extended multivisceral resection strategies demonstrated that cure is possible when complete tumour clearance can be achieved.

Across PE indications, achievement of a microscopically clear margin (R0 resection) has emerged as the dominant determinant of long‑term survival.^4–8 This principle has reshaped patient selection and intraoperative decision making, particularly for posterior and lateral compartment disease, where margins are threatened by bone, vessels and nerves.⁷ Consequently, contemporary PE increasingly incorporates en bloc bony resection (most commonly sacrectomy) and complex reconstruction, delivered within specialised high‑volume programmes.

Christchurch Hospital has been one of the Australasian sites central to this evolution. Since the mid‑1990s, a specialised pelvic oncology service has been established. This initially served the whole of New Zealand; more recently, with the development of a North Shore–based (Auckland) service, the Christchurch unit now mainly serves the South Island and lower North Island. The service has contributed to training across Australasia and participates in international collaborative research, including the establishment of the international PelvEx Collaborative Group.^8,9

The aim of this study is to describe the development of the Christchurch PE programme over three decades, highlight service and operative evolution (including sacrectomy and repeat PE) and summarise how PelvEx evidence has informed selection, benchmarking and survivorship care.

Methods

This article provides a retrospective descriptive account of the Christchurch PE service, drawing on institutional experience and published outputs, and contextualises this experience against contemporary international evidence, particularly PelvEx studies. Key domains were defined a priori: i) service organisation and MDT governance; ii) patient selection and pre‑operative work‑up; iii) operative strategies and reconstructive approaches; iv) peri‑operative optimisation and complication management; and v) survivorship and patient‑reported outcomes. Where available, quantitative service metrics are reported to illustrate programme scale.

Results

Service activity and case mix

The Christchurch PE programme developed in the mid‑1990s alongside early high‑volume centres internationally. Since 1995, Christchurch Hospital has undertaken more than 520 extended pelvic resections, with 89 involving bony resection, predominantly sacrectomy. The case mix includes primary locally advanced rectal cancer (LARC), LRRC, recurrent and locally advanced gynaecologic malignancies, anal carcinoma and sarcoma. Data from the most recent 5-year period demonstrate LRRC to be the most common indication for surgery at 38%, followed by LARC being 35% of the operative workload, with other indications accounting for the remaining 27%.

A substantial proportion (approximately 2/3) of patients are referred from outside Canterbury, reflecting the national centralisation of this surgical capability.

Multidisciplinary delivery model

From inception, the service was structured as a genuinely multidisciplinary programme. Colorectal surgeons lead the overall pathway, with embedded urology and gynaecologic oncology expertise for multivisceral resection; plastic and reconstructive surgery for perineal closure and dead‑space management; and orthopaedic collaboration for bony resections and vascular surgeon input as needed. Anaesthesia/intensive care unit (ICU), radiology, interventional radiology, oncology, specialist nursing (stoma and wound care), physiotherapy and nutrition, and pathologists are integrated throughout the pathway.

Peri‑operative pathway development

Progressive adoption of structured MDT decision making, enhanced recovery principles and proactive complication management has supported programme growth.

Service development and multidisciplinary governance

A defining feature of the Christchurch programme is the focus on governance and reproducibility. Rather than an individual surgeon-dependent model, PE is delivered by a stable team with defined roles, agreed operative strategy principles and standardised peri‑operative pathways. This structure enables consistent outcomes, facilitates training and provides resilience in the face of workforce change—an important consideration for a referral service.

The MDT philosophy in Christchurch reflected an early shift in thinking: instead of asking why such extensive operations should be performed, the question became why potentially curative surgery should not be considered for appropriately selected patients. This reframing was supported by improved radiologic prediction of resectability and increasing evidence that extended resection can achieve meaningful long‑term survival when R0 is obtained.^4–8

Regular audit, morbidity and mortality review and benchmarking against PelvEx outputs have informed incremental improvements in selection, technique and peri‑operative pathways.

