A Novel Classification of Posterior Pelvic Exenteration to Assess Prognosis in Female Patients with Locally Advanced Primary Rectal Cancer: A Retrospective Cohort Study from China PelvEx Collaborative

A Novel Classification of Posterior Pelvic Exenteration to Assess Prognosis in Female Patients with Locally Advanced Primary Rectal Cancer: A Retrospective Cohort Study from China PelvEx Collaborative | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Novel Classification of Posterior Pelvic Exenteration to Assess Prognosis in Female Patients with Locally Advanced Primary Rectal Cancer: A Retrospective Cohort Study from China PelvEx Collaborative Yuegang Li, Meng Zhuang, Gang Hu, Jinzhu Zhang, Wenlong Qiu, Shiwen Mei, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3985276/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Apr, 2024 Read the published version in International Journal of Colorectal Disease → Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that warrant additional assessment. Therefore, we compared short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification. Methods We retrospectively analysed a prospective database from China PelvEx Collaborative in three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified into four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed. Results Differences were significant among the four groups regarding colorectal reconstruction ( p < 0.001), vaginal reconstruction ( p < 0.001), in-hospital complications ( p < 0.05), and urinary retention ( p < 0.05). The R 0 resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, PPE-IV demonstrated the lowest 5-year overall survival rate ( p < 0.001) and 5-year disease-free survival rate ( p < 0.001). Conclusion The Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer. posterior pelvic exenteration oncological outcome Peking classification locally advanced rectal cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Locally advanced rectal cancer (LARC) often requires neoadjuvant chemoradiation (nCRT) combined with total mesorectal excision to achieve complete resection margins, minimise local recurrence rates, and enhance survival. While the European Society for Medical Oncology guidelines endorse nCRT for LARC [ 1 ], the debate over its ability to achieve satisfactory tumour stage reduction and local control in LARC remains controversial and requires further clarification [ 2 ]. Extensive surgery, frequently the only recourse for achieving complete resection for local control and palliation, raises concerns about patient survival. Total pelvic exenteration (TPE), involving resection of the rectum, bladder, lower ureters, and internal reproductive organs, could potentially impact patient survival [ 3 ]. However, TPE, an invasive radical treatment approach, is associated with considerable morbidity and mortality [ 4 , 5 ]. Additionally, TPE is relatively rare in female patients owing to their anatomy. Conversely, posterior pelvic exenteration (PPE) involving resection of the uterus, cervix, and vagina is a more commonly performed procedure. Despite the growing number of PPE procedures in the context of gynaecological tumours [ 6 ], the utilisation of PPE procedures for rectal cancer remains limited, often represented by a handful of reports with small sample case descriptions [ 7 ]. The use of PPE in the treatment of rectal cancer has not been extensively studied, particularly concerning surgical methods and oncological outcomes. Moreover, performing PPE for rectal cancer presents heightened challenges compared to TPE due to the imperative of organ preservation while achieving R 0 resection [ 8 ]. Consequently, a dedicated study on LARC involving internal reproductive organs and evaluating both short-term and oncological outcomes is essential. In this study of a specific group of individuals, carried out through the China PelvEx collaboration, we introduced a novel classification system for PPE and comprehensively investigated surgical outcomes and oncological prognosis based on this classification. Within this classification, PPE was categorised into four subtypes: PPE-I (uterine invasion), PPE-II (upper vaginal invasion), PPE-III (lower vaginal invasion), and PPE-IV (major vaginal invasion). Based on the TNM staging and rectal MRI, further clinical decisions might be better informed by this new classification. Materials and methods Ethical approval and patient consent The study received approval from the Ethics Committee of several institutions, including the Cancer Hospital of the Chinese Academy of Medical Sciences, Peking University First Hospital, and Gansu Provincial Hospital (approval number 22/442–3644). Written consent was obtained from all participants. Patients This retrospective study employed a multicentre approach to analyse data derived from a prospectively collected institutional database and tumour registry. This study focused on cT4b female patients who underwent multivisceral resection (MVR) across three institutions in the China PelvEx Collaboration between January 2010 and December 2020. The study encompassed consecutive female patients with LARC who underwent PPE implantation. The inclusion criteria comprised: (1) female patients with LARC (cT4b), (2) radical resection, and (3) histologically confirmed adenocarcinoma. Exclusion criteria were: (1) total pelvic exenteration (TPE), (2) recurrent rectal cancer, (3) simultaneous distant metastasis, (4) ovarian or adnexal proctectomy, and (5) PPE with sacrectomy. Prior to surgery, each patient underwent a comprehensive preoperative multidisciplinary consultation, wherein a group of experts from various fields, including radiotherapy, colorectal surgery, urology, gynaecology, and plastic surgery, was brought together. The salient role of multidisciplinary team meetings was underscored in the formulation of personalised treatment strategies. These deliberations encompassed pivotal determinations, including the selection of surgical approach (laparoscopic or open) and consideration of the potential use of preoperative chemoradiotherapy. Preoperative Management For those in the clinical stage of T4b, nCRT was advised, involving a standardised long-course chemotherapy regimen centred on 5-fluorouracil (5-FU), concomitant with external radiation administered at a cumulative dose of 45–54 Gy. Subsequent to nCRT, patients underwent reassessment through pelvic MRI. Surgery was scheduled approximately 8–12 weeks after completing the nCRT. Data Collection and Follow-up Information was collected on a range of clinicopathological factors, including age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, neoadjuvant treatment, tumour size, pathologic stage, as well as serum levels of haemoglobin (Hb), albumin (Alb), carcinoembryonic antigen (CEA), and carbohydrate antigen 199 (CA199). Additionally, perioperative outcomes were documented, involving operative time, blood loss, type of colorectal and vaginal reconstruction, circumferential resection margin (CRM) status, the number of retrieved or positive lymph nodes, morbidity, length of hospital stay, and postoperative complications. The classification of complications adhered to the Clavien–Dindo system, which differentiates between minor surgical complications (grades I or II) and major complications (grades III, IV, or V). Patient follow-up took place through telephone conversations or outpatient department visits. The primary endpoints of this study were 5-year overall survival (OS), disease-free survival (DFS), and 5-year local recurrence survival (LRS) in alignment with the Peking classification. Additionally, secondary endpoints were directed towards the assessment of surgical complications using the Peking classification and the exploration of prognostic factors influencing survival outcomes. New Classification and Surgical Procedures The absence of a universally agreed-upon definition for PPE within rectal cancer surgery has led to various proposed interpretations. Some definitions have been influenced by those established for gynaecological tumours [ 9 , 10 ], while others emphasise specific anatomical regions such as the sacrum, retrosacral space, presacral fascia, and coccyx [ 11 , 12 ]. In this study, PPE was defined as the extraction of the internal reproductive organs (uterus, cervix, and vagina) and rectum while preserving the bladder [ 13 ]. R 0 resection was defined as tumour resection with pathologically confirmed negative margins, devoid of distant metastasis, and maintaining a CRM exceeding 1 mm. Surgical interventions were exclusively performed by surgeons with more than 10 years of experience in rectal cancer resection. Drawing from our experience with pelvic exenteration, we introduced an innovative Peking classification system distinct from the PPE infralevator (PPEI) and PPE supralevator (PPES). Within this classification, PPE was categorised into four subtypes based on the preoperative MRI and the specific processes involved in the surgery: PPE-I (uterine invasion), PPE-II (upper vaginal invasion), PPE-III (lower vaginal invasion), and PPE-IV (major vaginal invasion). PPE-I involved instances where the uterus faced upper uterine invasion, prompting an anterior resection (AR) combined with a hysterectomy. The vagina was wholly preserved (Fig. 1 A), with subsequent suturing and performance of colorectal anastomosis or Hartmann’s procedure [ 14 , 15 ]. PPE-II encompassed cases of middle or low rectal cancer infiltration into the upper vagina or cervix, warranting low anterior resection (LAR) and hysterectomy coupled with upper vaginal dissection. Partial vaginal preservation and suturing followed this procedure (Fig. 1 B). PPE-III emerged when the lower vagina encountered invasion, necessitating abdominal perineal resection (APR) and posterior vaginal wall wedge resection, followed by suturing (Fig. 1 C). PPE-IV corresponded to instances mirroring PPE-II during the abdominal phase while encompassing the complete dissection of the posterior wall. Reconstruction of the residual vagina was undertaken via V-Y plasty or gluteal fold flap reconstruction (Fig. 1 D). Statistical Analysis Statistical analyses were carried out using IBM SPSS Statistics 26 (IBM, Inc., Armonk, NY, USA). Categorial variable comparisons were undertaken through Pearson’s chi-squared and Fisher’s exact tests, while continuous variable analyses involved the Kruskal–Wallis H test. To ascertain probabilities associated with OS, DFS, and LRS, the Kaplan–Meier method was employed, with subsequent comparisons using the log-rank test to identify significant differences in outcomes. Variables found to be significant in the univariate analysis were further examined using a Cox regression model in a multivariate analysis. A p-value of < 0.05 was considered statistically significant. Results Patient Characteristics A total of 172 patients diagnosed with rectal cancer and undergoing PPE involving the inner reproductive organs were included in this study, and they were separated into four distinct groups: PPE-I 37.2% (64/172), PPE-II 39.6% (68/172), PPE-III 12.2% (21/172), and PPE-IV 11.0% (19/172). The study’s flowchart is depicted in Fig. 2 , while a comprehensive overview of baseline patient characteristics is summarised in Table 1 . Across the four groups, no statistically significant differences were observed in terms of age, BMI, ASA score, comorbidities, neoadjuvant therapy, surgical approach, tumour size, tumour differentiation, (y)pT4b stage, (y)pN + stage, history of abdominal surgery, or laboratory test results. Table 1 Characteristics of patients in four groups Variables PPE-I (64) PPE-II (68) PPE-III (21) PPE-IV (19) P Age > 60, years 32(50.0) 33(48.5) 11(52.4) 10(52.6) 0.98 BMI > 23.9, kg/m 2 28(43.8) 25(36.8) 9(42.9) 8(42.1) 0.86 ASA category 0.97 I-II 56(87.5) 59(86.8) 19(90.5) 17(89.5) III 8(12.5) 9(13.2) 2(9.5) 2(10.5) Comorbidity 30(46.9) 31(45.6) 7(33.3) 12(63.2) 0.31 Surgery history 17(26.6) 22(32.4) 5(23.8) 8(42.1) 0.53 Preoperative treatment 0.70 Chemoradiotherapy 19(29.7) 17(25.0) 8(38.1) 6(31.6) None 45(70.3) 51(75.0) 13(61.9) 13(68.4) Surgical approach 0.35 Open 36(56.3) 28(41.2) 10(47.6) 8(42.1) Laparoscopic 28(43.7) 40(58.8) 11(52.4) 11(57.9) Tumor size, mm 0.48 >35 54(84.4) 53(77.9) 17(81.0) 13(68.4) ≤ 35 10(15.6) 15(22.1) 4(19.0) 6(31.6) Differentiation degree 0.79 Well/ Moderate 45(70.3) 38(55.9) 14(66.7) 11(57.9) Poor 19(29.7) 30(44.1) 7(33.3) 8(42.1) (y)pT stage 0.11 T 0 -T 4a 32(50.0) 23(33.8) 5(23.8) 8(42.1) T 4b 32(50.0) 45(66.2) 16(76.2) 11(57.9) (y)pN stage 0.72 N 0 37(57.8) 33(48.5) 11(52.4) 9(47.4) N 1 -N 2 27(42.2) 35(51.5) 10(47.6) 10(52.6) Vascular invasion 18(28.1) 18(26.5) 5(23.8) 6(31.6) 0.95 Perineural invasion 13(20.3) 20(29.4) 6(28.6) 7(36.8) 0.45 Hb < 110 g/L 28(43.8) 20(29.4) 9(42.9) 6(31.6) 0.32 ALB 5 ng/ml 28(43.8) 35(51.5) 8(38.1) 8(42.1) 0.66 CA199 > 37 U/ml Enrolled centers NCC PKUFM GSH 9(14.1) 35(54.7) 24(37.5) 5(7.8) 15(22.1) 40(58.8) 17(25.0) 11(16.2) 4(19.0) 7(33.3) 10(47.6) 4(19.1) 6(31.6) 8(42.1) 10(52.6) 1(5.3) 0.40 0.11 Perioperative and Pathological Results The intraoperative data and pathological results are presented in Table 2 . Significant differences were observed among the four groups in terms of the type of colorectal reconstruction ( p < 0.001) and vaginal reconstruction ( p < 0.001). However, no significant differences were identified regarding operative time, blood loss, or the count of retrieved and positive lymph nodes. The R 0 resection rates within the PPE-I, PPE-II, PPE-III, and PPE-IV subgroups were 90.6%, 89.7%, 90.5%, and 89.5%, respectively, with an overall positive CRM rate of 9.9%. Table 2 Intraoperative and pathologic characteristics in four groups Variables PPE-I (64) PPE-II (68) PPE-III (21) PPE-IV (19) P Operative time, min 266(212–356) 240(203–297) 255(192–308) 253(205–357) 0.21 blood loss, ml 265(100–500) 100(50–315) 100.0(50–725) 200(60–500) 0.11 Colorectal reconstruction < 0.001 LAR 55(85.9) 48(70.6) 0(0) 0(0) Hartmann 9(14.1) 20(29.4) 0(0) 0(0) APR 0(0) 0(0) 21(100) 19(100) Vagina reconstruction < 0.001 Suture 64(100) 68(100) 21(100) 0(0) Plasty 0(0) 0(0) 0(0) 19(100) No. of retrieved lymph nodes 22(15–29) 21(14–27) 20(14–24) 16(13–24) 0.32 No. of positive lymph nodes 0(0–3.0) 0.5(0–2.0) 1(0–2.0) 1(0–2.0) 0.998 CRM status 0.998 CRM > 1 mm 58(90.6) 61(89.7) 19(90.5) 17(89.5) CRM ≤ 1 mm 6(9.4) 7(10.3) 2(9.5) 2(10.5) Postoperative Recovery and Complications Information on postoperative recovery and complications can be found in Table 3 . There were no reports of postoperative deaths in any of the groups. The rate of complications that occurred while patients were in the hospital was 36.6% (63/172 patients). Specific to subgroup analysis, the complication rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 32.8%, 33.8%, 47.6%, and 47.4%, respectively ( p < 0.001). Notably, no statistically significant differences were detected among the four groups concerning reoperation rate ( p = 0.49), length of postoperative hospitalisation ( p = 0.69), anastomotic leakage rate ( p = 0.84), and the surgical site infection (SSI) complication rate, including abdominal incisions ( p = 0.60), perineal incisions (p = 0.16), pelvic infections ( p = 0.37), and urinary infections ( p = 0.09). Compared to the PPE-III/IV group, the PPE-I/II group had a significantly lower rate of urinary retention ( p = 0.04). Table 3 Postoperative parameters among four groups Variables PPE-I (64) PPE-II(68) PPE-III (21) PPE-IV (19) P Mortality 0(0) 0(0) 0(0) 0(0) 1.00 Clavien–Dindo grade 0.03 0 43(67.2) 45(66.2) 11(52.4) 10(52.6) I-II 19(29.7) 21(30.9) 6(28.6) 5(26.3) III-IV 2(3.1) 2(2.9) 4(19.0) 4(21.1) Surgical reintervention 2(3.1) 2(2.9) 1(4.8) 2(10.5) 0.49 Surgical site infection 13(20.3) 8(11.8) 2(9.5) 5(26.3) 0.27 Abdominal incision 7(10.9) 5(7.4) 1(4.8) 3(15.8) 0.60 Perineal incision a - - 2(9.5) 5(26.3) 0.16 Pelvic infection 5(7.8) 4(5.9) 0(0) 0(0) 0.37 Urinary infection 1(1.6) 1(1.5) 0(0) 2(10.5) 0.09 Rectal anastomotic leakage b 4(7.3) 3(6.3) - - 0.84 Intestinal leakage/fistula 0(0) 0(0) 0(0) 2(10.5) 0.001 Urinary leakage 1(1.6) 0(0) 0(0) 0(0) 0.64 Ileus 4(6.3) 7(10.3) 2(9.5) 1(5.3) 0.80 Pulmonary embolism 0(0) 1(1.5) 0(0) 0(0) 0.67 Urinary retention 6(9.4) 5(7.4) 6(28.6) 4(21.1) 0.04 Length of stay (days) 11(9–16) 11(8–14) 12(8–14) 10(8–15) 0.69 a: For patients receiving abdominal perineal resection only (40 cases in PPE-III and PPE-IV group) b: For patients receiving colorectal anastomosis only (132 cases in PPE-I and PPE-II group) Oncological Outcomes The median follow-up period spanned 40 months (interquartile range: 21–69 months) for the entire cohort, with subsequent subdivisions into 51 months (interquartile range: 32–89 months) for the PPE-I group, 31 months (interquartile range: 15–63 months) for the PPE-II group, 38 months (interquartile range: 24–79 months) for the PPE-III group, and 29 months (interquartile range: 13–62 months) for the PPE-IV group. Comprehensive follow-up was successfully conducted for all patients throughout the study period. The four groups showed significant differences in OS ( p < 0.001), DFS, and LRS ( p < 0.001) (Figs. 3 A, 3 B, and 3 C). The 5-year OS rates were 73.4%, 68.8%, 54.7%, and 37.3% in the PPE-I, PPE-II, PPE-III, and PPE-IV groups, respectively. Correspondingly, the 5-year DFS rates for the four groups were 76.0%, 62.5%, 57.7%, and 43.1%. Furthermore, the 5-year LRS rates were 24.0%, 37.5%, 42.3%, and 56.9% for the same groups. Additionally, there were significant differences in the 5-year OS and 5-year DFS rates among the subgroups categorised by CRM status (Figs. 4 A and 4 B) ( p < 0.001) and tumour differentiation (Figs. 5 A and 5 B ) ( p < 0.001). The 5-year OS rates reached 68.3% and 22.7% for the negative and positive CRM groups, respectively. In parallel, the 5-year DFS rates were 67.8% and 30.3% for the corresponding subgroups. In terms of tumour differentiation, the 5-year OS rates amounted to 71.9% and 46.5% for well/moderately and poorly differentiated subgroups, respectively. Similarly, the 5-year DFS rates were 72.3% and 42.2% for the same subgroups. The influence of prognostic factors on OS and DFS, as determined by univariate and multivariate analyses, is presented in Table 4 . In the univariate analysis, age > 60 years, higher Peking classification type, positive CRM, (y)pT stage, and poor differentiation were identified as independent risk factors for both OS and DFS ( p < 0.05). Further analysis unveiled that a higher Peking classification type (hazard ratio [HR] = 3.48, 95% confidence interval [CI], 1.65–7.36, p < 0.001), negative CRM status (HR = 3.59, 95% CI, 1.80–7.17, p < 0.001), and poor differentiation (HR = 2.81, 95% CI, 1.64–4.83, p < 0.001) independently contributed to OS. In parallel, higher Peking classification type (HR = 4.12, 95% CI, 1.85–9.15, p < 0.001), negative CRM status (HR = 2.89, 95% CI, 1.23–6.83, p = 0.015), and poor differentiation (HR = 2.12, 95% CI, 1.27–3.81, p = 0.005) were established as independent risk factors for DFS. Table 4 Univariate and multivariate analysis for overall survival and disease-free survival Variables Overall survival Diseases-free survival Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis HR (95%CI) p HR (95%CI) p HR (95%CI) p HR (95%CI) p Age 1.68(1.06–2.07) 0.03 1.53(0.95–2.47) 0.08 1.56(0.96–2.55) 0.07 1.49(0.87–2.54) 0.15 nCRT (yes/no) 0.82(0.50–1.33) 0.42 1.00(0.60–1.65) 0.99 CEA 1.28(0.81–2.02) 0.30 1.24(0.76–2.01) 0.40 CA199 1.21(0.70–2.11) 0.49 1.14(0.63–2.05) 0.67 Surgical approach (laparoscopic/open) 0.80(0.51–1.28) 0.35 0.67(0.41–1.11) 0.12 PPE classification (PPE-I) < 0.001 0.01 < 0.001 0.005 PPE-II 2.58(1.41–4.72) 0.002 1.92(1.03–3.60) 0.04 3.15(1.64–6.03) 0.001 2.46(1.27–4.78) 0.008 PPE-III 2.57(1.26–5.25) 0.010 2.20(1.05–4.60) 0.04 2.71(1.17–6.26) 0.02 2.47(1.06–5.78) 0.04 PPE-IV 5.84(2.92–12.10) < 0.001 3.48(1.65–7.36) 0.001 6.50(3.03–13.90) < 0.001 4.12(1.85–9.15) 0.001 CRM status (positive/negative) 4.27(2.22–8.20) < 0.001 3.59(1.80–7.17) < 0.001 4.41(2.23–8.74) < 0.001 2.89(1.23–6.83) 0.015 Perineural invasion (yes/no) 1.25(0.72–2.15) 0.43 1.72(1.01–2.92) 0.045 1.22(0.62–2.42) 0.56 Lymphatic invasion (yes/no) 0.67(0.40–1.24) 0.20 0.91(0.50–1.64) 0.74 Differentiation (well/ moderate, poor) 3.45(2.03–5.87) < 0.001 2.81(1.64–4.83) < 0.001 2.65(1.54–4.56) < 0.001 2.12(1.27–3.81) 0.005 (y)pT stage(T4b/non-T4b) 1.67(1.03–2.72) 0.04 1.03(0.61–1.73) 0.91 1.87(1.10–3.21) 0.02 1.18(0.67–2.07) 0.57 (y)pN stage (N1-2/N0) 1.17(0.74–1.84) 0.51 1.39(0.86–2.27) 0.18 Postoperative complications(yes/no) 1.31(0.83–2.08) 0.24 1.47(0.91–2.38) 0.12 Discussion Currently, there is an absence of evidence, both surgical and oncological, supporting the use of PPE in cases of cT4b rectal cancer involving the female internal reproductive organs. This study stands as the largest and first examination of cT4b rectal cancer involving the female internal reproductive organs. Based on this new classification, our findings demonstrate the safety and feasibility of PPE involving the female internal reproductive organs. Traditionally, PPEs are classified into PPEI and PPES based on rectal cancer height and anal preservation. Our surgical experience led to the formulation of the novel Peking classification for PPE, closely tethered to the surgical plan. This classification reflects both the site of reproductive system invasion and rectal cancer height. Notably, the results of this study indicate a significant correlation between oncological outcomes, including OS and DFS, and the Peking classification. Higher grades of classification are indicative of poorer oncological outcomes. As a result, further studies into PPE-IV management, encompassing preoperative multidisciplinary team consultation, neoadjuvant chemoradiotherapy, and extended radical excision, are warranted to enhance surgical and oncological outcomes. A study conducted by the National Cancer Center of Mexico enrolled 59 patients, with 51 and 8 undergoing PPE and TPE, respectively. This study reported an operative mortality rate of 3% (two cases), while postoperative complications were experienced by 29 patients (49.2%) [ 16 ]. Our study’s overall in-hospital complication rate was 36.6% (63/172). Among the four grgvoups, there were no statistically significant differences in terms of reoperation rate ( p = 0.49), postoperative hospital stay ( p = 0.69), anastomotic leakage rate ( p = 0.84), or SSI complication rate ( p = 0.27). Our study’s incidence of complications was lower than that reported by others [ 17 , 18 ], a trend potentially linked to the evolution of laparoscopy in PPE surgery and surgical approaches based on the Peking classification. Prognostic factors linked to survival rate in patients undergoing PPE include pathological nodal status, preoperative radiotherapy and chemotherapy, and pathological node status, although consensus is lacking. In our study, multivariate analysis established higher Peking classification type, CRM status, and poor differentiation as independent risk factors for both OS and DFS ( p < 0.001). This underscores the significance of our proposed PPE classification for cT4b rectal cancer involving the female internal reproductive organs. The R 0 resection rate stands as a critical parameter for assessing surgical quality. Unlike TPE, PPE allows organ-sparing surgery, preserving the bladder and innervating nerves. Consequently, achieving R 0 resection is more challenging in PPE compared to TPE. To preserve the bladder and pelvic plexus nerves during PPE, the dissection plane must be close to the parametrial tissue and paracolpium. This factor can impact the attainment of R 0 resection [ 19 , 20 ]. In our study, the R 0 resection rates for the PPE-I, PPE-II, PPE-III, and PPE-IV subgroups were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year OS and DFS rates in the negative CRM subgroup were 68.3% and 67.8%, respectively. A recent systematic review reported a lower median R 0 resection rate of 82.6% (range 66–95.5%) for LARC and a lower median 5-year survival rate of 32% [ 21 ]. Our results show promise, potentially attributed to the focused inclusion of patients with rectal cancer involving the female internal reproductive organs. Furthermore, adopting this new PPE classification, which facilitates varied surgical approaches based on tumour location, might improve R 0 resection rates and enhance long-term survival outcomes. This study has limitations, including its retrospective design, potential patient selection bias, and a relatively small number of cases. Additionally, the results may have been influenced by the limited data available for evaluating bladder function. Further research is needed to determine if the findings are applicable to male patients. Finally, less than one-third of patients with LARC received nCRT, and the lack of clinical data on postoperative adjuvant therapy could also potentially affect the prognosis, introducing bias into the analysis of the neoadjuvant role on survival. Conclusions This study introduced the novel classification of PPE; to the best of our knowledge, it is the most extensive assessment of short-term outcomes and oncological results in female patients to date. The new Peking classification facilitates precise surgery and correlates with survival outcomes. Investigating the impact of inflammation and cancer invasion in different reproductive organs on prognosis represents a promising avenue for future research. Therefore, further studies on the management of PPE-IV, in terms of preoperative multidisciplinary team consultation, neoadjuvant chemoradiotherapy, and extended radical excision, should be performed to improve surgical and oncological outcomes. Declarations Acknowledgements: The authors thank all members and staff in the China PelvEx collaborative for collecting data. This study was supported by grants from the National Natural Science Foundation of China (No. 82072732) and Beijing Natural Science Foundation (L222054,4232058) Author contributions: All authors contributed to the conception and design of the study. Material preparation, data collection, and analyses were performed by Yuegang Li, Meng Zhuang, Gang Hu, Jinzhu Zhang, Wenlong Qiu, Shiwen Mei, and Jianqiang Tang. Yuegang and Meng Zhuang wrote the first draft of the manuscript. All authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript. Compliance with Ethical Standards Conflicts of Interest and Source of Funding : The authors declare no conflicts of interest.. Data availability : The data will be made available upon request from the corresponding author. Ethical approval and patient consent The study received approval from the Ethics Committee of several institutions, including the Cancer Hospital of the Chinese Academy of Medical Sciences, Peking University First Hospital, and Gansu Provincial Hospital (approval number 22/442–3644). Written consent was obtained from all participants. References Glynne-Jones R, Wyrwicz L, Tiret E et al (2018) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 29:iv263. https://doi.org/10.1093/annonc/mdy161 Denost Q, Kontovounisios C, Rasheed S et al (2017) Individualizing surgical treatment based on tumour response following neoadjuvant therapy in T4 primary rectal cancer. Eur J Surg Oncol 43:92–99. https://doi.org/10.1016/j.ejso.2016.09.004 Austin KKS, Herd AJ, Solomon MJ, Ly K, Lee PJ (2016) Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer. Dis Colon Rectum 59:831–835. https://doi.org/10.1097/DCR.0000000000000656 Radwan RW, Jones HG, Rawat N et al (2015) Determinants of survival following pelvic exenteration for primary rectal cancer. Br J Surg 102:1278–1284. https://doi.org/10.1002/bjs.9841 López-Basave HN, Morales-Vásquez F, Herrera-Gómez A, Rosciano AP, Meneses-García A, Ruiz-Molina JM (2012) Pelvic exenteration for colorectal cancer: oncologic outcome in 59 patients at a single institution. Cancer Manag Res 4:351–356. https://doi.org/10.2147/CMAR.S34545 Houvenaeghel G, de Nonneville A, Blache G et al (2022) Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes. J Gynecol Oncol 33:e31. https://doi.org/10.3802/jgo.2022.33.e31 Pokharkar A, Bankar S, Rohila J, Jaiswal D, deSouza A, Saklani A (2020) Laparoscopic Posterior Pelvic Exenteration (Complete and Supralevator) for Locally Advanced Adenocarcinoma of the Rectum in Females: Surgical Technique and Short-Term Outcomes. J Laparoendosc Adv Surg Tech A 30:558–563. https://doi.org/10.1089/lap.2019.0691 Xin K, Ng D, Tan G, Teo MC (2014) Role of Pelvic Exenteration in the Management of Locally Advanced Primary and Recurrent Rectal Cancer. J Gastrointest Cancer 45:291–297. https://doi.org/10.1007/s12029-014-9586-y Yang T, Morris D, Chua T (2013) Pelvic Exenteration for Rectal Cancer: A Systematic Review. Dis Colon Rectum 56:519–531. https://doi.org/10.1097/DCR.0b013e31827a7868 Kazi M, Kumar N, Rohila J et al (2021) Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes. BJS Open 5:zrab074. https://doi.org/10.1093/bjsopen/zrab074 Koh C, Solomon M, Brown K et al (2017) The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases. Dis Colon Rectum 60:627–635. https://doi.org/10.1097/DCR.0000000000000825 PelvEx Collaborative (2019) Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg 269:315–321. https://doi.org/10.1097/SLA.0000000000002528 Revaux A, Rouzier R, Ballester M, Selle F, Daraï E, Chéreau E (2012) Comparison of Morbidity and Survival Between Primary and Interval Cytoreductive Surgery in Patients After Modified Posterior Pelvic Exenteration for Advanced Ovarian Cancer. Int J Gynecol Cancer 22:1349–1354. https://doi.org/10.1097/IGC.0b013e318265d358 Kato K, Tate S, Nishikimi K, Shozu M (2013) Bladder function after modified posterior exenteration for primary gynecological cancer. Gynecol Oncol 129:229–233. https://doi.org/10.1016/j.ygyno.2013.01.013 Gheorghe M, Cozlea AL, Kiss SL et al (2021) Primary pelvic exenteration: Our experience with 23 patients from a single institution. Exp Ther Med 22:1060. https://doi.org/10.3892/etm.2021.10494 Ghouti L, Pereira P, Filleron T et al (2015) Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: A single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010. Am J Surg 