You are in: eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery Pelvic ExenterationArticle Last Updated: Feb 2, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Margrit M Juretzka, MD, MS, Assistant Professor of Gynecologic Oncology, Stanford University Hospital and Clinics Margrit M Juretzka is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society of Clinical Oncology, and Society of Gynecologist Oncologists Coauthor(s): Nelson Teng, MD, PhD, Associate Professor, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, Stanford School of Medicine; Amreen Husain, MD, Assistant Professor, Department of Gynecology and Obstetrics, Stanford University School of Medicine Editors: Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Author and Editor Disclosure Synonyms and related keywords: pelvic exenteration, anterior exenteration, posterior exenteration, total exenteration, radical resection, supralevator exenteration, infralevator exenteration, vaginectomy, urethrectomy cervical cancer, vaginal cancer, vulvar cancer, uterine cancer, chemotherapy, intraoperative radiation therapy, IORT, ovarian cancer, cervical cancer, squamous cell carcinoma, adenocarcinomas of the cervix, rectal anastomosis, urinary diversion, vaginal reconstruction INTRODUCTIONSection 2 of 10
  History of the ProcedurePatients with recurrent cervical cancer after primary treatment with surgery and radiation or radiation alone are faced with few options because chemotherapy is at best palliative, and the 1- and 5-year survival rates are, respectively, 15% and less than 5%. Pelvic exenteration was first reported by Brunschwig in 1948 as an especially radical surgical treatment for advanced and recurrent cervical cancer. It was described as "the most radical surgical attack so far described for pelvic cancer" and at the time had an operative mortality rate of 23%. Pelvic exenteration continues to be the only curative option in certain patients with centrally recurrent cervical, vaginal, or vulvar cancers. Since Brunschwig's time, improvements in critical care, antibiotics, hyperalimentation, and thromboembolism prophylaxis, accompanied by similar advances in surgical technique, including the use of stapling devices, separate urinary conduits, and pelvic reconstruction, have improved the morbidity and mortality rates associated with the procedure. Currently, operative mortality rates are 3-5%, the major perioperative complication rate is 30-44%, and the overall 5-year survival rate in patients who successfully undergo the procedure is 20-50%. The first steps in the approach to treating a patient with a biopsy-proven central recurrence are an exhaustive search for distant metastatic disease and evaluation for comorbid conditions. The initial surgical exploration involves a further search for disseminated disease and necessitates a complete assessment of intraperitoneal and retroperitoneal areas that would preclude proceeding with exenteration. This task can be accomplished by laparoscopy in selected patients. ProblemCancers arising in the pelvis are often treated with multimodality therapies, including surgical resection and radiation. When these cancers recur, many may be locally advanced but still limited to the pelvis; however, prior treatment with high doses of radiation makes limited surgical resection a difficult undertaking fraught with complications. Furthermore, the response of tumors to chemotherapy within a previously radiated field is extremely poor. In some instances, the only opportunity for cure may lie in complete resection. Pelvic exenteration is a salvage procedure performed for centrally recurrent gynecologic cancers. To a greater or lesser degree, the procedure involves en bloc resection of all pelvic structures, including the uterus, cervix, vagina, bladder, and rectum. Most candidates for this procedure have a diagnosis of recurrent cervical cancer that has previously been treated with surgery and radiation or radiation alone. In some cases, patients with recurrent uterine, vulvar, or vaginal cancers may benefit from pelvic exenteration. In general, patients with ovarian cancer are not candidates because of the distant pattern of spread associated with ovarian cancers. ClinicalPatients with recurrent cervical cancer after radiation therapy usually present with bleeding, hematuria, or pelvic pain. In some cases, the first sign of recurrence is the discovery of hydronephrosis or abnormal cytology on routine follow-up. Before proceeding with the surgical procedure, confirming a recurrence with a pathologic specimen obtained by biopsy is essential. In patients who have previously had high doses of pelvic radiation, physical examination is notoriously unreliable, and bleeding and pain may be related to radiation changes rather than recurrent disease. The clinical triad of leg edema, ureteral obstruction, and leg pain is almost pathognomonic for disease extending to the pelvic sidewall and is generally considered a contraindication to surgery. INDICATIONSSection 3 of 10
