Overview of Pelvic Exenteration

Pelvic exenteration is an extensive surgical procedure that involves removing a significant portion of the organs in the pelvic region. This includes parts of both the digestive and reproductive systems. In the digestive tract, it may include the lower part of the colon (sigmoid colon), the rectum, and the anus. For the reproductive system, in men, it might involve the removal of the prostate and seminal vesicles, and in women, the uterus, ovaries, and vagina. For both genders, this surgery usually includes the bladder and urethra.

A complete pelvic exenteration includes removing all these mentioned parts. However, for women, there is a possibility of having a partial procedure in which the surgeon removes only the reproductive and urine-related parts but leaves the rectum and anus. Alternatively, the surgeon may opt to remove the digestive and reproductive organs, preserving the bladder and urethra.

Originally, in 1948, pelvic exenteration was done for women who had severe cervical cancer. But, at that time, the surgery was risky and survival rates were low, so it was not frequently done. However, advances in medicine including improvements in anesthesia, blood transfusions, imaging technology, and surgical techniques have made this procedure much safer and improved the results patients can expect.

From the mid 20th century onwards, pelvic exenteration started being used to treat various types of advanced cancers affecting the pelvic region. These include cancers of rectum, ovaries, vulva, and prostate, as well as melanoma and sarcomas in the pelvic area. These days, the surgery may also be done to address complications from radiation therapy, which is known as radiation necrosis.

Despite these advancements, pelvic exenteration is still a major surgery and is not without risks or complications, including leakage at the surgical site, connections forming between organs (fistulas), infection, and injury to the urinary system. It’s also worth noting that nowadays, pelvic exenteration is more commonly done to treat recurring diseases rather than primary tumor removals.

Regardless of reason, this surgery is generally only considered when it is possible to completely remove all cancerous tissue (clear surgical margins), and the patient understands the procedure and its risks. In the majority of cases, pelvic exenteration is done using an open surgical procedure (laparotomy), but less invasive surgical techniques, including traditional and robot-assisted laparoscopic surgery, are becoming more common.

Anatomy and Physiology of Pelvic Exenteration

According to research by Hockel, the urinary, reproductive, and digestive systems all originally come from the same “morphogenetic unit” in the pelvis when we are embryos. These three systems eventually separate and each has its own blood vessels, connecting tissues (mesenteries), and lymphatic (body’s defense) system. For instance, the rectum, anus, and their associating tissues come from the hindgut division of the embryo. The tubes (Fallopian tubes), uterus, the upper part of the vagina, and their associating tissues make up what’s called the Mullerian morphogenetic unit. The lower parts of the ureters, bladder, urethra and the lower part of the vagina originate from the urogenital sinus and Wolf ducts in the embryo.

At first, these different structures serve as a natural protective boundary to stop a tumour from spreading to the nearby areas. However, modern cancer treatment guidelines highlight the importance of removing the entire unit, including the linking tissues. Based on Hockel’s findings, it’s crucial to remove the whole unit with the affected organs at once. If doctors have to remove 2 or more of these morphogenetic units, it’s called an ultra-radical compartmentalized surgery or pelvic exenteration.

In current surgical practice, if needed, the removal process can be extended to include the sacrum bone with the rectum to achieve a complete removal of all cancerous areas. In the same way, an enclosure that houses a tumor could expand to include the pubic bone as well. In case the cancer grows towards the side of the pelvis, the surgery could involve removing the structures at the side of the pelvic wall, which includes the blood vessels, nerves, and muscles.

Why do People Need Pelvic Exenteration

If your pelvic cancer is advanced or has come back, you might experience severe pain, bleeding, or other problems due to infection, blockages, and unusual connections (or fistulas) between different parts of the body. These symptoms can also be associated with radiation treatment done earlier.

The primary reason for a large surgical procedure known as pelvic exenteration is an advanced form of cancer that has started growing into the surrounding pelvic organs or structures. This includes the sides of the pelvis, the blood vessels and nerves in the area, or the bones at the back and front of the pelvis. The aim during this surgery is to entirely remove all the cancer (an R0 resection), leaving no traces of it on the edges of the removed tissue.

