Chapter 8: Pelvic Exenteration

BACKGROUND AND EVOLUTION

Exenteration was first reported by Brunchswig in 1948 as a palliative procedure, and, in his subsequent series of 561 patients collected from 1948 to 1964, the operative mortality was 26% and the 5-year survival rate was 20%.¹ Advances in anesthesia, surgical instrumentation, technique, pelvic floor reconstruction, antibiotics, fluid management, blood products, the use of intermediate or intensive care units, and the training of gynecologic oncologists have decreased operative mortality; in addition, improved patient selection preoperatively and intraoperatively have increased survival rates. At the Mayo Clinic from 1950 to 1986, the operative mortality rate decreased from 12% to 6.7%, and the 5-year survival rate increased from 26% to 41%.² Patient rehabilitation has also remarkably improved. From loss of vaginal function and 1 or 2 permanent stomas, reconstructive techniques have resulted in no stoma bags (due to low rectosigmoid anastomosis and continent urinary reservoir), and restoration of vaginal function by using different type of pedicle flaps. Other factors to consider for all exenteration candidates are the need for family support due to long rehabilitation, usually 6 months or longer depending on the extent of the operation and whether there were or not postoperative complications, quality of life before and after surgery, and the need for appropriate care if an exenteration cannot be performed or cure is not achieved.

INDICATIONS AND CLINICAL APPLICATIONS

Pelvic exenteration remains a salvage operation when other forms of therapy have been exhausted. Most candidates are patients with cervical cancer postirradiation or those with advanced primary disease. Because of dosimetry improvements and the addition of sensitizing concomitant chemotherapy, the number of exenteration candidates has decreased, with only about 8% of patients with advanced cervical cancer being candidates. Other candidates are patients with recurrent endometrial, vaginal, urethral, vulvar, rectal, bladder, and, even occasionally, ovarian malignancies. Most often, the clinical scenario for consideration of exenterative surgery involves a cervical or endometrial cancer patient presenting with a recurrence after having received pelvic irradiation for a postsurgical recurrence. Occasionally, patients with an advanced primary malignancy of the vulva or vagina, who are not candidates for irradiation, are best treated by primary pelvic exenteration.

Prognostic Factors and Contraindications

Prognostic factors impacting survival and the risk of morbidity include the patient’s age, body mass index (BMI), general medical condition, the origin site of the primary lesion, the time interval from primary treatment to recurrence, the volume and location of the recurrent lesion, histological type of tumor, lymphatic invasion, degree of tissue invasion and pelvic viscera involved, parametrial invasion, levator muscle invasion, postresection margins, positive nodes, peritoneal involvement, small bowel involvement, lateral pelvic wall extension or fixation, invasion of other soft tissues or bone, and extrapelvic metastases.^2,3,4,5,6 The combination of several adverse prognostic factors decreases survival rates.⁵

Optimal candidates for pelvic exenteration are young ...