Patient selection and pre‑operative work‑up

Good outcomes depend on appropriate patient selection and are central to PE management. Selection integrates anatomical resectability (particularly the likelihood of R0), biological behaviour (including absence of uncontrolled extra‑pelvic disease) and physiological capacity to tolerate prolonged surgery and recovery. In Christchurch, selection is MDT-driven and informed by high‑quality pelvic magnetic resonance imaging, contrast computed tomography (CT) and positron emission tomography (PET) CT.^10,11

Functional and psychosocial readiness are explicitly assessed. Patients require counselling regarding possible urinary diversion, permanent stomas, sexual dysfunction, neuropathic pain risk (particularly with sacrectomy) and prolonged rehabilitation. Prehabilitation is tailored, with emphasis on nutrition, sarcopenia risk, anaemia management, smoking cessation and optimisation of comorbidities. This approach reflects the growing understanding that peri‑operative physiological reserve influences morbidity and the ability to complete adjuvant therapies.

Operative evolution: contemporary PE strategy

Modern PE is heterogeneous and includes central, anterior, posterior and lateral compartment resections. Historically, exenteration series were dominated by central disease. With widespread adoption of total mesorectal excision and neoadjuvant chemoradiotherapy, recurrence patterns have shifted and LRRC is now frequently posterior or lateral, often in previously irradiated tissue.^12,13 These tumours are technically challenging due to fibrosis, distorted anatomy and involvement of the presacral fascia, sacrum, iliac vessels or lumbosacral plexus.

The Christchurch operative strategy emphasises en bloc resection of involved compartments, guided by the principle that piecemeal dissection increases margin positivity. Operative planning includes vascular control, anticipated nerve sacrifice and reconstruction. Intraoperative reassessment may lead to modification or abandonment of resection if R0 cannot be achieved safely.

Margin status as the dominant determinant of outcome

International PelvEx data have consistently shown that R0 resection is the single most important predictor of long‑term survival following PE for LARC and LRRC (Figures 1 and 2).^4–8 These findings have shaped global practice by reinforcing that the principal aim of PE is complete oncologic clearance, not simply debulking or symptom relief. In practical terms, this means that anatomical resectability and expected margin status drive selection and operative strategy.

For tumour types other than primary or recurrent rectal cancer, the need for R0 resection holds true. PelvEx outcome data for PE performed for urological, gynaecological, anal and sarcoma tumour types show 3-year overall survival in the range of 40–59%, with multivariate analysis consistently identifying R0 resection as the key factor associated with long-term survival.¹⁴

View Figure 1–2, Table 1.

Margin risk varies by compartment. Central pelvic disease is generally more amenable to clear margins, whereas lateral compartment disease often threatens the iliac vessels and lumbosacral plexus. Posterior disease with sacral invasion requires consideration of sacrectomy to avoid an R1/R2 outcome. The increasing focus on R0 has therefore driven willingness to undertake complex bony resections and reconstruction when required to facilitate margin clearance.

In Christchurch, margin probability is explicitly discussed at MDT and communicated to patients as part of consent. This includes realistic discussion of the balance between oncological intent and functional consequence, as well as the possibility that intraoperative findings may prevent achieving R0 resection.

Sacrectomy and en bloc bony resection

Sacrectomy represents one of the most demanding components of PE. It increases technical complexity, blood loss risk and perineal wound complications, and has functional consequences related to sacral nerve root sacrifice.^7–9 Nonetheless, for posterior compartment disease, sacrectomy may be essential to achieve R0 resection and therefore offers the possibility of cure.

PelvEx sub-group analyses have clarified morbidity and oncological outcomes following sacrectomy. Compared with soft tissue PE, sacrectomy is associated with longer operative time and higher wound complication rates, but acceptable peri‑operative mortality in specialist centres.^8,15–17 Importantly, survival outcomes improve when sacrectomy enables R0 resection, reinforcing its role as an oncological adjunct rather than a technical flourish.⁸ Further work comparing high versus low sacrectomy demonstrates that higher resections increase functional compromise, but many patients adapt and report acceptable global quality of life over time.^17,18

In Christchurch, increasing sacrectomy volume has been supported by close collaboration with orthopaedic and selective neurosurgical colleagues. Perineal reconstruction has evolved with use of vascularised flap reconstruction and alternative perineal closure strategies on a case-by-case basis attempting to minimise the sequelae of empty pelvis syndrome.¹⁹ Dead‑space management, careful drain strategies and early identification of wound complications have been important components of pathway refinement.

Repeat PE and re‑resection strategies

Repeat PE and re‑resection for intrapelvic re‑recurrence were historically viewed as contraindicated given cumulative surgical trauma and morbidity. PelvEx studies have demonstrated that repeat PE is feasible in carefully selected patients, with morbidity higher than primary PE but with survival outcomes superior to purely palliative strategies when R0 is achieved.^20,21 These data support consideration of re‑resection in patients with isolated recurrence, biologically favourable disease and adequate physiological reserve.