The purpose of this radical surgery is to offer you a reasonable chance of getting rid of the cancer permanently. Estimates suggest it might be successful for up to 63% patients. Among all the factors that predict survival rates and quality of life for patients with advanced cancer, achieving an R0 resection is the most significant one.

In the past, if you had one swollen kidney, leg swelling on one side, and sciatica pain on one side (which together formed a triad of symptoms), it meant that the cancer in the pelvic sidewall was inoperable. However, with advanced preparations using modern imaging techniques like pelvic MRIs, CT angiograms, and venograms, the success rates in achieving an R0 resection have gone up to around 66.5%.

When a Person Should Avoid Pelvic Exenteration

Pelvic exenteration, a major surgical procedure often done to treat cancer, might not be the best option in certain situations. One such situation is when the surgeon is sure before the operation that they won’t be able to remove all cancerous cells from the body. This procedure is rather complex and can result in a lot of discomfort after the surgery. Hence, it is typically considered only for those patients where it’s likely to remove all the cancer and with an intention to cure the disease.

Although the procedure can somewhat extend a patient’s lifespan when done to ease symptoms without curing the disease (known as a palliative approach), it may not significantly improve their quality of life. However, there isn’t much information available on how the palliative method affects patient’s quality of life. So, this approach should ideally be chosen for special cases only. Some doctors might consider a palliative pelvic exenteration for patients suffering severe symptoms like uncontrollable openings in the body (fistulas), big skin tumors, or unbearable pain.

The effectiveness of pelvic exenteration on patients with cancer that has spread to other organs (metastatic disease) is not certain. Usually, this procedure is not suggested for patients who cannot receive supplementary cancer treatments (adjuvant chemotherapy) within the usual period following the surgery. This is because recovery from pelvic exenteration can take a long time.

Preparing for Pelvic Exenteration

Pelvic exenteration is a major surgical procedure which involves removing a number of organs in the pelvic area. Without a doubt, it’s a complex operation with high chances of complications and potential risks. Therefore, before the operation, doctors perform a number of evaluations to ensure that everything goes as smoothly as possible. A cystoscopy, a vaginal exam, and a lower GI endoscopy are generally performed to determine the degree of involvement of pelvic organs. If a patient is being considered for this operation due to cancer, a tissue sample or biopsy is required to confirm the diagnosis.

Before the surgery, it’s essential to ensure there are no cancer cells elsewhere in the body. Doctors perform CT scans for the chest, abdomen, and pelvic area. PET scans, a type of imaging test, is an effective way to look for any metastatic or spread-out cancer cells in the body. If there are any suspicious areas found in these scans, a biopsy may be performed for further investigation. An MRI of the pelvis can give more details about the affected area, while CT scans can help doctors plan exactly how they’ll perform the operation with precision and safety.

On top of these evaluations, the patient’s heart and lung health needs to be assessed thoroughly before the surgery. Doctors anticipate potential complications such as significant blood loss and fluid shifts, making sure the patient is capable of withstanding the procedure. Anesthesiologists will evaluate the patient to determine the best sedation methods for the operating room, and additional blood products should be ready in case they’re needed during the operation.

A team of surgical and critical care doctors will be in charge after the surgery, monitoring the patient’s health closely. Due to the complexity of the procedure, there may need to be several surgical teams ready to handle any unexpected issues that may arise. The surgeon in charge will organize the plan for removing the tumor with as much precision as possible.

When the plan for surgery is ironed out, necessary preparations are made. An enterostomal therapist will educate the patient and mark the locations for any needed surgical openings called ostomies. Physical therapists will collaborate in preparing the patient for surgery and work out a recovery plan. Since many patients who go for this operation may be malnourished, they might be put on parenteral nutrition (nutrition provided through an IV drip) before and after the operation. The patient’s physical condition, recovery potential, and psychological readiness for the operation and recovery are carefully evaluated.

