Second opinion · Pelvic exenteration

A second opinion when rectal cancer has come back, or grown into nearby organs

Pelvic exenteration removes the rectum together with the nearby organs a cancer has grown into, aiming to leave no cancer behind. It is a big operation, and whether it suits you depends on fine details in your scans. Dr Daniel Lee, FRCS (Edinburgh), trained in advanced and recurrent rectal cancer surgery at the John Goligher Unit in Leeds, and has published a review of this surgery with colleagues there.

How a second opinion works

Mount Elizabeth Novena · Mount Alvernia · Parkway East · Gleneagles · Farrer Park

A quiet clinic lounge with sofas, plants and a window onto the city

FRCS (Edinburgh)

Fellow, Royal College of Surgeons of Edinburgh

Fellowship, Leeds

Colorectal fellowship, John Goligher Unit, St James's University Hospital

Ex-Head, KTPH

Former Head of Colorectal Surgery and Surgical Lead, Geriatric Surgery

Faculty, NUS

Adjunct Senior Clinical Lecturer, NUS and Lee Kong Chian School of Medicine

Second opinion

How a second opinion with Dr Lee works

You may already have a surgeon and a plan, or have been told surgery is not possible. A second opinion is a fresh, careful look at the same facts, so you can decide with confidence.

What it is

Rectum and nearby organs removed

Only the organs the cancer has reached

Who it is for

Advanced or returning rectal cancer

Grown into nearby organs, or back in the pelvis

Before deciding

A team review of your scans

MRI, CT and PET, with surgeons and cancer doctors

Your care

Your choice where it happens

Take the opinion back to your own surgeon if you wish

Before you meet
Send what you have
Scan reports, operation notes and the latest letter from your team are enough to begin. The team tells you what else is needed.
A close look at the scans
The scans answer three questions: has the cancer spread elsewhere, can it be removed completely, and how wide the operation must be. MRI is the road map for that last one.
A team view
Cases like this are discussed by surgeons, cancer doctors, radiation doctors, pathologists and radiologists: is a clear margin likely, and would treatment before surgery help?
A plain answer
You hear whether surgery is possible, what it would involve, the risks, and the other options open to you.
No pressure to move
Your decision
Take the second opinion back to your own surgeon, or ask Dr Lee to plan the treatment with you.

The operation

Where the cancer sits decides the operation

Rectal cancer comes back in the pelvis less often than it used to. With modern surgery and radiotherapy, 5-year rates of 5 to 10% are now reported, against 20 to 30% before, and most come back within 2 years of the first operation.

When it does, where it sits shapes everything. Dr Lee's review describes three patterns: in the centre of the pelvis, on the side walls, and at the back against the sacrum, the bone at the base of the spine. A central recurrence has the highest chance of being removed completely. One that has grown into bone or the side wall needs a wider operation.

Pelvic exenteration takes out the rectum, or the recurrence, together with the organs it has reached: the bladder, the womb and vagina, or the prostate. Sometimes only part of an organ needs to go. Where the cancer has reached bone, part of the sacrum or pubic bone may be removed with it.

Afterwards the pelvis is rebuilt. A flap of muscle, often from the tummy wall, can fill the space and help the wound heal. If the bladder is removed, a new way to pass urine is made from a short piece of bowel (an ileal conduit).

Centre: the rectum, with the bladder, womb, vagina or prostate in front of it
Side walls: the blood vessels, nerves and ureters at each side
Back: the sacrum, the bone at the base of the spine

The pelvis seen from above, drawn after the three patterns in Dr Lee's 2017 review.

Who it suits

When a second opinion on this surgery can help

A second opinion may help if

Rectal cancer has come back in the pelvis after earlier surgery
A new rectal cancer has grown into the bladder, womb, vagina, prostate or bone
You were told the cancer cannot be removed, and want a second look
You have been offered pelvic exenteration and want to understand it before you decide
The cancer has also spread elsewhere, which does not always rule surgery out

It may not be the right path when

The cancer has spread too widely for surgery to remove it
Scans show a clear margin is unlikely, so the operation would leave cancer behind
Your general health would make a very long operation unsafe
You would rather focus on comfort and quality of life, a choice that deserves respect

Published results

What the published figures show

Results from published studies, gathered in Dr Lee's 2017 review, not a promise of your result.

5 to 10%

Comes back in the pelvis

Within 5 years of modern rectal cancer surgery, down from 20 to 30% before. Most do so within 2 years.

35 to 50%

5-year survival

After surgery for cancer that came back, in reports from centres that do this work often.

62%

Removed with a clear margin

In recurrent cases in one large series, against 91% for first-time cancers. With a clear margin, survival was similar: 79% and 85%.

33 to 75%

Have a complication

Reported after pelvic exenteration. Between 2 and 14 in 100 do not survive the operation, which is why choosing the right patient matters.

What to bring

What to bring to a second opinion

Your scans

The images on a disc or a link, as well as the reports: MRI of the pelvis, CT, and PET if you had one.

Your first operation

The operation notes and the pathology report, which show how the first cancer was removed.

Earlier treatment

Letters on any radiotherapy or chemotherapy, with dates, because earlier radiotherapy changes the order of treatment.

Bring your questions too, and someone close to you if you like. Missing a document is fine; the team can ask for it.

Dr Lee's work on this surgery

Trained in this surgery in Leeds, and written about it

Dr Lee's colorectal fellowship was at the John Goligher Unit, St James's University Hospital, Leeds. In 2017 he and colleagues there published a review of surgery for rectal cancer that has come back in the pelvis, covering scans, team planning, each pattern of recurrence and the newer, wider operations.

He was later Head of Colorectal Surgery at Khoo Teck Puat Hospital. His review ends on the point that guides a second opinion with him: a careful look at whether the operation is right for you, not only whether it can be done.

Although surgical options for [recurrent rectal cancer] have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.

Dr Daniel Lee and colleagues, World Journal of Gastroenterology, 2017

Common questions

Pelvic exenteration and second opinions, answered plainly

What is pelvic exenteration?

An operation that removes the rectum, or a cancer that has come back in the pelvis, together with the nearby organs it has grown into. Depending on where the cancer is, that can mean the bladder, the womb and vagina, the prostate, or part of the sacrum. The aim is to remove all of the cancer with a clear margin around it.

Why get a second opinion?

Because the decision is big either way. Whether surgery is possible depends on fine details in the scans, and surgeons with different training can read them differently. A second look at the scans and the plan helps you decide with more confidence.

Will I need a stoma?

Often, yes. To remove the cancer with a wide margin, the bowel is usually not joined back together, so a permanent colostomy is common. If the bladder is removed, a second opening for urine (an ileal conduit) is made. Dr Lee explains what your operation would involve before you decide.

Can it be done by keyhole surgery?

Rarely. Only a few small series of keyhole operations for recurrent rectal cancer have been published, and none of them were exenterations. Most of these operations are done as open surgery.

The cancer has also spread to my liver or lungs. Is surgery ruled out?

Not always. About half of people whose rectal cancer comes back in the pelvis also have spread elsewhere. Where that spread can be treated too, surgery in the pelvis may still be considered. It is decided case by case.

I had radiotherapy before. Does that change things?

It changes the order. If you have had pelvic radiotherapy before, surgery usually comes next. If you have not, chemoradiation is usually given first, with surgery about 6 weeks after it ends.

Do I have to move my care to Dr Lee?

No. A second opinion is yours to use. You can take it back to your current surgeon, or ask Dr Lee's team to plan treatment with you.

Does insurance cover a second opinion?

It depends on your plan. The team checks what your insurer covers and gives you a written estimate before anything is booked.

Fees & insurance

Fees, MediSave and insurance for a second opinion

Every case is different. The fee for a consultation, and for any treatment that follows, is explained clearly and confirmed in writing before anything is booked. The team checks what MediSave and your Integrated Shield plan cover.

Dr Daniel Lee practises with Colorectal Clinic Associates (CCA). The clinic works with the insurers below, and the team assists with claims and eligibility checks.

Integrated Shield Plans