209:352–362. https://doi.org/10.1016/j.amjsurg.2014.01.008 Akasu T, Yamaguchi T, Fujimoto Y et al (2007) Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns. Ann Surg Oncol 14:74–83. https://doi.org/10.1245/s10434-006-9082-0 Park JK, Kim YW, Hur H et al (2009) Prognostic factors affecting oncologic outcomes in patients with locally recurrent rectal cancer: impact of patterns of pelvic recurrence on curative resection. Langenbecks Arch Surg 394:71–77. https://doi.org/10.1007/s00423-008-0391-6 Nielsen M, Rasmussen P, Lindegaard J, Laurberg S (2012) A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database. Colorectal Dis 14:1076–1083. https://doi.org/10.1111/j.1463-1318.2011.02893.x Bhangu A, Ali S, Brown G, Nicholls RJ, Tekkis P (2014) Indications and Outcome of Pelvic Exenteration for Locally Advanced Primary and Recurrent Rectal Cancer. Ann Surg 259:315–322. https://doi.org/10.1097/SLA.0b013e31828a0d22 Platt E, Dovell G, Smolarek S (2018) Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol 22:835–845. https://doi.org/10.1007/s10151-018-1883-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Apr, 2024 Read the published version in International Journal of Colorectal Disease → Version 1 posted Reviews received at journal 23 Mar, 2024 Reviewers agreed at journal 15 Mar, 2024 Reviewers invited by journal 28 Feb, 2024 Editor assigned by journal 26 Feb, 2024 Submission checks completed at journal 26 Feb, 2024 First submitted to journal 24 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3985276","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275388459,"identity":"cb32e18b-6622-4aca-a590-550423dcf460","order_by":0,"name":"Yuegang Li","email":"","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuegang","middleName":"","lastName":"Li","suffix":""},{"id":275388460,"identity":"51ee7c62-e66d-4c36-abf6-98a85a7e8933","order_by":1,"name":"Meng Zhuang","email":"","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Meng","middleName":"","lastName":"Zhuang","suffix":""},{"id":275388461,"identity":"2d3a5089-70e5-4ba0-86c9-ab6e7ef4b447","order_by":2,"name":"Gang Hu","email":"","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Hu","suffix":""},{"id":275388462,"identity":"c569ec04-eeab-4bce-90e1-3df6c927aec6","order_by":3,"name":"Jinzhu Zhang","email":"","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical 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Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYDCCAyCCh0HOAMwzsCBSywEeBmMDBmaQFglitTAwJG4Aa2EgQgvf8eYHzB9krNO3s/cf3fCjQIKBv707Aa8WyTPHDIAOS8/d2XOY7WYP0GESZ85uwKvF4EYOyC+HczfcSGa7wQPUYiCRS5yWdAOglpt/SNGSANJymyhbwH45w5NuuOHMYbPbMgYSPAT9Agoxhsoea3mD443Pbr75YyPH396LXwsQsP9g7GGG83gIKYeCH8yE1YyCUTAKRsHIBQCCsUhIQ59vKQAAAABJRU5ErkJggg==","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jianqiang","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2024-02-24 14:44:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3985276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3985276/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00384-024-04632-9","type":"published","date":"2024-04-26T22:11:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51823331,"identity":"cbca334a-4c4b-4ce5-b463-67973a141445","added_by":"auto","created_at":"2024-02-29 16:27:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":409885,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic of Peking classification of PPE\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/3a9fa5e19ab8e01b63e74b2f.png"},{"id":51824466,"identity":"5f8003ac-3c50-45e0-81cf-00b02f4c24ab","added_by":"auto","created_at":"2024-02-29 16:35:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92716,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/63ff5fd8774952cfdd0dc47c.png"},{"id":51824465,"identity":"d3985b52-87a3-418f-b7b1-4db124e338cd","added_by":"auto","created_at":"2024-02-29 16:35:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":63471,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves comparing overall survival (A), disease-free survival (B), and local recurrence (C) for different types of PPE classified by the new Peking classification\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/6254739b13cc82aa26782491.png"},{"id":51823327,"identity":"def69c84-5d9d-4b52-a864-d939bfa486be","added_by":"auto","created_at":"2024-02-29 16:27:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":40270,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves comparing overall survival (A) and disease-free survival (B) in the CRM (+) and CRM (–) groups\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/a4670b5577f3aaa62c9c2b82.png"},{"id":51823329,"identity":"0586c03c-0117-4adf-ab66-2934aebe21ba","added_by":"auto","created_at":"2024-02-29 16:27:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":35702,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves comparing overall survival (A) and disease-free survival (B) in the well/moderate differentiation and poor differentiation groups\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/b2dcc7edc0f6f24f4b20a5c8.png"},{"id":55689753,"identity":"e2d86212-0e91-47bf-88d3-ccb4f23c3f40","added_by":"auto","created_at":"2024-05-01 22:11:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1504585,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3985276/v1/688df61d-7933-4e37-be20-4f4b4914f4bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Novel Classification of Posterior Pelvic Exenteration to Assess Prognosis in Female Patients with Locally Advanced Primary Rectal Cancer: A Retrospective Cohort Study from China PelvEx Collaborative","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLocally advanced rectal cancer (LARC) often requires neoadjuvant chemoradiation (nCRT) combined with total mesorectal excision to achieve complete resection margins, minimise local recurrence rates, and enhance survival. While the European Society for Medical Oncology guidelines endorse nCRT for LARC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the debate over its ability to achieve satisfactory tumour stage reduction and local control in LARC remains controversial and requires further clarification [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Extensive surgery, frequently the only recourse for achieving complete resection for local control and palliation, raises concerns about patient survival. Total pelvic exenteration (TPE), involving resection of the rectum, bladder, lower ureters, and internal reproductive organs, could potentially impact patient survival [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, TPE, an invasive radical treatment approach, is associated with considerable morbidity and mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, TPE is relatively rare in female patients owing to their anatomy. Conversely, posterior pelvic exenteration (PPE) involving resection of the uterus, cervix, and vagina is a more commonly performed procedure. Despite the growing number of PPE procedures in the context of gynaecological tumours [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the utilisation of PPE procedures for rectal cancer remains limited, often represented by a handful of reports with small sample case descriptions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The use of PPE in the treatment of rectal cancer has not been extensively studied, particularly concerning surgical methods and oncological outcomes. Moreover, performing PPE for rectal cancer presents heightened challenges compared to TPE due to the imperative of organ preservation while achieving R\u003csub\u003e0\u003c/sub\u003e resection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consequently, a dedicated study on LARC involving internal reproductive organs and evaluating both short-term and oncological outcomes is essential.\u003c/p\u003e \u003cp\u003eIn this study of a specific group of individuals, carried out through the China PelvEx collaboration, we introduced a novel classification system for PPE and comprehensively investigated surgical outcomes and oncological prognosis based on this classification. Within this classification, PPE was categorised into four subtypes: PPE-I (uterine invasion), PPE-II (upper vaginal invasion), PPE-III (lower vaginal invasion), and PPE-IV (major vaginal invasion). Based on the TNM staging and rectal MRI, further clinical decisions might be better informed by this new classification.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e \u003cb\u003eand patient consent\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e The study received approval from the Ethics Committee of several institutions, including the Cancer Hospital of the Chinese Academy of Medical Sciences, Peking University First Hospital, and Gansu Provincial Hospital (approval number 22/442\u0026ndash;3644). Written consent was obtained from all participants.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective study employed a multicentre approach to analyse data derived from a prospectively collected institutional database and tumour registry. This study focused on cT4b female patients who underwent multivisceral resection (MVR) across three institutions in the China PelvEx Collaboration between January 2010 and December 2020. The study encompassed consecutive female patients with LARC who underwent PPE implantation. The inclusion criteria comprised: (1) female patients with LARC (cT4b), (2) radical resection, and (3) histologically confirmed adenocarcinoma. Exclusion criteria were: (1) total pelvic exenteration (TPE), (2) recurrent rectal cancer, (3) simultaneous distant metastasis, (4) ovarian or adnexal proctectomy, and (5) PPE with sacrectomy.