A noteworthy risk of this procedure is pulmonary embolism, which is a sudden blockage in a lung artery. To prevent this, mechanical compression devices are often used to boost blood flow, which helps reduce the risk of blood clots. Given the nature of operation, the risk for bleedings, anticoagulants might not be preferable. Surgeons carefully balance the risk of bleeding against the risk of developing a significant lung clot.

How is Pelvic Exenteration performed

To perform a complex surgical procedure known as “pelvic exenteration”, the patient is positioned on the operating room table, with their legs lifted and spread apart. This allows the surgeon to access and clean the abdomen and perineal areas – the area around your anus. To get a better view of the pelvis area, the table is titled downwards towards the patient’s head.

The surgeon makes a vertical cut in the middle of the patient’s abdomen and carries out a thorough exploration of the abdominal cavity to check for any abnormalities or tumors in the liver, spleen, gastrointestinal viscera, omentum, and peritoneal surfaces. These are all parts of your digestive and immune systems.

The surgeon begins the operation by making a cut in the peritoneum – the membrane that lines the abdomen – over the iliac vessels (blood vessels in the pelvis). The surgeon then moves the tissue containing lymph nodes towards the center to include it with the specimen being removed. The blood vessels supplying the area being operated on are tied off. The surgeon cuts into the peritoneum of the front of the bladder to move it backwards with the specimen. Each ureter (tubes that carry urine from the kidneys to the bladder) is tied off close to the tumor and kept safe for later use.

In male patients, the anterior dissection is carried to the pelvic floor to move the prostate gland. The urethra (tube that carries urine) is tied off. In female patients, the dissection is also carried down to the pelvic floor and ends at the urethra and vagina. The inferior mesenteric pedicle, which carries blood to the distal part of the large intestine, is tied off at or above the place where the aorta splits. The sigmoid mesentery, which carries blood to the sigmoid colon, is divided, while keeping the remaining blood supply. The sigmoid colon (end part of the colon) is cut in readiness for a colostomy – a procedure that allows waste to leave your body through an opening in the abdomen.

The rectum is separated from the presacral fascia, a layer of tissue at the back of the pelvic cavity, all the way to the end of the backbone. This dissection is done on both sides along the lining of the pelvic sidewalls until the rectum and either the vagina or the prostate are fully mobilized to the pelvic floor. To remove the part being operated on, the remaining perineal attachments are cut off. The reconstruction that follows surgery is significant. A mesh or a muscular flap from the patient’s abdomen is used to close the pelvic floor defect. The vagina is also reconstructed with skin grafts or a segment of the bowel keeping urinary outflow in mind. A segment of ileum (last part of the small intestine) is isolated and stitched into the skin, creating a urostomy – an opening in the abdomen to allow urine to exit your body.

Additional procedures can be carried out depending on the situation, such as a partial or total removal of the abdominal bladder or other structures. This procedure is complex and long, often taking between 5 and 14 hours, and can result in substantial blood loss. Robotic surgery methods can also be used with the same goals as open surgery.

Possible Complications of Pelvic Exenteration

Pelvic exenteration, a major surgery involving the removal of organs from the pelvis, can potentially lead to health problems—from mild to severe—in 20% to 80% of cases. In fact, a study found that more than half of the patients faced health issues while still in the hospital, stayed there around 22 days, and about 6.3% passed away during their hospital stay.

Before the surgery, if patients have gone through radiation treatment and have had previous surgeries, they face a high risk of urinary complications. The occurrence of these complications ranges between 9% to 24%. This includes cases where urine leaks out of its normal path in about 7% to 16% of patients. There’s also a 6% chance that leakage may occur at the point where the gut has been stitched back together after surgery. In some serious cases, this can go up to 54%.

Some patients, up to 15%, suffer from pelvic abscesses or enteric fistulas—pockets of infection or abnormal connections between organs—if their pelvis has been irradiated and is empty. To address these issues, various techniques like using the omentum (a fat-filled fold of tissue) to suspend or lift the gut from the pelvis or fill the pelvis have been adopted, leading to fewer abscesses and fistulas.

It’s crucial to note that around one-third of the patients who go through pelvic exenteration need further procedures to manage the complications. