Chapter 9: (Laterally) Extended Endopelvic Resection

BACKGROUND

Insights in the topology of locoregional tumor spread from developmental biology call for redefining the principles of cancer surgery.¹ Surgical procedures translating these concepts into practice have achieved excellent locoregional tumor control at low rates of treatment-related morbidity.^2,3,4,5 The corresponding surgical techniques for the therapy of locally advanced and recurrent cancer of the lower female genital tract are termed (laterally) extended endopelvic resection ([L]EER).⁶ (L)EER enables R0 resection and locoregional tumor control not only in patients who are regarded as suitable candidates for conventional pelvic exenteration but also in patients with tumors fixed to the pelvic sidewall who are currently excluded from exenteration candidacy either pre- or intraoperatively.⁷

INDICATIONS AND CLINICAL APPLICATIONS

Pelvic sidewall recurrences or locally advanced cancer of the lower female genital tract have traditionally been considered inoperable. If patients with this clinical presentation have not been irradiated, then radiotherapy or combined chemoradiotherapy can lead to remission. However, in the majority of cases, pelvic sidewall disease is diagnosed following primary or adjuvant pelvic irradiation or has not been controlled by radiotherapy. Consequently, patients with persistent and recurrent cervicovaginal cancer following radiotherapy and patients with advanced primary disease with fistulae between the genital and urinary tracts and/or anorectum are candidates for (L)EER if the following conditions are met preoperatively:

1. Exclusion of distant metastases,

2. No tumor involvement at the site of the sciatic foramen, and

3. Physical status and mental fitness adequate for the megaoperation.

Patients with locally advanced disease without fistulae and patients with postsurgical pelvic recurrence in an non-irradiated pelvis are primarily considered for chemoradiation. However, they may be evaluated for (L)EER if the radiotherapist votes for or the patient requests surgical treatment.

ANATOMIC CONSIDERATIONS

A prerequisite for the performance of (L)EER is a working knowledge of the ontogenetic anatomy of the pelvis in the human female, which will be briefly outlined here, supplemented by Figures 9-1,2,3. For further details, the reader is referred to textbooks and monographs.^8,9,10,11,12