Chapter 32: Pelvic Exenteration

A. TOTAL PELVIC EXENTERATION

PROCEDURE OVERVIEW

Total pelvic exenteration is a surgical procedure that involves the en bloc removal of female reproductive organs, rectosigmoid colon, and lower urinary tract. It may include a perineal phase to remove the urethra, vagina, and anus. Modifications can be made depending on tumor location and size.

The first series of pelvic exenterations was published in 1948 by Alexander Brunschwig for the palliative treatment of advanced pelvic malignancies.¹ Although the operative mortality in this group of 22 patients was 23%, there were also several long-term survivors, indicating potential benefit beyond palliation. The original operation included implanting both ureters into the colon to produce a wet colostomy; however, this resulted in significant problems with hyperchloremic acidosis, pyelonephritis, and renal failure. In 1956, Bricker² published a technique of using a closed loop of ileum as a bladder substitution. Over the past 50 years, there have been many advances in perioperative care such as blood products, antibiotics, intensive care support, and surgical techniques such as retractors, cautery, and staplers that now allow for a variety of vaginal reconstructions and urinary conduits that can reduce the impact this procedure has on quality of life.^{3,4,5,6,7,8,9, and 10} As a result, pelvic exenteration is now considered a safe and feasible procedure that can cure selected patients for whom there are no other treatment options. In modern series, operative mortality ranges from 0% to 5%, and 5-year survival rates range from 39% to 53% depending on the specific indications for the exenteration.^{3,4,5,6, and 7} Patient selection, patient preparation, surgical technique, and postoperative care can have a major impact on the outcome for patients undergoing this operation.

Indications

The main indication for pelvic exenteration is the central persistence or recurrence of cervical, vaginal, or vulvar cancer after primary radiation or chemoradiation. Central recurrence is defined as the absence of both pelvic sidewall involvement and distant disease. Some have advocated the use of exenteration for primary treatment of stage IVA cervical cancer; however, with modern chemoradiation, this has become uncommon. Long-term survival after exenterative surgery in women with pelvic failure after surgery and radiation for endometrial cancer or sarcomas has also been reported.^11,12 Extensive radiation injury to bladder, vagina, and/or rectum, especially if patients have evidence of significant necrosis with fistula formation, is another potential indication for exenteration.⁷

Exenterative surgery to resect centrally recurrent pelvic cancer is only rational in the absence of metastatic disease. Para-aortic nodal involvement is generally considered an absolute contraindication for exenteration. If pelvic lymph nodes are found to be the only site of metastatic disease, then patients can still be considered surgical candidates, although long-term cure rates will only be about 15%.¹³ Palliative ...