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Background The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. Methods This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. Results Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510–678 min) and significant blood loss (median 2–5 l). R0 resection can be achieved in 58–82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30–40 per cent) and perioperative mortality is acceptable (0–4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. Conclusion En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.

Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS).Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery.Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P 0.01) with either major bony (70% vs. 50%; P 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications.Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.

Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty. Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME. There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18). A surgeon’s intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis.

AIM This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. METHOD Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots. RESULTS Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P

The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon’s subjective assessment of the individual patient’s pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach. MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty. Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty. Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.

This study aimed to describe short- and medium-term longitudinal quality-of-life (QoL) outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Consecutive patients undergoing CRS and HIPEC were recruited. The primary outcome was QoL, measured using the short-form 36 questionnaire and expressed as a physical component score (PCS) and a mental component score (MCS), with higher scores representing better QoL. Data were collected prospectively at baseline and before discharge, then 3, 6, and 12 months postoperatively. Trajectories of the PCS and MCS were described for the study period and grouped according to a peritoneal carcinomatosis index (PCI) (≤ 12 vs. ≥ 13) and a completeness of cytoreduction (CC) score (CC0 vs. CC1–CC3). Overall, 117 patients underwent CRS and HIPEC and 115 (98.3%) of the 117 patients participated in the study. The main primary pathology was colorectal in 52 (45%) of the 115 patients and appendiceal in 27 (23.5%) of the 115 patients. The median baseline PCS [48.16; interquartile range (IQR), 38.6–54.9] had decreased at pre-discharge (35.34; IQR, 28.7–41.8), then increased slightly at 3 months (42.54; IQR, 37.6–51.6), before returning to baseline within 6 months (48.35; IQR, 39.1–52.5) and remaining unchanged 12 months after surgery (48.55; IQR, 40.8–55.5). The MCS remained unchanged during the study period. The patients with a PCI of 13 or higher had worse PCS and MCS during the postoperative period than the patients with a PCI of 12 or lower. The CRS and HIPEC procedures impaired PCS, with scores returning to baseline within 6 months after surgery, whereas MCS remained unchanged. The patients with a lower PCI had better postoperative QoL outcomes. For patients with peritoneal malignancy, CRS and HIPEC can be performed with acceptable short- to medium-term QoL outcomes.

Tumour infiltration of the lateral pelvic compartment has previously been associated with the highest rate of involved resection margins and carries significant risk of morbidity. In this study, consecutive patients undergoing pelvic exenteration at a single centre between 1994 and 2019 who required en bloc resection of the common or external iliac artery or vein were included.The results demonstrate that complete resection of the iliac vascular system, including resection and reconstruction of the common and external iliac vessels, can be performed safely during pelvic exenteration with oncological outcomes comparable to more central tumours.

Objectives To determine what constitutes a clear resection margin (R0) in patients with LRRC. Summary of background data R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences. Methods A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis. Results There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins >0.5 mm were not predictive of local recurrence free survival. Conclusions A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.

Background Anorectal cancer arising in IBD can be challenging to manage. There is a paucity of reports describing locally advanced and recurrent anorectal cancer in this setting. Objective This study aimed to describe patients who underwent extended radical pelvic resection for locally advanced and recurrent IBD-associated anorectal cancer. Design This is a retrospective review of a prospectively maintained database of extended radical pelvic resection. Settings This study was conducted at a quaternary pelvic malignancy referral center. Patients All of the patients who underwent extended radical pelvic resection for IBD-associated anorectal cancer between September 1994 and September 2019 were included. Main outcome measures Demographic, operative, and oncologic outcomes were assessed. Results Ten patients (1.3%) were identified of 765 (6 men; median age = 51 y). The average time from the diagnosis of IBD to cancer was 23 years. Five patients had surgery for primary cancer previously. All of the patients had previous complex abdominal and perineal surgical interventions. There were 7 adenocarcinomas and 3 squamous cell carcinomas. Nine underwent pelvic exenteration and 1 rectal resection with radical vaginectomy. The median operating time, intraoperative blood loss, and blood transfusion were 698 minutes, 1.8 L, and 4.5 units. The median hospital stay was 24 days. The operative mortality and morbidity rates were 0% and 60%. At a median follow-up of 51.3 months, 7 patients remained alive and free of cancer. Limitations This is a retrospective study of a small number of patients. Conclusions Extended radical pelvic resection offers a potential cure for locally advanced and recurrent IBD-associated anorectal cancer with acceptable operative mortality and morbidity rates. A high index of suspicion is required to achieve early diagnosis. Multiple factors need to be considered in the multimodal treatment of such complex patients. See Video Abstract at http://links.lww.com/DCR/B418. Excelentes resultados despus de la reseccin plvica radical extendida por cncer anorrectal recurrente y localmente avanzada, asociada a enfermedad inflamatoria intestinal ANTECEDENTES:Cancer anorrectal surgiendo de la enfermedad inflamatoria intestinal, puede ser dificil de manejar. Hay escasez de informes que describan el cancer anorrectal localmente avanzado y recurrente en este contexto.OBJETIVO:El estudio tiene como objetivo, describir a los pacientes que se sometieron a reseccion pelvica radical extendida por cancer anorrectal recurrente y localmente avanzada, asociada con enfermedad inflamatoria intestinal.DISENO:Esta es una revision retrospectiva, de una base de datos mantenida prospectivamente de reseccion pelvica radical extendida.AJUSTES:El estudio se realizo en un centro de referencia cuaternaria en malignidad pelvica.PACIENTES:Se incluyeron a todos los pacientes sometidos a reseccion pelvica radical ampliada por cancer anorrectal, asociada a enfermedad inflamatoria intestinal entre septiembre de 1994 y septiembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los resultados demograficos, quirurgicos y oncologicos.RESULTADOS:Diez pacientes (1.3%) fueron identificados de 765 (seis masculinos; mediana de edad 51 anos). El tiempo promedio desde el diagnostico de la enfermedad inflamatoria intestinal hasta el cancer, fue de 23 anos. Cinco pacientes fueron previamente sometidos a cirugia por cancer primario. Todos los pacientes tuvieron previamente, intervenciones quirurgicas abdominales y perineales complejas. Hubo siete adenocarcinomas y tres carcinomas de celulas escamosas. Nueve se sometieron a exenteracion pelvica y una a reseccion rectal con vaginectomia radical. La mediana del tiempo de operacion, perdida de sangre intraoperatoria y transfusion sanguinea, fueron 698 minutos, 1.8 litros y 4.5 unidades respectivamente. La mediana de la estancia hospitalaria fue de 24 dias. Las tasas de mortalidad y morbilidad operatoria fueron 0% y 60% respectivamente. En una mediana de seguimiento de 51,3 meses, siete pacientes permanecieron vivos y libres de cancer.LIMITACIONES:Es un estudio retrospectivo con numero pequeno de pacientes.CONCLUSIONES:La reseccion pelvica radical extendida, ofrece una cura potencial para el cancer anorrectal recurrente y localmente avanzada, asociada a0 enfermedad inflamatoria intestinal y con tasas aceptables de mortalidad y morbilidad operatoria. Se requiere un alto indice de sospecha para obtener un diagnostico temprano. Se deben considerar multiples factores en el tratamiento multimodal de pacientes tan complejos. Consulte Video Resumen en http://links.lww.com/DCR/B418. (Traduccion-Dr Fidel Ruiz Healy).

Aim There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer. Method A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging. Results Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes; 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications. Conclusion Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.

Introduction Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has gained traction for the management of peritoneal metastases. The number of specialist units globally offering CRS/HIPEC is increasing. The aim of this survey was to assess current practices and barriers to referral for CRS/HIPEC among colorectal surgeons in Australia and New Zealand (ANZ). Materials and methods An online questionnaire was emailed to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey contained 3 sections: namely; demographics, referral patterns and clinical scenarios. Questions on referral patterns included number of peritoneal metastases patients seen per year and referred to a CRS/HIPEC unit, awareness of such a unit and distance from principle place of practice. Different pathologies referred were also explored, as well as investigations performed. Barriers to referral were also surveyed. Results The response rate was 28% (83/296). Twenty-five percent received CRS training. Most surgeons (95%) were aware of a CRS/HIPEC unit and had referred to one previously. Thirty-nine percent would refer all patients. Provision of good service and/or relationship with CRS/HIPEC specialist were the main reasons for referring to the nearest unit, followed by accessibility. Major factors preventing referral included extent of peritoneal disease (48%), patient characteristics and comorbidities (44%) and lack of evidence (20%). The most common pathologies referred included colorectal and appendiceal peritoneal metastases and pseudomyxoma peritonei. Conclusion Colorectal specialist awareness of CRS/HIPEC units and accessibility is high. Strategies to improve referring physician/surgeon knowledge on patient selection and indications for CRS/HIPEC should be investigated and instituted to ensure all appropriate patients are referred to specialist units for discussion of suitability.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.

Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty.Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME.There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18).A surgeon's intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis.

An 84-year-old man presented to a rural hospital in Australia with haemodynamic instability and abdominal pain. Investigation revealed haemorrhage from a lesion in his liver—an incidental finding of a hepatocellular carcinoma. Initial resuscitation and damage control surgery was performed at the peripheral hospital prior to transfer to a tertiary centre 386 km away for the second stage of management. The second stage of management included interventional radiological embolization of the bleeding liver vessel and subsequent resection of the liver tumour. This was all undertaken with new policies in place to limit the spread of infection at the peak of the COVID-19 epidemic.

There have been significant developments in the management of advanced and recurrent colorectal cancer in recent decades. 70% of primary colorectal tumours arise in the colon and for patients with stage I-III disease, the standard of care is surgical resection followed by adjuvant therapy where appropriate. Locoregional recurrence (LR) occurs in 4-11.5% of patients following treatment of primary colon cancer with curative intent, and can be categorised as peri-anastomotic, mesenteric/paracolic (nodal), retroperitoneal and peritoneal. Of these, peritoneal recurrence is usually recognised as the most challenging type of recurrence to manage. Patients with isolated peri-anastomotic or limited nodal recurrence in the mesentery or retroperitoneum may be curable by radical salvage surgery, which often requires en bloc multi-visceral resection, while patients with low volume peritoneal metastases may be candidates for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ensuring complete resection along embryonic mesocolic planes or en bloc resection of contiguously involved structures are best strategies to reduce the likelihood of local recurrence through a R1 resection margin. The role of complete mesocolic excision (CME) with high vascular ligation has been demonstrated to increase nodal yield and improve overall survival although this is more contentious. In patients with T4a disease and serosal surface involvement, peritoneal recurrence represents the greatest threat. Efforts for early diagnosis of peritoneal recurrence in these patients or prophylactic treatment, while intuitive have not demonstrated the survival benefit that would be expected. Other than locoregional recurrence (LR), systemic recurrence may occur in up to 50% of patients who have undergone curative resection for colorectal cancer. In keeping with portal venous outflow, the most common site of systemic recurrence is the liver. Although previously thought to be a fatal condition, liver resection is now the standard of care where liver metastases can be completely resected with clear margins plus leaving an adequate liver remnant with intact vascular inflow, outflow and biliary drainage. This can usually be achieved in 26-45% of patients presenting with liver metastases. Liver surgeons at the forefront of liver resection have also developed techniques to induce liver hypertrophy so as to improve likelihood of resectability. Even where patients have non-resectable disease, ablative techniques have become increasingly common. Naturally, none of these would be possible without the advent of improved chemotherapeutic and biological options in the field of medical oncology. Pulmonary metastasectomy with curative intent may be possible in a small number (10%) of patients with lung metastases, which is associated with an overall survival of up to 40%. Unlike liver metastases, proportionally less patients with pulmonary metastases will be resectable. For these patients, several ablative options are available. For all patients with recurrent colon cancer, patient selection for radical salvage surgery and decisions surrounding treatment strategy (including use of systemic therapy or ablative procedures) should take place in a multidisciplinary team setting.

The evolving coronavirus disease 2019 (COVID‐19) pandemic represents an unprecedented and largely unanticipated challenge to the delivery of surgical care in Australia and New Zealand. The first confirmed COVID‐19 case in Australia occurred on 25 January 2020. Since then, 2675 patients have been diagnosed nationally, resulting in 12 deaths (at the time of writing). New South Wales has been the most affected state based on case volume, with 1219 documented cases. During the initial response in New South Wales, all patients with confirmed COVID‐19 requiring hospitalization were managed at a nominated COVID‐19 centre (Westmead Hospital). As the pandemic evolved and the confirmed cases increased, a second COVID‐19 centre was established at Royal Prince Alfred (RPA) Hospital on 4 March 2020. RPA is a 900‐bed teaching hospital located in metropolitan Sydney, which provides surgical care for the local community but also serves as a quaternary referral centre for complex surgical services including advanced gastrointestinal malignancy, complex cardiovascular and neurosurgery, and renal and liver transplantation. As the third week of the response period at RPA comes to an end, this article aims to share our initial experience as a dedicated COVID‐19 centre by describing the issues faced in providing acute and elective surgical care, the broad impacts on staff and the early strategies adopted to address these challenges.

Aim The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. Methods A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. Results The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. Conclusion While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.

BACKGROUND: For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. OBJECTIVE: To determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in metastatic rectal cancer patients who did not undergo upfront intervention for their primary tumor. DESIGN: Retrospective analysis. SETTING: Comprehensive cancer center. PATIENTS: Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary, and no prior primary tumor-directed intervention. MAIN OUTCOME MEASURES: Rate of primary tumor-related complications in the cohort that did not receive any primary tumor directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. RESULTS: The cohort comprised 358 patients with median age of 56 years (22–92). Median follow-up was 26 months (range, 1 to 93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21 out of 34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. LIMITATIONS: Single center. CONCLUSION: A significant proportion of patients with metastatic rectal cancer and untreated primary experience primary tumor-related complications. These patients should be followed closely and preemptive intervention (resection, diversion, or radiation) considered if the primary progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400.

Distributive justice refers to the fair and appropriate distribution of benefits, risks and costs within a society. In a medical context, this requires patients with similar cases to be treated in a similar manner, and for there to be overarching equality of access to finite health resources. Distributive justice is a derivative of the broader principle of justice, which is one of the four biomedical ethics pillars described by Beauchamp and Childress as underpinning modern medical practice, along with beneficence, non‐maleficence and autonomy.1 The concept of distributive justice as it relates to the delivery of surgical care requires attention in the context of the coronavirus disease 2019 (COVID‐19) pandemic. Significant measures have been taken by our governments, health ministries and public and private hospitals in an effort to prepare the Australian healthcare system for high volumes of patients with COVID‐19. In the Australian context where a relatively low societal burden of disease has emerged, a question arises about the opportunity cost of these unprecedented interventions and restrictions, which have resulted in significant disruptions to the delivery of emergency and elective medical treatment – are we upholding the principle of distributive justice during the present pandemic?

To determine what constitutes a clear resection margin (R0) in patients with LRRC.R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences.A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X2 test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis.There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins0.5 mm were not predictive of local recurrence free survival.A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.

There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.

While the endovascular approach has been the treatment of choice for abdominal aortic aneurysm (AAA) repair in the modern era, open AAA repair remains a treatment option and may have a resurgence after the recent release of draft guidelines from the National Institute for Health and Care Excellence (NICE). Incisional hernia is a common long-term complication of open AAA repair and causes significant patient morbidity. As the number of patients undergoing open AAA repair increases, it is imperative that vascular surgeons are aware of and aim to reduce the complications associated with open surgery. This article summarises current evidence, highlighting the risk factors for incisional hernia and the modern surgical techniques that can prevent complications.

Improving advanced colorectal cancer care

AIM The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure. METHODS Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases. RESULTS Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases. CONCLUSION Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.

