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BACKGROUND

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Most recurrent and locally advanced gynecologic malignancies carry a poor prognosis. Advances in multimodality management have improved local control and overall survival (OS).1,2,3 Historically, tumors invading the pelvic sidewall or involving the major vessels or nerves were considered inoperable. Early reports of central pelvic exenteration were discouraging and associated with high perioperative mortality (28%) and major complications (100%).4 Advances in several medical disciplines have resulted in greatly improved outcome and reduced morbidity and mortality in the management of these complex tumors. Increasingly effective chemotherapy and refinement in methods of radiation administration have rendered these large tumors, most of which had previous radiation therapy, amenable to wide surgical resection.

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The use of modern imaging technology has improved our ability to accurately outline the anatomy of the tumors preoperatively and rule out distant metastases. Several studies have shown that obtaining negative surgical margins of resection is essential to local tumor control and improvement of OS.1 Preoperative medical assessment and management, expert anesthesia, and postoperative intensive care have reduced perioperative mortality to less than 5%.1,2,3 The majority of patients undergoing radical pelvic surgery including those with recurrent endometrial and cervical tumors have already had surgery and radiation therapy. Patients with locally advanced primary carcinomas and a minority with advanced primary or recurrent sarcomas may also be candidates for the type of radical pelvic surgery described in this chapter.

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INDICATIONS AND CLINICAL APPLICATIONS

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This chapter describes the surgical management of a small group of tumors, which, due to their proximity to or invasion of bone, require bony pelvic resections in order to achieve a wide surgical margin. We also discuss management of tumors involving major vessels and nerves. Major sidewall soft tissue resections are discussed in Chapter 9.

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Bony involvement occurs from extension of tumor growth into the periosteum by direct invasion or by spread through local vessels into the bone (local metastasis). In some cases, the tumors do not actually involve bone but are inseparable from it, such that a wide resection can only be accomplished by resecting the adjacent bone. Better understanding of the functional anatomy of the pelvis and our ability to reconstruct following major bony resections has made these procedures possible. Resection of the periacetabular area or the hip usually requires extensive reconstruction, while resection of the area above and below the hip may not.5 It should be emphasized that the number of patients who are suitable candidates following full local and systemic staging are few and that a multidisciplinary approach is essential to ensure a satisfactory outcome.

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ANATOMIC CONSIDERATIONS

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A thorough knowledge of the topographic and functional anatomy of the pelvis is essential for surgeons embarking on these operations. Knowledge of the topographic anatomy ensures that the surgeon is familiar with important landmarks and relationships of various ...

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