Christchurch practice has evolved accordingly. Repeat PE is considered via MDT when cure is a realistic objective and when functional trade-offs are acceptable to the patient. The decision requires careful judgement: the presence of prior complications, baseline function and psychosocial support strongly influence post-operative recovery. The increasing evidence base has enabled more nuanced counselling and shared decision making for this high‑risk sub-group.

Morbidity, complication management and pathway optimisation

PE remains associated with substantial morbidity and prolonged recovery, reflecting operative duration, multivisceral resection, pelvic dead-space and prior irradiation. Common complications include pelvic sepsis, perineal wound breakdown, urinary diversion complications, thromboembolism and prolonged ileus. Sacrectomy cases carry higher wound complication risk and may be complicated by chronic presacral infection.^15–18

High‑volume centres mitigate risk through standardised care pathways and experienced MDT. In Christchurch, peri‑operative optimisation has progressively incorporated enhanced recovery elements, including multimodal analgesia, early mobilisation, structured nutrition plans and early physiotherapy. ICU/high dependency unit utilisation is planned in advance, with escalation triggers agreed. Proactive management of pelvic collections with interventional radiology has reduced the need for re‑operation in carefully selected patients.

Quality of life, patient‑reported outcomes and survivorship

While survival remains central, quality of life has become a critical outcome in exenteration research (see Table 1 for outcome results).

The historical perception that PE inevitably results in unacceptable long‑term quality of life has been challenged by prospective patient‑reported outcome studies. PelvEx data demonstrate an early post-operative decline in quality of life followed by gradual recovery, with many survivors returning to baseline or near‑baseline global health status by 12–18 months.^22,23 Adaptation is common even among patients living with permanent dual stomas. ^22,23

Sacrectomy-specific quality of life and functional outcomes are particularly relevant given risks of neuropathic pain, gait impairment and bladder/bowel dysfunction.¹⁷ Available data indicate that although functional compromise is measurable—especially with high sacrectomy—many patients adapt successfully and report acceptable long‑term wellbeing.¹⁷ These findings allow counselling to move beyond morbidity statistics towards survivorship trajectories, supporting informed consent and realistic expectations.

In Christchurch, survivorship is increasingly embedded in the pathway through structured rehabilitation, psychological support, comprehensive stoma care and long‑term follow‑up that incorporates function as well as oncological surveillance. Future priorities include routine prospective capture of patient‑reported outcomes to refine counselling and benchmark survivorship care.

Contribution to research, training and system impact

Christchurch has contributed substantially to the international evidence base through our own and collaborative research, and more recently through supporting the establishment of the PelvEx Collaborative Group. This group now has over 100 international centres contributing to the dataset. This collaborative work has clarified prognostic factors, characterised morbidity patterns in high‑risk sub-groups and advanced understanding of survivorship after PE. Beyond publications, the programme has influenced training: Christchurch has served as a sought‑after colorectal fellowship site, and many regional exenteration services in Australia and New Zealand are staffed by surgeons who trained in Christchurch, including Royal Prince Alfred, Sydney, Peter MacCallum Cancer Centre, Melbourne, and Royal Brisbane and Women’s Hospital.

At a system level, Christchurch supports equitable access to PE for New Zealand patients through referral pathways and national centralisation. Centralised models are increasingly recognised as essential for procedures requiring high operative volume, complex reconstruction, multidisciplinary infrastructure and robust audit capacity.

Discussion

Over three decades, the Christchurch PE programme has evolved from an early adopter of extended pelvic resection into a mature, centralised pelvic oncology service aligned with international best practice. This experience mirrors the broader transformation of PE from a palliative “procedure of desperation” into a potentially curative operation for carefully selected patients with locally advanced or recurrent pelvic malignancy. The present description highlights how sustained multidisciplinary governance, rigorous patient selection and willingness to undertake complex en bloc resections—including sacrectomy—have underpinned this evolution.

Across indications, the primacy of achieving a microscopically clear margin (R0 resection) is unequivocal. Both single-centre series and PelvEx data consistently demonstrate margin status as the dominant determinant of long-term survival following PE. This has reshaped not only patient selection but also operative philosophy. In Christchurch, margin probability rather than tumour size or symptom burden has become the key driver of decision making, particularly for posterior and lateral compartment disease where margins are threatened by bone, vessels and neural structures. The acceptance that cure is unlikely without R0 resection has appropriately narrowed indications while simultaneously justifying more extensive en bloc resections when margin clearance is anatomically feasible.

The increasing incorporation of sacrectomy into contemporary PE reflects this shift. Historically regarded as prohibitively morbid, sacral resection is now recognised as an oncological adjunct that may be essential to achieve clear posterior margins in LRRC. PelvEx analyses demonstrate that while sacrectomy is associated with higher operative complexity and wound morbidity, peri-operative mortality remains acceptable in specialist centres, and survival outcomes are superior when R0 resection is achieved. Christchurch’s growing experience with sacrectomy has been facilitated by close collaboration with orthopaedic, plastic and anaesthetic colleagues, as well as iterative refinement of reconstruction and pelvic dead-space management. These developments underscore the importance of delivering PE within a stable, high-volume multidisciplinary environment.

A defining feature of the Christchurch programme has been its emphasis on governance and reproducibility. PE is delivered as a team-based service rather than an individual surgeon-dependent endeavour, with structured multidisciplinary meetings, agreed operative principles and standardised peri-operative pathways. This approach promotes consistency of outcomes, supports training and provides resilience in the face of workforce change—an important consideration for a national referral service in a geographically dispersed health system. Regular audit and benchmarking against international collaborative data have enabled incremental improvements in selection, technique and peri-operative care.

Patient selection remains central to good outcomes. In Christchurch, selection integrates anatomical resectability, biological behaviour and physiological reserve, supported by high-quality imaging and comprehensive MDT discussion. Increasing recognition of the role of prehabilitation, sarcopenia and psychosocial readiness reflects a broader shift in PE practice towards optimisation of the whole patient rather than a focus on technical resectability alone. Explicit counselling regarding functional consequences—including permanent stomas, urinary diversion, sexual dysfunction and potential neuropathic pain—is essential to informed consent and shared decision making.

Repeat PE and re-resection for intrapelvic re-recurrence represent another important evolution in practice. Once considered contraindicated, these strategies are now supported by collaborative data demonstrating feasibility and meaningful survival in carefully selected patients when R0 resection is achieved. Christchurch’s selective adoption of repeat PE reflects a more nuanced understanding of disease biology and survivorship trade-offs, reinforcing the need for individualised MDT assessment rather than rigid exclusion criteria.

While oncological outcomes remain central, quality of life and survivorship have emerged as critical end points in contemporary PE evaluation. Prospective patient-reported outcome studies from PelvEx challenge the assumption that PE inevitably results in unacceptable long-term quality of life. Although an early post-operative decline is common, many patients recover to baseline or near-baseline global health status within 12–18 months, including those living with permanent dual stomas. Sacrectomy-specific data demonstrate measurable functional compromise, particularly with higher resections, but also highlight patient adaptation and acceptable long-term wellbeing in many survivors. These findings have materially improved the quality of pre-operative counselling and reframed PE as a survivorship-focussed intervention rather than solely a life-prolonging one.

The Christchurch programme has contributed substantially to this evolving evidence base through publication off its results as well as participation in PelvEx and related collaborative initiatives. Beyond publication, this engagement has influenced training and service development across Australasia, with many regional PE services staffed by surgeons trained in Christchurch. At a system level, the programme illustrates the value of centralisation for ultra-complex cancer surgery, where volume, multidisciplinary infrastructure and audit capability are essential to safety and quality.

Future challenges include improving prediction of resectability in lateral compartment disease, embedding routine prospective capture of patient-reported outcomes, and integrating emerging technologies such as advanced imaging and navigation. Workforce and resource constraints further strengthen the case for national and international collaboration. Overall, the Christchurch experience demonstrates that PE can be safely and effectively delivered within a centralised, governance-driven model, offering selected patients the possibility of cure with acceptable long-term quality of life.

Conclusion

Christchurch Hospital has established a high‑volume PE programme that aligns with international benchmarks and contributes meaningful international collaborative research, including the PelvEx evidence base. Through sustained multidisciplinary collaboration and centralisation, PE has evolved from a last‑resort procedure to an operation offering cure and acceptable long‑term quality of life in selected patients. Future progress will be driven by continued collaboration, prospective capture of patient‑reported outcomes and refinement of selection and reconstructive pathways.