Total pelvic exenteration (PE) is a radical operation, involving en bloc resection of pelvic organs, including reproductive structures, bladder, and rectosigmoid. In gynecologic oncology, it is most commonly indicated for the treatment of advanced primary or locally recurrent cancer. Careful patient selection and counseling are of paramount importance when considering someone for PE. Part of the evaluation process includes comprehensive assessment to exclude unresectable or metastatic disease. PE can be curative for carefully selected patients with gynecologic cancers. Major complications can be seen in as many as 50% of patients undergoing PE, underscoring the need to carefully discuss risks and benefits of this procedure with patients considering exenterative surgery.
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Pelvic exenteration (PE) describes a radical surgery involving the en bloc resection of the pelvic organs, including the internal reproductive organs, bladder, and rectosigmoid. Indications include advanced primary or recurrent pelvic malignancies, most commonly centrally recurrent cervical carcinoma, but also other gynecologic tumors and urologic and rectal cancers. Distant metastasis has traditionally been a contraindication to PE with curative intent. As the best chance for disease-free survival is surgical resection of regional disease, this procedure is an opportunity to cure advanced and recurrent cancers confined to the pelvis. PE has also been used for palliation of symptoms related to radiation necrosis or extensive tumor burden. Both total and partial PE require extensive reconstruction and surgical recovery with significant associated morbidity and mortality. Careful patient selection is required to balance the potential goal of cure or symptom palliation with surgical risk.
The first cases of total PE were described by Brunschwig in 1948 as a palliative procedure for symptoms caused by locally advanced gynecologic cancers. This demonstrated proof of concept for PE, with a postoperative survival of up to 8 months, and a 23% surgical mortality rate [1]. Subsequent data demonstrated that the technique could offer a chance of cure for centrally located tumors, not just palliation, and the focus of the surgery shifted to one of curative intent. Various surgical approaches both for sparing uninvolved pelvic organs and removing extraperitoneal structures such as the sacrum were attempted. Major breakthroughs included separate stomata for urine and fecal diversion and the use of omentum to protect the empty and denuded pelvic space and reduce abscess formation and intestinal obstruction [2, 3]. More recently, techniques to resect tumor involving the pelvic sidewall, previously a contraindication to PE, have been described offering more patients a chance at curative surgery [4]. PE may also be combined with intra-operative radiation therapy for improved disease control at the pelvic sidewall or possible positive margins [5, 6].
Traditionally PE has been used for centrally recurrent cervical carcinoma, both squamous and adenocarcinoma, with well-documented salvage potential. Up to 25% of women with FIGO stage IB-IIA cervical cancer may recur after initial therapy [9]. Frequently, these recurrences may be treated with radiotherapy; however, radical surgery may offer an alternative for curative treatment. Survival rates ranging from 16 to 60% are reported for these patients [10, 11]. Long-term survival is directly correlated with complete tumor resection [12, 13], so establishing resectability is a key aspect of preoperative planning. Time from primary treatment, with radiation or chemoradiation, to time of PE has also been shown to be related to survival and disease-free interval [12], with women requiring PE for recurrence less than 2 years following primary therapy demonstrating an 8-month survival versus 33 months in women who recurred more than 2 years following initial treatment in one study [14], though this has not been shown in all series [10]. PE has also been utilized as a potentially curative primary treatment for locally advanced cervical cancer (FIGO stage IVa), a practice exercised more frequently in Germany than the United States [15]. For example, in their series, Marnitz et al. reported a 52.5% five-year survival [12].
PE is a radical operation, involving en bloc resection of pelvic organs, including reproductive structures, bladder, and rectosigmoid. In gynecologic oncology, it is most commonly indicated for the treatment of advanced primary or locally recurrent cancer. Patients need to be carefully selected and counseled about risks and long-term issues related to the surgery. A comprehensive evaluation is required in order to exclude unresectable or metastatic disease. Total PE is associated with significant surgical morbidity, a fact that underscores the importance of careful patient selection and counseling. The emergence of minimally invasive surgery and application of this technology to radical pelvic surgery including PE may result in a reduction operative morbidity and mortality. Further studies are necessary prior to a widespread adoption of this technology to exenterative procedures. 2ff7e9595c
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