Background A rural general surgeon has historically been required to perform a wide variety of subspecialist procedures. Increasingly sub-specialized training programs have restricted younger surgeons' experience in the general surgery-associated subspecialties. Time critical vascular surgical emergencies are frequently encountered by rural general surgeons. This study aims to audit the prevalence of vascular surgical emergencies at a geographically remote regional centre and define the role of the general surgeon in managing these patients. Methods A single-centre, retrospective study was performed to analyse the outcomes of the patients who presented to Dubbo Base Hospital with an emergency vascular pathology or developed such a condition during admission, between October 2010 and June 2019. Patients were identified by relevant International classification of diseases (ICD) (10th revision) diagnostic codes for vascular emergencies. Acute complications following surgery for haemodialysis access were excluded. Results A total of 134 patients were identified during the study period and the majority were transferred to a tertiary centre for surgical intervention. Sixteen patients underwent emergency vascular surgery locally due to concerns about potential loss of life or limb if intervention was delayed by transfer; 69% of patients who underwent surgery locally survived with limb salvation. Conclusion While most patients can safely be transferred to a tertiary centre, some require surgery locally in order to maximize chance of life or limb preservation. There is a strong argument for exposure of general surgical trainees with an interest in rural surgery to vascular surgery and other subspecialties.

Objective To report survival, functional, and quality-of-life (QoL) outcomes after extended radical resection for advanced pelvic tumors with en bloc sciatic or femoral nerve resection. Background Advanced pelvic tumors involving the sciatic or femoral nerve have traditionally been considered inoperable. Small studies have suggested acceptable functional outcomes can be achieved after pelvic exenteration with en bloc sciatic nerve resection. Method Consecutive patients who underwent extended radical pelvic surgery with en bloc resection of the sciatic or femoral nerves at a single center were included. Results Of 713 radical pelvic resections, 68 patients (9.5%) had en bloc sciatic or femoral nerve resection. Complete sciatic, partial sciatic, and complete femoral nerve resection was performed in 26 (38%), 38 (56%), and 4 patients (6%), respectively. Overall and major postoperative complication rates were 63% and 40%, respectively. R0 resection was achieved in 65% of patients, which translated to 55% and 76% overall and local recurrence-free 5-year survival in those with colorectal cancer. Twenty-two (96%) and 25 (92%) patients could mobilize independently after complete and partial sciatic nerve resection, respectively. Physical QoL was significantly lower at 6 months after surgery compared with baseline (P = 0.041), but returned to baseline at 12 months (P = 0.163). There was no difference in mental or overall QoL at 6 or 12 months compared with baseline. Conclusion En bloc sciatic and femoral nerve resection can be performed during extended radical pelvic resections with morbidity and survival outcomes comparable with existing exenteration literature, including in patients with recurrent rectal cancer. Physical QoL may be impaired after surgery, but returns to baseline by 12 months.

To assess the outcome of ligation of intersphincteric fistula tract (LIFT) and bioprosthetic graft (BioLIFT) in the management of transsphincteric perianal fistula. A single-institution retrospective analysis of all patients undergoing LIFT and BioLIFT from January 2009 to June 2018 was performed. Only patients who had LIFTs and BioLIFT performed as their primary sphincter-preserving procedure was included. Primary outcome measured was primary healing. Secondary outcomes measured were secondary healing, morbidity, time to recurrence, and pre- and post-operative anorectal manometry. Chi-square analysis was used to determine predictive factors. A total of 116 patients were identified. One hundred five had LIFT and 11 had BioLIFT. The total primary healing rate was 60.3% (62.9% and 34.9% for LIFT and BioLIFT respectively). The overall secondary healing rate was 80.2% (80.0% and 81.9% for LIFT and BioLIFT respectively). There was no inpatient morbidity or post-procedural faecal incontinence reported. There was no significant change in the pre- and post-operative manometries in either group (P = 0.417 and P = 0.834 for LIFT and BioLIFT respectively). The only predictor for primary failure identified was anteriorly located fistula. LIFT and BioLIFT compare favourably with other sphincter-preserving procedures. LIFT and BioLIFT can be performed safely, with minimal morbidity and with no reported loss of sphincteric function.