\u003c/p\u003e \u003cp\u003ePrior to surgery, each patient underwent a comprehensive preoperative multidisciplinary consultation, wherein a group of experts from various fields, including radiotherapy, colorectal surgery, urology, gynaecology, and plastic surgery, was brought together. The salient role of multidisciplinary team meetings was underscored in the formulation of personalised treatment strategies. These deliberations encompassed pivotal determinations, including the selection of surgical approach (laparoscopic or open) and consideration of the potential use of preoperative chemoradiotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Management\u003c/h2\u003e \u003cp\u003eFor those in the clinical stage of T4b, nCRT was advised, involving a standardised long-course chemotherapy regimen centred on 5-fluorouracil (5-FU), concomitant with external radiation administered at a cumulative dose of 45\u0026ndash;54 Gy. Subsequent to nCRT, patients underwent reassessment through pelvic MRI. Surgery was scheduled approximately 8\u0026ndash;12 weeks after completing the nCRT.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection and Follow-up\u003c/h2\u003e \u003cp\u003eInformation was collected on a range of clinicopathological factors, including age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, neoadjuvant treatment, tumour size, pathologic stage, as well as serum levels of haemoglobin (Hb), albumin (Alb), carcinoembryonic antigen (CEA), and carbohydrate antigen 199 (CA199). Additionally, perioperative outcomes were documented, involving operative time, blood loss, type of colorectal and vaginal reconstruction, circumferential resection margin (CRM) status, the number of retrieved or positive lymph nodes, morbidity, length of hospital stay, and postoperative complications. The classification of complications adhered to the Clavien\u0026ndash;Dindo system, which differentiates between minor surgical complications (grades I or II) and major complications (grades III, IV, or V). Patient follow-up took place through telephone conversations or outpatient department visits. The primary endpoints of this study were 5-year overall survival (OS), disease-free survival (DFS), and 5-year local recurrence survival (LRS) in alignment with the Peking classification. Additionally, secondary endpoints were directed towards the assessment of surgical complications using the Peking classification and the exploration of prognostic factors influencing survival outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eNew Classification and Surgical Procedures\u003c/h2\u003e \u003cp\u003eThe absence of a universally agreed-upon definition for PPE within rectal cancer surgery has led to various proposed interpretations. Some definitions have been influenced by those established for gynaecological tumours [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], while others emphasise specific anatomical regions such as the sacrum, retrosacral space, presacral fascia, and coccyx [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this study, PPE was defined as the extraction of the internal reproductive organs (uterus, cervix, and vagina) and rectum while preserving the bladder [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. R\u003csub\u003e0\u003c/sub\u003e resection was defined as tumour resection with pathologically confirmed negative margins, devoid of distant metastasis, and maintaining a CRM exceeding 1 mm. Surgical interventions were exclusively performed by surgeons with more than 10 years of experience in rectal cancer resection. Drawing from our experience with pelvic exenteration, we introduced an innovative Peking classification system distinct from the PPE infralevator (PPEI) and PPE supralevator (PPES). Within this classification, PPE was categorised into four subtypes based on the preoperative MRI and the specific processes involved in the surgery: PPE-I (uterine invasion), PPE-II (upper vaginal invasion), PPE-III (lower vaginal invasion), and PPE-IV (major vaginal invasion). PPE-I involved instances where the uterus faced upper uterine invasion, prompting an anterior resection (AR) combined with a hysterectomy. The vagina was wholly preserved (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), with subsequent suturing and performance of colorectal anastomosis or Hartmann\u0026rsquo;s procedure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. PPE-II encompassed cases of middle or low rectal cancer infiltration into the upper vagina or cervix, warranting low anterior resection (LAR) and hysterectomy coupled with upper vaginal dissection. Partial vaginal preservation and suturing followed this procedure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). PPE-III emerged when the lower vagina encountered invasion, necessitating abdominal perineal resection (APR) and posterior vaginal wall wedge resection, followed by suturing (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). PPE-IV corresponded to instances mirroring PPE-II during the abdominal phase while encompassing the complete dissection of the posterior wall. Reconstruction of the residual vagina was undertaken via V-Y plasty or gluteal fold flap reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were carried out using IBM SPSS Statistics 26 (IBM, Inc., Armonk, NY, USA). Categorial variable comparisons were undertaken through Pearson\u0026rsquo;s chi-squared and Fisher\u0026rsquo;s exact tests, while continuous variable analyses involved the Kruskal\u0026ndash;Wallis H test. To ascertain probabilities associated with OS, DFS, and LRS, the Kaplan\u0026ndash;Meier method was employed, with subsequent comparisons using the log-rank test to identify significant differences in outcomes. Variables found to be significant in the univariate analysis were further examined using a Cox regression model in a multivariate analysis. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 172 patients diagnosed with rectal cancer and undergoing PPE involving the inner reproductive organs were included in this study, and they were separated into four distinct groups: PPE-I 37.2% (64/172), PPE-II 39.6% (68/172), PPE-III 12.2% (21/172), and PPE-IV 11.0% (19/172). The study\u0026rsquo;s flowchart is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, while a comprehensive overview of baseline patient characteristics is summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Across the four groups, no statistically significant differences were observed in terms of age, BMI, ASA score, comorbidities, neoadjuvant therapy, surgical approach, tumour size, tumour differentiation, (y)pT4b stage, (y)pN\u0026thinsp;+\u0026thinsp;stage, history of abdominal surgery, or laboratory test results.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients in four groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPE-I (64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPE-II (68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPE-III (21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePPE-IV (19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;60, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33(48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11(52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10(52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026gt;\u0026thinsp;23.9, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28(43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25(36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56(87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59(86.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19(90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17(89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9(13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31(45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12(63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22(32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemoradiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8(38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51(75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13(61.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13(68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36(56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28(43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40(58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11(52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11(57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54(84.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53(77.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17(81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13(68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15(22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferentiation degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell/ Moderate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38(55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11(57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30(44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(y)pT stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT\u003csub\u003e0\u003c/sub\u003e-T\u003csub\u003e4a\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23(33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT\u003csub\u003e4b\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45(66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16(76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11(57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(y)pN stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003csub\u003e0\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37(57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33(48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11(52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9(47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003csub\u003e1\u003c/sub\u003e-N\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27(42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35(51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10(52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18(28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18(26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineural invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7(36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb\u0026thinsp;\u0026lt;\u0026thinsp;110 g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28(43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALB\u0026thinsp;\u0026lt;\u0026thinsp;35 g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEA\u0026thinsp;\u0026gt;\u0026thinsp;5 ng/ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28(43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35(51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8(38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA199\u0026thinsp;\u0026gt;\u0026thinsp;37 U/ml\u003c/p\u003e \u003cp\u003eEnrolled centers\u003c/p\u003e \u003cp\u003eNCC\u003c/p\u003e \u003cp\u003ePKUFM\u003c/p\u003e \u003cp\u003eGSH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(14.1)\u003c/p\u003e \u003cp\u003e35(54.7)\u003c/p\u003e \u003cp\u003e24(37.5)\u003c/p\u003e \u003cp\u003e5(7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15(22.1)\u003c/p\u003e \u003cp\u003e40(58.8)\u003c/p\u003e \u003cp\u003e17(25.0)\u003c/p\u003e \u003cp\u003e11(16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4(19.0)\u003c/p\u003e \u003cp\u003e7(33.3)\u003c/p\u003e \u003cp\u003e10(47.6)\u003c/p\u003e \u003cp\u003e4(19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003cp\u003e8(42.1)\u003c/p\u003e \u003cp\u003e10(52.6)\u003c/p\u003e \u003cp\u003e1(5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative and Pathological Results\u003c/h2\u003e \u003cp\u003eThe intraoperative data and pathological results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Significant differences were observed among the four groups in terms of the type of colorectal reconstruction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and vaginal reconstruction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no significant differences were identified regarding operative time, blood loss, or the count of retrieved and positive lymph nodes. The R\u003csub\u003e0\u003c/sub\u003e resection rates within the PPE-I, PPE-II, PPE-III, and PPE-IV subgroups were 90.6%, 89.7%, 90.5%, and 89.5%, respectively, with an overall positive CRM rate of 9.9%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative and pathologic characteristics in four groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPE-I (64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPE-II (68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPE-III (21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePPE-IV (19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e266(212\u0026ndash;356)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240(203\u0026ndash;297)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e255(192\u0026ndash;308)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e253(205\u0026ndash;357)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eblood loss, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e265(100\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(50\u0026ndash;315)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0(50\u0026ndash;725)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e200(60\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHartmann\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVagina reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of retrieved lymph nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(15\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(14\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(14\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16(13\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of positive lymph nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0\u0026ndash;3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5(0\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(0\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(0\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRM status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRM\u0026thinsp;\u0026gt;\u0026thinsp;1 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58(90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61(89.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17(89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRM\u0026thinsp;\u0026le;\u0026thinsp;1 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Recovery and Complications\u003c/h2\u003e \u003cp\u003eInformation on postoperative recovery and complications can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There were no reports of postoperative deaths in any of the groups. The rate of complications that occurred while patients were in the hospital was 36.6% (63/172 patients). Specific to subgroup analysis, the complication rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 32.8%, 33.8%, 47.6%, and 47.4%, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, no statistically significant differences were detected among the four groups concerning reoperation rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.49), length of postoperative hospitalisation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.69), anastomotic leakage rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84), and the surgical site infection (SSI) complication rate, including abdominal incisions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.60), perineal incisions (p\u0026thinsp;=\u0026thinsp;0.16), pelvic infections (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.37), and urinary infections (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09). Compared to the PPE-III/IV group, the PPE-I/II group had a significantly lower rate of urinary retention (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative parameters among four groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPE-I (64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPE-II(68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPE-III (21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePPE-IV (19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien\u0026ndash;Dindo grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII-IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical reintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal incision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineal incision\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal anastomotic leakage\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal leakage/fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(9\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ea: For patients receiving abdominal perineal resection only (40 cases in PPE-III and PPE-IV group)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eb: For patients receiving colorectal anastomosis only (132 cases in PPE-I and PPE-II group)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOncological Outcomes\u003c/h2\u003e \u003cp\u003eThe median follow-up period spanned 40 months (interquartile range: 21\u0026ndash;69 months) for the entire cohort, with subsequent subdivisions into 51 months (interquartile range: 32\u0026ndash;89 months) for the PPE-I group, 31 months (interquartile range: 15\u0026ndash;63 months) for the PPE-II group, 38 months (interquartile range: 24\u0026ndash;79 months) for the PPE-III group, and 29 months (interquartile range: 13\u0026ndash;62 months) for the PPE-IV group. Comprehensive follow-up was successfully conducted for all patients throughout the study period. The four groups showed significant differences in OS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), DFS, and LRS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB, and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). The 5-year OS rates were 73.4%, 68.8%, 54.7%, and 37.3% in the PPE-I, PPE-II, PPE-III, and PPE-IV groups, respectively. Correspondingly, the 5-year DFS rates for the four groups were 76.0%, 62.5%, 57.7%, and 43.1%. Furthermore, the 5-year LRS rates were 24.0%, 37.5%, 42.3%, and 56.9% for the same groups. Additionally, there were significant differences in the 5-year OS and 5-year DFS rates among the subgroups categorised by CRM status (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and tumour differentiation (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB\u003cb\u003e)\u003c/b\u003e (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The 5-year OS rates reached 68.3% and 22.7% for the negative and positive CRM groups, respectively. In parallel, the 5-year DFS rates were 67.8% and 30.3% for the corresponding subgroups. In terms of tumour differentiation, the 5-year OS rates amounted to 71.9% and 46.5% for well/moderately and poorly differentiated subgroups, respectively. Similarly, the 5-year DFS rates were 72.3% and 42.2% for the same subgroups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe influence of prognostic factors on OS and DFS, as determined by univariate and multivariate analyses, is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In the univariate analysis, age\u0026thinsp;\u0026gt;\u0026thinsp;60 years, higher Peking classification type, positive CRM, (y)pT stage, and poor differentiation were identified as independent risk factors for both OS and DFS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Further analysis unveiled that a higher Peking classification type (hazard ratio [HR]\u0026thinsp;=\u0026thinsp;3.48, 95% confidence interval [CI], 1.65\u0026ndash;7.36, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), negative CRM status (HR\u0026thinsp;=\u0026thinsp;3.59, 95% CI, 1.80\u0026ndash;7.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and poor differentiation (HR\u0026thinsp;=\u0026thinsp;2.81, 95% CI, 1.64\u0026ndash;4.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) independently contributed to OS. In parallel, higher Peking classification type (HR\u0026thinsp;=\u0026thinsp;4.12, 95% CI, 1.85\u0026ndash;9.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), negative CRM status (HR\u0026thinsp;=\u0026thinsp;2.89, 95% CI, 1.23\u0026ndash;6.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015), and poor differentiation (HR\u0026thinsp;=\u0026thinsp;2.12, 95% CI, 1.27\u0026ndash;3.81, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) were established as independent risk factors for DFS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate analysis for overall survival and disease-free survival\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eOverall survival\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eDiseases-free survival\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.68(1.06\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.53(0.95\u0026ndash;2.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.56(0.96\u0026ndash;2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.49(0.87\u0026ndash;2.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enCRT (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.82(0.50\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00(0.60\u0026ndash;1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.28(0.81\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.24(0.76\u0026ndash;2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.21(0.70\u0026ndash;2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.14(0.63\u0026ndash;2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach (laparoscopic/open)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.80(0.51\u0026ndash;1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.67(0.41\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPE classification (PPE-I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPE-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.58(1.41\u0026ndash;4.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.92(1.03\u0026ndash;3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.15(1.64\u0026ndash;6.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.46(1.27\u0026ndash;4.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPE-III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.57(1.26\u0026ndash;5.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.20(1.05\u0026ndash;4.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.71(1.17\u0026ndash;6.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.47(1.06\u0026ndash;5.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPE-IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.84(2.92\u0026ndash;12.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.48(1.65\u0026ndash;7.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.50(3.03\u0026ndash;13.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.12(1.85\u0026ndash;9.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRM status (positive/negative)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.27(2.22\u0026ndash;8.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.59(1.80\u0026ndash;7.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.41(2.23\u0026ndash;8.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.89(1.23\u0026ndash;6.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineural invasion (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.25(0.72\u0026ndash;2.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.72(1.01\u0026ndash;2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.22(0.62\u0026ndash;2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphatic invasion (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.67(0.40\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.91(0.50\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferentiation (well/ moderate, poor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.45(2.03\u0026ndash;5.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.81(1.64\u0026ndash;4.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.65(1.54\u0026ndash;4.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.12(1.27\u0026ndash;3.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(y)pT stage(T4b/non-T4b)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.67(1.03\u0026ndash;2.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.03(0.61\u0026ndash;1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.87(1.10\u0026ndash;3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.18(0.67\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(y)pN stage (N1-2/N0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.17(0.74\u0026ndash;1.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.39(0.86\u0026ndash;2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications(yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.31(0.83\u0026ndash;2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.47(0.91\u0026ndash;2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCurrently, there is an absence of evidence, both surgical and oncological, supporting the use of PPE in cases of cT4b rectal cancer involving the female internal reproductive organs. This study stands as the largest and first examination of cT4b rectal cancer involving the female internal reproductive organs. Based on this new classification, our findings demonstrate the safety and feasibility of PPE involving the female internal reproductive organs.\u003c/p\u003e \u003cp\u003eTraditionally, PPEs are classified into PPEI and PPES based on rectal cancer height and anal preservation. Our surgical experience led to the formulation of the novel Peking classification for PPE, closely tethered to the surgical plan. This classification reflects both the site of reproductive system invasion and rectal cancer height. Notably, the results of this study indicate a significant correlation between oncological outcomes, including OS and DFS, and the Peking classification. Higher grades of classification are indicative of poorer oncological outcomes. As a result, further studies into PPE-IV management, encompassing preoperative multidisciplinary team consultation, neoadjuvant chemoradiotherapy, and extended radical excision, are warranted to enhance surgical and oncological outcomes.\u003c/p\u003e \u003cp\u003eA study conducted by the National Cancer Center of Mexico enrolled 59 patients, with 51 and 8 undergoing PPE and TPE, respectively. This study reported an operative mortality rate of 3% (two cases), while postoperative complications were experienced by 29 patients (49.2%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our study\u0026rsquo;s overall in-hospital complication rate was 36.6% (63/172). Among the four grgvoups, there were no statistically significant differences in terms of reoperation rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.49), postoperative hospital stay (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.69), anastomotic leakage rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84), or SSI complication rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.27). Our study\u0026rsquo;s incidence of complications was lower than that reported by others [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], a trend potentially linked to the evolution of laparoscopy in PPE surgery and surgical approaches based on the Peking classification. Prognostic factors linked to survival rate in patients undergoing PPE include pathological nodal status, preoperative radiotherapy and chemotherapy, and pathological node status, although consensus is lacking. In our study, multivariate analysis established higher Peking classification type, CRM status, and poor differentiation as independent risk factors for both OS and DFS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This underscores the significance of our proposed PPE classification for cT4b rectal cancer involving the female internal reproductive organs.\u003c/p\u003e \u003cp\u003eThe R\u003csub\u003e0\u003c/sub\u003e resection rate stands as a critical parameter for assessing surgical quality. Unlike TPE, PPE allows organ-sparing surgery, preserving the bladder and innervating nerves. Consequently, achieving R\u003csub\u003e0\u003c/sub\u003e resection is more challenging in PPE compared to TPE. To preserve the bladder and pelvic plexus nerves during PPE, the dissection plane must be close to the parametrial tissue and paracolpium. This factor can impact the attainment of R\u003csub\u003e0\u003c/sub\u003e resection [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our study, the R\u003csub\u003e0\u003c/sub\u003e resection rates for the PPE-I, PPE-II, PPE-III, and PPE-IV subgroups were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year OS and DFS rates in the negative CRM subgroup were 68.3% and 67.8%, respectively. A recent systematic review reported a lower median R\u003csub\u003e0\u003c/sub\u003e resection rate of 82.6% (range 66\u0026ndash;95.5%) for LARC and a lower median 5-year survival rate of 32% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our results show promise, potentially attributed to the focused inclusion of patients with rectal cancer involving the female internal reproductive organs. Furthermore, adopting this new PPE classification, which facilitates varied surgical approaches based on tumour location, might improve R\u003csub\u003e0\u003c/sub\u003e resection rates and enhance long-term survival outcomes.\u003c/p\u003e \u003cp\u003eThis study has limitations, including its retrospective design, potential patient selection bias, and a relatively small number of cases. Additionally, the results may have been influenced by the limited data available for evaluating bladder function. Further research is needed to determine if the findings are applicable to male patients. Finally, less than one-third of patients with LARC received nCRT, and the lack of clinical data on postoperative adjuvant therapy could also potentially affect the prognosis, introducing bias into the analysis of the neoadjuvant role on survival.