Pelvic exenteration is primarily indicated for centrally recurrent cervical cancers in patients who have received definitive radiation therapy. The procedure is appropriate in patients who meet criteria for any recurrent pelvic tumor if a chance of cure exists with the procedure. On occasion, pelvic exenteration can be performed as a palliative procedure for control of local disease causing severe fistulas or other unmanageable symptoms. CONTRAINDICATIONSSection 4 of 10
Absolute contraindications include peritoneal metastasis and skip metastasis to bowel. Relative contraindications include metastasis to retroperitoneal nodes, direct tumor invasion of adherent bowel loops, and hydroureter or hydronephrosis. Determination of the extent of resection is based on sidewall involvement, infralevator versus supralevator, and anterior versus posterior versus total exenteration. WORKUPSection 5 of 10
Lab Studies
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Other Tests
Diagnostic Procedures
Histologic FindingsMost cervical cancers are squamous cell carcinomas, though the incidence of adenocarcinomas of the cervix is rising. Rare histologic types are occasionally encountered and include adenosarcomas, uterine sarcomas, and cervical or vulvar melanomas. TREATMENTSection 6 of 10
Medical therapyChemotherapy in patients with recurrent cervical cancer is an option for patients with distant metastatic disease and for those who are not candidates for pelvic exenteration. Several regimens have been evaluated, and response rates of 5-40% are described. Most responses are at best partial and of short duration; therefore, chemotherapy is generally a poor alternative to surgery in patients with recurrent disease. Preoperative detailsPreparation An antibiotic and a mechanical bowel preparation are administered on the day prior to surgery. The stoma sites are marked on the skin before surgery. Prophylactic antibiotics are administered in the operating room, and pneumatic calf compression units are placed on the legs prior to the anesthetic induction. Prepare and drape the potential operative field, including the entire abdomen, perineum, vagina, rectum, and thighs. Position The procedure is typically performed with the patient in the lithotomy position. The patient's legs are carefully placed in Allen or other supported stirrups. The correct positioning places the weight on the feet and includes padding to ensure protection from neurologic injury and to prevent compartment syndrome. Vascular access Adequate vascular access must be available in order to ensure that rapid fluid and blood product resuscitation can be instituted if needed. Vascular access also allows invasive cardiovascular monitoring as indicated. Intraoperative detailsExplorationThe patient is placed in the low lithotomy position, and, through a midline incision, the abdomen and pelvis are thoroughly explored. The liver, peritoneal and bowel surfaces, aortic and pelvic nodal groups, and pelvic sidewall are carefully evaluated. Biopsies of any suspicious sites are obtained and examined by frozen section. Distant and peritoneal metastases are absolute contraindications to exenteration. Controversy exists regarding whether to proceed in the presence of nodal metastasis, which reduces the survival rate to 5%, or direct tumor invasion of any adherent loop of sigmoid colon or small bowel. The issue of sidewall involvement is important in determining resectability because the goal is to achieve negative surgical margins. In some centers, the availability of intraoperative radiation therapy (IORT) allows resection with close margins, but grossly positive margins confer an extremely poor prognosis. The process of dissecting open avascular spaces allows for further determination of resectability with adequate margins. The pararectal, paravesical, and Retzius spaces are developed under direct visualization, and the cardinal ligaments are isolated by this method. The pelvic retroperitoneal spaces are opened, and the ureters and internal and external iliac vessels are identified and tagged as necessary. This allows identification of pelvic nodal metastasis, dissection of the ureter, and visualization of vessels, which may require ligation to control or prevent excessive bleeding. ExenterationTotal pelvic exenteration After the hypogastric artery is identified and its anterior division or the uterine artery is divided, the cardinal ligaments are divided at the pelvic sidewall. This can be accomplished using endoscopic stapling devices. The ureters are dissected free of the lateral peritoneum and are clipped and divided, leaving as much length as feasible. The retrorectal space between the sigmoid and the sacrum and coccyx is developed. The sigmoid arcade and the superior rectal vessels are ligated. The sigmoid is then divided using a gastrointestinal assistant (GIA) stapler. Supralevator exenteration The rectum is lifted off the sacral hollow posteriorly using blunt and sharp dissection. The lateral attachments are freed using the endoscopic GIA. Anteriorly, the bladder is completely freed from the public symphysis, and the vesicourethral junction is identified. (The resection is thus carried en bloc to the level of the levator ani.) If a supralevator exenteration is adequate, the urethra is divided anteriorly; the rectum, posteriorly at the level of the pelvic floor; and the vagina, below the level of the tumor with adequate margins. Infralevator exenteration For the perineal phase, a second team of surgeons is usually involved. A total vaginectomy and urethrectomy is accomplished by making a circumferential incision inside the vulva; if necessary, resection of the anus is also incorporated. The vagina is dissected off the levator muscles unless they have tumor involvement. If this is the case, the muscle is excised to obtain an adequate margin. The rectovaginal space is developed from above and below, and lateral rectal pillars are divided. The rectum is divided using the GIA stapler at the level of the mid vagina (if a complete perineal resection is not being performed), and the specimen is thus freed completely and removed. ReconstructionRectal anastomosis The decision to perform an end-sigmoid colostomy or a low rectal anastomosis is based on the level of the resection, the length of the rectal stump, and the extent of other concomitant procedures. A low rectal anastomosis can usually be accomplished using the circular end-to-end anastomotic stapling device. Reports have evaluated the complications associated with a rectal anastomosis at the time of pelvic exenteration, and the overall incidence of anastomotic leaks or fistula formation is 30-50%. A protective colostomy or omental wrap has not been found to have a significant impact on the incidence of successful healing. Recent data suggest that a higher leak rate occurs in patients undergoing concomitant procedures such as IORT and continent urinary diversions. Urinary diversion Several options exist for urinary diversion, and the choice of continent versus noncontinent urinary diversion is based on assessment of the patient's ability to care for a continent pouch and availability of right colon and ileum with the ileocecal valve. The best option for noncontinent diversion is an ileal urinary conduit in which the ureters are implanted in an isoperistaltic manner into a segment of small bowel, one end of which is brought out as a cutaneous stoma. The continent pouch uses the right colon as a low-pressure reservoir, with the ileum, ileocecal valve, or appendix specially configured to create the continence mechanism. A variety of continent pouches with small variations have been described. Complications associated with both continent and noncontinent urinary diversions in women who are gynecologic oncology patients have been reported by several authors. A continent urinary diversion allows the patient to have only a single ostomy bag, or none at all, and it can be successfully accomplished in patients with gynecologic cancer. Early complication rates range from 12-53%, and long-term complication rates from 33-37%. The reoperation rate is 6-8%. Vaginal reconstruction Several methods for vaginal and pelvic reconstruction have been described. An omental flap can be accomplished, generally with minimal morbidity, and serves to carpet the raw exposed surfaces of the exenterated pelvis. Myocutaneous grafts, including rectus and gracilis muscle flaps, can be brought into the pelvis and perineum to create pelvic support and a neovagina. Split-thickness skin grafts have also been used to create neovaginas. Follow-upFor excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cervical Cancer. COMPLICATIONSSection 7 of 10
The potential complications after pelvic exenteration are numerous. Almost every patient develops at least 1 complication, and approximately 40-50% experience a major complication requiring further diagnostic and therapeutic procedures. The operative mortality rate is 2-5% in modern series. The major early postoperative complications include blood loss, sepsis, wound dehiscence, and anastomotic breakdown at the level of the bowel, urinary pouch, or ureteral sites. The rate of late complications is lower, but approximately one third of patients experience fistula, bowel obstruction, ureteral strictures, renal failure, pyelonephritis, and chronic bowel obstructions. Other complications include deep venous thrombosis and pulmonary emboli, flap necrosis, and stomal necrosis. OUTCOME AND PROGNOSISSection 8 of 10
Reported 5-year survival rates after pelvic exenteration range from 23-61%. The most common site of recurrence is the pelvis. Poor prognostic factors associated with recurrence after exenteration include tumor size greater than 3 cm, pelvic sidewall or resection margin involvement, nodal metastasis, and time interval of less than 1 year from prior radiation treatment. FUTURE AND CONTROVERSIESSection 9 of 10
Controversy continues regarding the appropriate selection of patients for exenteration and the use of IORT, preexenteration chemotherapy, concomitant continent urinary diversion, and low rectal anastomosis. REFERENCESSection 10 of 10
Article Last Updated: Feb 2, 2006 |
