Obstetric balloon as a pelvic spacer to mitigate the risk of empty pelvis syndrome in patients undergoing total pelvic exenteration for rectal cancer

Abstract Aim Empty pelvis syndrome (EPS) causes substantial morbidity after total pelvic exenteration. We evaluated whether an obstetric (Bakri) balloon used as a pelvic spacer reduced EPS after exenteration for rectal cancer. Method This single-centre retrospective study included adults undergoing total pelvic exenteration between October 2013 and December 2025. Patients undergoing bladder-sparing, posterior or supralevator exenteration were excluded. The Bakri balloon became unit protocol in December 2019. The primary outcome was EPS, defined by pelvic collection, bowel descent causing obstruction, perineal hernia, enteroperineal fistula or delayed urinary leak. Factors associated with EPS were assessed using multivariable logistic regression. Results Overall, 211 patients were included; 186 (88.2%) were men and median age was 46 years. A Bakri balloon was used in 115 patients (54.5%). EPS occurred in 46 patients (21.8%): 22 (47.8%) presented within 30 days and 24 (52.2%) thereafter. Pelvic collections were the commonest manifestation (45.7%), followed by acute bowel obstruction (21.7%), enteroperineal fistula (15.2%), delayed bowel obstruction (8.7%) and delayed urinary leak (8.7%). Radiological and surgical interventions were required in 25 and 21 patients, respectively. Bakri balloon placement did not significantly reduce EPS (OR 0.71, 95% CI 0.37–1.37; P = 0.305). Minimally invasive surgery was independently associated with lower EPS risk (adjusted OR 0.39, 95% CI 0.19–0.80; P = 0.011). Conclusion EPS remains a significant early and late complication after total pelvic exenteration. Temporary Bakri balloon placement did not provide sustained protection against EPS.