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study introduced the novel classification of PPE; to the best of our knowledge, it is the most extensive assessment of short-term outcomes and oncological results in female patients to date. The new Peking classification facilitates precise surgery and correlates with survival outcomes. Investigating the impact of inflammation and cancer invasion in different reproductive organs on prognosis represents a promising avenue for future research. Therefore, further studies on the management of PPE-IV, in terms of preoperative multidisciplinary team consultation, neoadjuvant chemoradiotherapy, and extended radical excision, should be performed to improve surgical and oncological outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors thank all members and staff in the China PelvEx collaborative for collecting data.\u0026nbsp;This study was supported by grants from the National Natural Science Foundation of China (No. 82072732) and Beijing Natural Science Foundation (L222054,4232058)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e All authors contributed to the conception and design of the study. Material preparation, data collection, and analyses were performed by Yuegang Li, Meng Zhuang, Gang Hu, Jinzhu Zhang, Wenlong Qiu, Shiwen Mei, and Jianqiang Tang. Yuegang and Meng Zhuang wrote the first draft of the manuscript. All authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest and Source of Funding\u003c/strong\u003e: The authors declare no conflicts of interest..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: The data will be made available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and patient consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Ethics Committee of several institutions, including the Cancer Hospital of the Chinese Academy of Medical Sciences, Peking University First Hospital, and Gansu Provincial Hospital (approval number 22/442\u0026ndash;3644). Written consent was obtained from all participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e Glynne-Jones R, Wyrwicz L, Tiret E et al (2018) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 29:iv263. https://doi.org/10.1093/annonc/mdy161\u003c/li\u003e\n \u003cli\u003eDenost Q, Kontovounisios C, Rasheed S et al (2017) Individualizing surgical treatment based on tumour response following neoadjuvant therapy in T4 primary rectal cancer. Eur J Surg Oncol 43:92\u0026ndash;99.\u0026nbsp;https://doi.org/10.1016/j.ejso.2016.09.004\u003c/li\u003e\n \u003cli\u003eAustin KKS, Herd AJ, Solomon MJ, Ly K, Lee PJ (2016) Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer. Dis Colon Rectum 59:831\u0026ndash;835.\u0026nbsp;https://doi.org/10.1097/DCR.0000000000000656\u003c/li\u003e\n \u003cli\u003eRadwan RW, Jones HG, Rawat N et al (2015) Determinants of survival following pelvic exenteration for primary rectal cancer. Br J Surg 102:1278\u0026ndash;1284.\u0026nbsp;https://doi.org/10.1002/bjs.9841\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez-Basave HN, Morales-V\u0026aacute;squez F, Herrera-G\u0026oacute;mez A, Rosciano AP, Meneses-Garc\u0026iacute;a A, Ruiz-Molina JM (2012) Pelvic exenteration for colorectal cancer: oncologic outcome in 59 patients at a single institution. Cancer Manag Res 4:351\u0026ndash;356.\u0026nbsp;https://doi.org/10.2147/CMAR.S34545\u003c/li\u003e\n \u003cli\u003eHouvenaeghel G, de Nonneville A, Blache G et al (2022) Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes. J Gynecol Oncol 33:e31.\u0026nbsp;https://doi.org/10.3802/jgo.2022.33.e31\u003c/li\u003e\n \u003cli\u003ePokharkar A, Bankar S, Rohila J, Jaiswal D, deSouza A, Saklani A (2020) Laparoscopic Posterior Pelvic Exenteration (Complete and Supralevator) for Locally Advanced Adenocarcinoma of the Rectum in Females: Surgical Technique and Short-Term Outcomes. J Laparoendosc Adv Surg Tech A 30:558\u0026ndash;563.\u0026nbsp;https://doi.org/10.1089/lap.2019.0691\u003c/li\u003e\n \u003cli\u003eXin K, Ng D, Tan G, Teo MC (2014) Role of Pelvic Exenteration in the Management of Locally Advanced Primary and Recurrent Rectal Cancer. J Gastrointest Cancer 45:291\u0026ndash;297.\u0026nbsp;https://doi.org/10.1007/s12029-014-9586-y\u003c/li\u003e\n \u003cli\u003eYang T, Morris D, Chua T (2013) Pelvic Exenteration for Rectal Cancer: A Systematic Review. Dis Colon Rectum 56:519\u0026ndash;531.\u0026nbsp;https://doi.org/10.1097/DCR.0b013e31827a7868\u003c/li\u003e\n \u003cli\u003eKazi M, Kumar N, Rohila J et al (2021) Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes. BJS Open 5:zrab074.\u0026nbsp;https://doi.org/10.1093/bjsopen/zrab074\u003c/li\u003e\n \u003cli\u003eKoh C, Solomon M, Brown K et al (2017) The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases. Dis Colon Rectum 60:627\u0026ndash;635.\u0026nbsp;https://doi.org/10.1097/DCR.0000000000000825\u003c/li\u003e\n \u003cli\u003ePelvEx Collaborative (2019) Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg 269:315\u0026ndash;321.\u0026nbsp;https://doi.org/10.1097/SLA.0000000000002528\u003c/li\u003e\n \u003cli\u003eRevaux A, Rouzier R, Ballester M, Selle F, Dara\u0026iuml; E, Ch\u0026eacute;reau E (2012) Comparison of Morbidity and Survival Between Primary and Interval Cytoreductive Surgery in Patients After Modified Posterior Pelvic Exenteration for Advanced Ovarian Cancer. Int J Gynecol Cancer 22:1349\u0026ndash;1354.\u0026nbsp;https://doi.org/10.1097/IGC.0b013e318265d358\u003c/li\u003e\n \u003cli\u003eKato K, Tate S, Nishikimi K, Shozu M (2013) Bladder function after modified posterior exenteration for primary gynecological cancer. Gynecol Oncol 129:229\u0026ndash;233.\u0026nbsp;https://doi.org/10.1016/j.ygyno.2013.01.013\u003c/li\u003e\n \u003cli\u003eGheorghe M, Cozlea AL, Kiss SL et al (2021) Primary pelvic exenteration: Our experience with 23 patients from a single institution. Exp Ther Med 22:1060.\u0026nbsp;https://doi.org/10.3892/etm.2021.10494\u003c/li\u003e\n \u003cli\u003eGhouti L, Pereira P, Filleron T et al (2015) Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: A single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010. Am J Surg 209:352\u0026ndash;362.\u0026nbsp;https://doi.org/10.1016/j.amjsurg.2014.01.008\u003c/li\u003e\n \u003cli\u003eAkasu T, Yamaguchi T, Fujimoto Y et al (2007) Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns. Ann Surg Oncol 14:74\u0026ndash;83.\u0026nbsp;https://doi.org/10.1245/s10434-006-9082-0\u003c/li\u003e\n \u003cli\u003ePark JK, Kim YW, Hur H et al (2009) Prognostic factors affecting oncologic outcomes in patients with locally recurrent rectal cancer: impact of patterns of pelvic recurrence on curative resection. Langenbecks Arch Surg 394:71\u0026ndash;77.\u0026nbsp;https://doi.org/10.1007/s00423-008-0391-6\u003c/li\u003e\n \u003cli\u003eNielsen M, Rasmussen P, Lindegaard J, Laurberg S (2012) A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database. Colorectal Dis 14:1076\u0026ndash;1083.\u0026nbsp;https://doi.org/10.1111/j.1463-1318.2011.02893.x\u003c/li\u003e\n \u003cli\u003eBhangu A, Ali S, Brown G, Nicholls RJ, Tekkis P (2014) Indications and Outcome of Pelvic Exenteration for Locally Advanced Primary and Recurrent Rectal Cancer. Ann Surg 259:315\u0026ndash;322.\u0026nbsp;https://doi.org/10.1097/SLA.0b013e31828a0d22\u003c/li\u003e\n \u003cli\u003ePlatt E, Dovell G, Smolarek S (2018) Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol 22:835\u0026ndash;845. https://doi.org/10.1007/s10151-018-1883-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"posterior pelvic exenteration, oncological outcome, Peking classification, locally advanced rectal cancer","lastPublishedDoi":"10.21203/rs.3.rs-3985276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3985276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSurgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that warrant additional assessment. Therefore, we compared short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analysed a prospective database from China PelvEx Collaborative in three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified into four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDifferences were significant among the four groups regarding colorectal reconstruction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), vaginal reconstruction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in-hospital complications (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and urinary retention (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The R\u003csub\u003e0\u003c/sub\u003e resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, PPE-IV demonstrated the lowest 5-year overall survival rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 5-year disease-free survival rate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.\u003c/p\u003e","manuscriptTitle":"A Novel Classification of Posterior Pelvic Exenteration to Assess Prognosis in Female Patients with Locally Advanced Primary Rectal Cancer: A Retrospective Cohort Study from China PelvEx Collaborative","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 16:27:47","doi":"10.21203/rs.3.rs-3985276/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-03-23T07:41:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"04f8db12-0143-40c9-a61d-9323275c099b","date":"2024-03-15T06:38:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-28T12:38:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-27T02:18:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-27T02:18:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2024-02-24T14:40:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1845abc4-9973-400c-8c35-56e0866ff884","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-01T22:11:22+00:00","versionOfRecord":{"articleIdentity":"rs-3985276","link":"https://doi.org/10.1007/s00384-024-04632-9","journal":{"identity":"international-journal-of-colorectal-disease","isVorOnly":false,"title":"International Journal of Colorectal Disease"},"publishedOn":"2024-04-26 22:11:22","publishedOnDateReadable":"April 26th, 2024"},"versionCreatedAt":"2024-02-29 16:27:47","video":"","vorDoi":"10.1007/s00384-024-04632-9","vorDoiUrl":"https://doi.org/10.1007/s00384-024-04632-9","workflowStages":[]},"version":"v1","identity":"rs-3985276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3985276","identity":"rs-3985276","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}