eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Pelvic Exenteration

Author: Margrit M Juretzka, MD, MS, Assistant Professor of Gynecologic Oncology, Stanford University Hospital and Clinics
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
Contributor Information and Disclosures

Updated: Dec 22, 2008

Introduction

History of the Procedure

Patients 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%.2,13

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%.1

Pelvic exenteration continues to be the only curative option in certain patients with centrally recurrent cervical, vaginal, or vulvar cancers. Although patients with other gynecologic malignancies generally are not candidates for exenterative procedures, some centers have reported exenterations in select cases of central pelvic recurrences such as low-grade uterine sarcomas. 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%.6,12,16

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.5 This task can be accomplished by laparoscopy in selected patients.10

Problem

Cancers 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.2,13 In general, patients with ovarian cancer are not candidates because of the distant pattern of spread associated with ovarian cancers.

Presentation

Patients with recurrent cervical cancer after radiation therapy usually present with bleeding, hematuria, or pelvic pain.7 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, historically, has generally been considered a contraindication to surgery. However, some surgeons have reported on an even more radical resection, the laterally extended endopelvic resection (LEER), which extends the lateral extent of the resection to include structures of the pelvic sidewall including striated muscle and vessels.15 Further study is required to evaluate the indications and outcomes of these procedures.

Indications

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.

Contraindications

Absolute contraindications include peritoneal metastasis, skip metastasis to bowel, and other distant sites such as pulmonary metastases. 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.

More on Pelvic Exenteration

Overview: Pelvic Exenteration
Workup: Pelvic Exenteration
Treatment: Pelvic Exenteration
Follow-up: Pelvic Exenteration
References
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References

  1. Brunschwig A. Complete excision of the pelvic viscera for advanced carcinoma. Cancer. 1948;1:177.

  2. Eifel P, Berek JS, Thigpen JT. Cancer of the cervix, vagina and vulva. In: Cancer Principles and Practice of Oncology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1997:1433-1478.

  3. Hatch KD, Gelder MS, Soong SJ, et al. Pelvic exenteration with low rectal anastomosis: survival, complications, and prognostic factors. Gynecol Oncol. Sep 1990;38(3):462-7. [Medline].

  4. Husain A, Curtin J, Brown C, et al. Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies. Gynecol Oncol. Aug 2000;78(2):208-11. [Medline].

  5. Miller B, Morris M, Rutledge F, et al. Aborted exenterative procedures in recurrent cervical cancer. Gynecol Oncol. Jul 1993;50(1):94-9. [Medline].

  6. Morley GW, Hopkins MP, Lindenauer SM, Roberts JA. Pelvic exenteration, University of Michigan: 100 patients at 5 years. Obstet Gynecol. Dec 1989;74(6):934-43. [Medline].

  7. Morrow CP, Curtin JP. Surgery for cervical neoplasia. In: Gynecologic Cancer Surgery. First ed. Churchill Livingstone; 1996.

  8. Penalver MA, Barreau G, Sevin BU, Averette HE. Surgery for the treatment of locally recurrent disease. J Natl Cancer Inst Monogr. 1996;(21):117-22. [Medline].

  9. Penalver MA, Angioli R, Mirhashemi R, Malik R. Management of early and late complications of ileocolonic continent urinary reservoir (Miami pouch). Gynecol Oncol. Jun 1998;69(3):185-91. [Medline].

  10. Plante M, Roy M. The use of operative laparoscopy in determining eligibility for pelvic exenteration in patients with recurrent cervical cancer. Gynecol Oncol. Dec 1995;59(3):401-4. [Medline].

  11. Rose PG, Blessing JA, Gershenson DM, et al. Paclitaxel and cisplatin as first-line therapy in recurrent or advanced squamous cell carcinoma of the cervix: a gynecologic oncology group study. J Clin Oncol. Sep 1999;17(9):2676-80. [Medline].

  12. Rutledge FN, Smith JP, Wharton JT, O'Quinn AG. Pelvic exenteration: analysis of 296 patients. Am J Obstet Gynecol. Dec 15 1977;129(8):881-92. [Medline].

  13. Stehman FB, Perez CA, Kurman RJ. Uterine cervix. In: Principles and Practice of Gynecologic Oncology. 3rd ed. Lippincott Williams & Wilkins; 2000:841-918.

  14. Sugiyama T, Yakushiji M, Noda K, et al. Phase II study of irinotecan and cisplatin as first-line chemotherapy in advanced or recurrent cervical cancer. Oncology. 2000;58(1):31-7. [Medline].

  15. Höckel M. Laterally extended endopelvic resection. Novel surgical treatment of locally recurrent cervical carcinoma involving the pelvic side wall. Gynecol Oncol. Nov 2003;91(2):369-77. [Medline].

  16. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003). Gynecol Oncol. May 2006;101(2):261-8. [Medline].

  17. Long HJ 3rd, Bundy BN, Grendys EC Jr, Benda JA, McMeekin DS, Sorosky J, et al. Randomized phase III trial of cisplatin with or without topotecan in carcinoma of the uterine cervix: a Gynecologic Oncology Group Study. J Clin Oncol. Jul 20 2005;23(21):4626-33. [Medline].

  18. Husain A, Akhurst T, Larson S, Alektiar K, Barakat RR, Chi DS. A prospective study of the accuracy of 18Fluorodeoxyglucose positron emission tomography (18FDG PET) in identifying sites of metastasis prior to pelvic exenteration. Gynecol Oncol. Jul 2007;106(1):177-80. [Medline].

  19. Tran PT, Su Z, Hara W, Husain A, Teng N, Kapp DS. Long-term survivors using intraoperative radiotherapy for recurrent gynecologic malignancies. Int J Radiat Oncol Biol Phys. Oct 1 2007;69(2):504-11. [Medline].

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Further Reading

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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

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Contributor Information and Disclosures

Author

Margrit M Juretzka, MD, MS, Assistant Professor of Gynecologic Oncology, Stanford University Hospital and Clinics
Margrit M Juretzka, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists and Society of Gynecologist Oncologists
Disclosure: Nothing to disclose.

Coauthor(s)

Nelson Teng, MD, PhD, Associate Professor, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, Stanford School of Medicine
Disclosure: Nothing to disclose.

Amreen Husain, MD, Assistant Professor, Department of Gynecology and Obstetrics, Stanford University School of Medicine
Amreen Husain, MD is a member of the following medical societies: American Association for Cancer Research, American College of Obstetricians and Gynecologists, and Society of Gynecologist Oncologists
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine
Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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