Background Total cystectomy and subsequent reconstruction of the urinary tract may be required for primary malignancy of the bladder, or in the context of multi-visceral resection for more advanced pelvic tumors. Complications following urinary diversion are a major source of morbidity, particularly in pelvic exenteration (PE) patients. Methods All patients who underwent radical cystectomy alone or during PE at a single tertiary referral centre between 2008 and 2014 were reviewed. Postoperative urological complications were collected and compared between groups. Results Two hundred and thirty-one patients underwent en bloc cystectomy (98 cystectomy alone, 133 as part of a PE). Postoperative urological complications occurred in 33% of the cystectomy alone group and 59% of the PE group (P

Presacral (or retrorectal) tumors are rare tumors which arise in the space between the mesorectum and the sacrum. This space contains tissues derived from all three germ cell layers and from which presacral tumors may arise. Presacral tumors can be broadly categorized as congenital or acquired, and benign or malignant, and morphologically they may be cystic, solid or heterogeneous. This group of tumors are often asymptomatic and may be identified incidentally on clinical examination or pelvic imaging. Magnetic resonance imaging (MRI) is the gold standard imaging modality as it can accurately demonstrate the relationship between the tumor and adjacent structures and helps to delineate between benign and malignant lesions. PET/CT can be useful when assessing malignant and indeterminate lesions in order to identify aggressive pathology and exclude metastatic disease. Radiologically-guided percutaneous biopsy of malignant or indeterminate tumors can be performed safely in order to obtain a histological diagnosis and determine whether there is a role for adjuvant therapies. Surgery is the mainstay of treatment of presacral tumors. Benign lesions can be monitored with regular MRI, particularly smaller lesions which are asymptomatic. If resection is required, benign lesions can often be “shelled out” with preservation of adjacent structures and therefore function, whereas malignant tumors generally require radical excision with wide margins and sacrifice of involved pelvic organs or soft tissues, bone and neurovascular structures.

BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. METHODS This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed. RESULTS A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality. CONCLUSION This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.

Aim Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these multi-visceral resections leads to fluid accumulation and translocation of bowel within the pelvic cavity, which may increase the risk of pelvic abscess, perineal fluid discharge with perineal wound dehiscence and prolonged ileus. This study describes a novel technique using degradable synthetic mesh with overlying omentum to preclude small bowel and fill the empty space after total pelvic exenteration, and aimed to investigate the rate of pelvic abscess and perineal wound-related complications in this group. Method Ten patients who underwent total pelvic exenteration followed by implantation of degradable synthetic mesh at a quaternary referral centre were identified and included. The mesh was moulded to the contours of the bony pelvis at the level of the pubic symphysis anteriorly and inferior to the sacral promontory posteriorly. The data on the number of postoperative perineal wound-related complications including pelvic abscesses were collected. Results There was no perioperative mortality. Five patients (50%) developed postoperative complications. One patient developed an abscess inferior to the mesh that required surgical drainage and another had a pre-sacral collection that was successfully managed conservatively. Two patients developed intra-abdominal collections requiring percutaneous drainage. Median length of stay was 20 days (range 16-35). No perineal hernia or entero-perineal fistula was detected in any patient either clinically or radiologically at a median follow-up of 7 months. Conclusion Degradable synthetic mesh reconstruction following exenterative surgery may reduce postoperative complications related to the perineal wound.

This article describes a novel technique for en bloc resection of locally recurrent rectal cancer that invades the high sacral bone (above S3). The involved segment of the sacrum is mobilised with osteotomes during an initial posterior approach before an anterior abdominal phase where the segment of sacral bone is delivered with the specimen. This allows en bloc resection of the involved sacrum while preserving uninvolved distal and contralateral sacral bone and nerve roots. The goal is to obtain a clear bony margin and offer a chance of cure while improving functional outcomes by maintaining pelvic stability and minimising neurological deficit.

There have been at least 10 major revisions of the medical curriculum since the inauguration of the Faculty of Medicine at the University of Sydney in 1883. This study traced the evolution of the teaching of surgery at our institution by examination of the set curriculum of each period; the expectations of student knowledge in the final examination as well as examining some of the insights provided by past students of their surgical experience through their writings. In the early years, medical graduates were qualified to perform operative surgery without any further training, whereas the modern postgraduate medical curriculum provides students with the basis for further surgical training.

Background Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment. Methods Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review. Results Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage. Conclusion The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.

Advanced pelvic cancers involving the lateral pelvic compartment, and particularly the iliac vasculature, are difficult to manage. Common or external iliac vessel involvement has traditionally been considered a contraindication for curative surgery.The purpose of this study was to investigate pathological and surgical outcomes, particularly postoperative morbidity of pelvic exenteration with en bloc major iliac vascular excision and reconstruction.This study was a case series.The study was conducted at a quaternary referral center for pelvic exenteration in Sydney.Patients included those undergoing en bloc iliac vessel excision as part of their pelvic exenteration for a locally advanced pelvic malignancy.Over the study period, 336 patients underwent pelvic exenteration. Twenty-one patients (6.3%) underwent en bloc vascular excision of 29 vessels for tumor involvement. Twenty-four vessels required reconstruction. The primary outcomes were postoperative complications and pathologic outcomes. Survival rates were estimated using the Kaplan-Meier technique.Operating time for patients who underwent vascular excision and reconstruction was longer, but this did not reach significance (631 vs 531 minutes; p = 0.052). Mean blood loss was significantly higher in the vascular excision and reconstruction group (6.8 vs 3.4 L; p0.001). Patients who required en bloc vascular excision were less likely to have R0 margins compared with patients who did not (38% vs 78%; p0.001). There was no intraoperative or 30-day mortality. Overall graft patency and limb loss at 1 year were 96% and 0%. A total of 52% of patients had at least 1 vascular related complication. Median overall and disease-free survival times were 34 and 26 months.This study is limited by a relatively small number of heterogeneous patients.En bloc vascular resection and reconstruction for contiguous tumor involvement is feasible and safe in selected patients. Advanced pelvic tumors involving iliac vessels should not be precluded from curative surgery in specialized institutions.

This article describes a great saphenous vein spiral graft technique for reconstruction of iliac vessels after en bloc resection during pelvic exenteration. Use of different size syringes as a scaffold allows the surgeon to construct autologous vascular interposition conduits of variable diameter to match the luminal size of the vessel requiring reconstruction. Autologous vascular grafts are preferred in exenteration surgery in which the operative field is commonly contaminated by concomitant bowel resection, which carries an increased risk of graft infection.

There is minimal reported experience with long-range retrieval of pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support. We report the case of a 10-month old boy with necrotizing staphylococcal pneumonia complicated by a bronchopleural fistula, who was successfully retrieved and transported while receiving ECMO to our unit in Sydney, Australia, from a referring hospital 2,000 kilometers away in the Pacific Islands. He was successfully weaned from ECMO to receive single-lung ventilation after 13 days, and he underwent surgical repair of his bronchopleural fistula through a thoracotomy 3 days after decannulation. He has made a full recovery.

We describe a case of fatal acute appendicitis in a neonate associated with congenital cardiac disease requiring staged surgery. Neonatal appendicitis is extremely rare and usually associated with prematurity and congenital abdominal conditions. This report serves to highlight the risk of this disease due to vascular insufficiency and ischemia in neonates with congenital cardiac disease and highlight the importance of considering this diagnosis in such a neonate with unexplained sepsis even in the absence of clear abdominal signs.

Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.

Background Urine leak following pelvic exenteration for locally advanced pelvic malignancy is a major complication leading to increased mortality, morbidity and length of stay. We reviewed our experience and developed a diagnostic and management algorithm for urine leaks in this patient population. Methods Consecutive patients who underwent en bloc cystectomy and conduit formation as part of pelvic exenteration at a single quaternary referral centre from 1995 to 2012 were reviewed. Patients with urine leak were identified. Medical records were reviewed to extract data on diagnosis and management and a suggested clinical algorithm was developed. Results Of 325 exenterations, there were 102 conduits, of which 15 patients (15%) developed a conduit related urine leak. Most (14/15) patients were symptomatic. Diagnosis was made by drain creatinine studies (12/15) and/or imaging (15/15). Management comprised of conservative management, radiologic urinary diversion, early surgical revision and late surgical revision in 3, 11, 2 and 1 patients respectively. Important lessons from our 17 year experience include a high index of suspicion in a patient who is persistently septic despite appropriate treatment, the importance of regular drain creatinine studies, CT (computer tomography) with delayed images (CT intravenous pyelogram) when performing a CT for investigation of sepsis and early aggressive management with radiologic urinary diversion to facilitate early healing. Conclusion Urine leak after pelvic exenteration is a complex problem. Conservative management usually fails and early diagnosis and intervention is the key. It is hoped that our algorithms will facilitate diagnosis and subsequent management of this group of patients.