Locally recurrent cancer or, less commonly, a bulky, primary tumor arising adjacent to the urologic organs, requires an extended operation for salvage. During surgery for colorectal carcinoma (CRC), or pelvic surgery, a carcinomatous infiltration of adjacent urological organs is found in 5–10% of all cases [1]. However, this rate increases to ~50% in T4 and even higher rates for rectal carcinomas, as it is only partially covered by the visceral peritoneum, and to ~80% in recurrent carcinomas [2]. In these advanced cases in particular, an inherent surgical problem is the impossibility of distinguishing between inflammation and malignant infiltration of the adjacent organs during surgery [3]. Total pelvic exenteration (PE) and its modifications are surgical options for treating locally advanced rectal cancer. Total PE may involve en bloc removal of the rectum, bladder, prostate, or ureters, since it is essential to create clear margins if the procedure is to be curative. As a result, patients often require double stomas, which severely compromise quality of life (QoL) despite achieving acceptable locoregional control.

In a patient undergoing surgery with curative intent, obtaining adequate negative margins is paramount in the surgical plan. In the absence of distant metastasis, combining primary resection with multivisceral resection can aid in providing a prolonged disease-free interval. With regard to the urinary bladder, location and extent of involvement will determine whether a partial or complete cystectomy with urinary diversion is necessary. If complete cystectomy is necessary, the choice of urinary diversion is dependent on a multitude of factors, including patient age, comorbidities, neurologic function, manual dexterity, baseline renal function, and the need for adjuvant radiation therapy. In very select cases of rectal cancer involving only the prostate or seminal vesicals, isolated prostatectomy with urethrovesical anastomosis has been performed with encouraging results.

A combined radical prostatectomy and proctosigmoidectomy as an alternative to total PE for patients with rectal carcinoma with isolated extension to the prostate or seminal vesicles has been recommended, because it fulfills oncological/ surgical requirements and achieves a significant improvement in the patient’s QoL in comparison with total PE

Anterior and lateral vascular pedicle ligation is necessary on either side of the bladder. With the bladder retracted medially, the branches of the hypogastric artery and vein are skeletonized and ligated. These branches include the superior, middle, and inferior vesical arteries and veins, as well as branches from obturator and pudendal vessels [4].

In the male patient, when dividing the lateral vascular pedicles, the peritoneum overlying the seminal vesicles is opened sharply to expose the plane between bladder and rectum. This plane is dissected with both sharp and blunt dissection to separate the rectum in the midline below the posterior wall of the bladder and prostate, and laterally where the shared vascular supply of the bladder and rectum are encountered. These vessels make up the posterior vascular pedicle of the bladder and can be divided using clips, staples, or sealing devices. Ultimately, this leads to Denonvilliers fascia and to the space below the level of the prostate. Denonvilliers fascia is incised, and the space is developed using sharp or blunt dissection. From here, the remainder of the operation is performed anteriorly, with the opening of the endopelvic fascia lateral to the prostate and division of the dorsal venous complex over the anterior urethra distal to the apex of the prostate. The use of a 2-0 polyglactin braided suture with suturing to the periosteum of the pubis helps secure this fragile tissue once tied.

The traditional cystectomy in the female patient involves anterior PE with removal of the bladder, adjoining cervix, uterus, and anterior vaginal wall. This procedure ensures a sufficient soft tissue margin, even for most stage T3 and T4 lesions originating in the bladder. Initially, tissues of the anterior pelvis are isolated, and the vagina posterior to the cervix is identified. The posterior vaginal cuff is then incised and the vault entered. This allows for simple identification of the posterior and lateral pedicles of the bladder because they are opposed to the lateral surface of the vaginal wall. With this landmark identified, endovascular staples, titanium clips, or an electrocautery vascular sealing device can be applied to safely control the lateral vascular supply. The anterior vaginal wall, uterus, cervix, and bladder are then taken en bloc to the level of the apex. The complete urethra, including the meatus, is excised, and the specimen is removed from the field. Hemostasis at this stage is necessary because the vaginal wall consists of a rich vascular plexus that can be a source of intraoperative and postoperative hemorrhage. The remaining field consists of the posterior vaginal wall and an opening at the level of the introitus between the labia minora. The posterior vaginal wall is then incised in a semicircular fashion, and a plane is developed between the vagina and anterior rectal wall such that a sufficient flap of vagina can be produced to allow for coverage of the defect. This flap is then sutured to the defect using a running or interrupted 0 polyglactin braided suture [5].

When removing a portion of the bladder for malignant infiltration, the bladder can be closed either primarily or with the use of a bowel augmentation (enterocystoplasty). When closed primarily, local tissue (peritoneum) or omental interposition flaps can be used in patients at high risk for fistula formation.

The goal of the native bladder is to (1) store urine in a compliant, low-pressure reservoir, and (2) contract with significant magnitude to achieve sufficient emptying. With decreased compliance (due to radiation side effects or significant resection), the bladder will store urine at higher pressures. High storage pressures can have chronic deleterious effects on renal function, as well as presenting with symptomatic overactive bladder symptoms (detrusor overactivity). Enterocystoplasty may be considered in patients with preoperative compliance abnormalities or symptomatic bladder overactivity due to radiation therapy, as well as in patients with significant volume reduction after resection. Volume of bladder resected is a subjective indication and is difficult to quantitate at the time of surgery. Some patients closed primarily (without augmentation) will develop symptomatic storage abnormalities and may require subsequent augmentation.

As described by Rackley et al. [6], the surgical technique of enterocystoplasty has several prerequisites: