Comparative outcomes of MPPE and segmental rectosigmoid resection in cytoreductive surgery for advanced ovarian cancer

Background: To compare outcomes between modified posterior pelvic exenteration (MPPE) and segmental rectosigmoid resection performed separately from reproductive organ removal during primary cytoreductive surgery for advanced ovarian cancer. Methods: We conducted a retrospective cohort study of 113 patients who underwent cytoreductive surgery for advanced epithelial ovarian cancer with rectosigmoid resection at a single tertiary care center from 2010 to 2024. Clinical, surgical, and oncologic outcomes were compared using univariate tests, Kaplan-Meier analysis, and multivariable regression models. Results: Complete gross resection was achieved in 99% of MPPE cases and 93% of non-MPPE cases (p = 0.13). MPPE was associated with higher rates of diverting loop ileostomy (p < 0.001) but similar operative time, blood loss, hospital stay, and postoperative complication rates. Rectovaginal fistulas and anastomotic strictures were numerically less frequent in the MPPE group, and pelvic recurrence rates were similar (p = 0.84). Time from surgery to adjuvant chemotherapy was not delayed in the MPPE group (p = 0.64). Complete response to upfront treatment was higher in the MPPE group (p = 0.05). Recurrence-free survival and overall survival did not differ significantly between groups (median recurrence-free survival: p = 0.39; median overall survival: p = 0.69). Conclusions: MPPE is an effective approach for advanced ovarian cancer, achieving high rates of complete resection without increased perioperative morbidity or inferior survival. MPPE did not delay adjuvant therapy and may reduce the risk of rectovaginal fistula and stricture while maintaining similar pelvic recurrence rates. MPPE is a valuable option when en bloc resection is required to achieve optimal cytoreduction.

Advanced ovarian cancer; Cytoreductive surgery; MPPE; Rectosigmoid resection; Colorectal anastomosis; Surgical outcomes; Recurrence-free survival; Pelvic morbidity

[1] Minar L, Felsinger M, Rovny I, Zlamal F, Bienertova-Vasku J, Jandakova E. MPPE for advanced ovarian malignancies: a single-institution study of 35 cases. Acta Obstetricia et Gynecologica Scandinavica. 2017; 96: 1136–1143.

[2] Eisenkop SM, Nalick RH, Teng NN. Modified posterior exenteration for ovarian cancer. Obstetrics & Gynecology. 1991; 78: 879–885.

[3] Hoffman MS, Zervose E. Colon resection for ovarian cancer: intraoperative decisions. Gynecologic Oncology. 2008; 111: S56–S65.

[4] Bristow RE, del Carmen MG, Kaufman HS, Montz FJ. Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. Journal of the American College of Surgeons. 2003; 197: 565–574.

[5] Chang SJ, Bristow RE. Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining ‘optimal’ residual disease. Gynecologic Oncology. 2012; 125: 483–492.

[6] Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. Journal of Clinical Oncology. 2023; 41: 4065–4076.

[7] Rafii A, Stoeckle E, Jean-Laurent M, Ferron G, Morice P, Houvenaeghel G, et al. Multi-center evaluation of post-operative morbidity and mortality after optimal cytoreductive surgery for advanced ovarian cancer. PLOS ONE. 2012; 7: e39415.

[8] Rosati A, Vargiu V, Santullo F, Lodoli C, Attalla El Halabieh M, Scambia G, et al. Rectosigmoid mesorectal-sparing resection in advanced ovarian cancer surgery. Annals of Surgical Oncology. 2021; 28: 6721–6722.

[9] Son JH, Kim J, Shim J, Kong TW, Paek J, Chang SJ, et al. Comparison of posterior rectal dissection techniques during rectosigmoid colon resection as part of cytoreductive surgery in patients with epithelial ovarian cancer: close rectal dissection versus total mesorectal excision. Gynecologic Oncology. 2019; 153: 362–367.

[10] Firth D. Bias reduction of maximum likelihood estimates. Biometrika. 1993; 80: 27–38.

[11] Peiretti M, Bristow RE, Zapardiel I, Gerardi M, Zanagnolo V, Biffi R, et al. Rectosigmoid resection at the time of primary cytoreduction for advanced ovarian cancer. A multi-center analysis of surgical and oncological outcomes. Gynecologic Oncology. 2012; 126: 220–223.

[12] Kato K, Omi M, Fusegi A, Takeshima N. MPPE with pelvic side-wall resection requiring both intestinal and urinary reconstruction during surgery for ovarian cancer. Gynecologic Oncology. 2019; 155: 172–173.

[13] Wang H, Li X, Jiang Y, Chen J, Cao R, Zhang J. Clinical analysis of different intestinal reconstruction methods after primary cytoreductive surgery combined with rectal resection for advanced ovarian cancer. Frontiers in Oncology. 2025; 15: 1500042.

[14] Praiss AM, Hirani R, Zhou Q, Iasonos A, Sonoda Y, Abu-Rustum NR, et al. Impact of postoperative morbidity on outcomes in patients with advanced epithelial ovarian cancer undergoing intestinal surgery at the time of primary or interval cytoreductive surgery: a Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecologic Oncology. 2023; 179: 169–179.

[15] Ceylan ÖO, Turan İ, Erdemoglu E, González MS, Magrina J. Impact of bowel resection on operative mortality and overall survival in advanced epithelial ovarian cancer. Cancers. 2025; 17: 2086.

[16] Angeles MA, Viveros-Carreño D, Bonaldo G, Bebia V, Agustí N, Luzarraga Aznar A, et al. Pelvic peritonectomy versus rectosigmoid resection in advanced epithelial ovarian cancer with Douglas pouch involvement: a systematic review and meta-analysis. International Journal of Gynecological Cancer. 2026; 36: 101983.

[17] Gallotta V, Fanfani F, Vizzielli G, Panico G, Rossitto C, Gagliardi ML, et al. Douglas peritonectomy compared to recto-sigmoid resection in optimally cytoreduced advanced ovarian cancer patients: analysis of morbidity and oncological outcome. European Journal of Surgical Oncology. 2011; 37: 1085–1092.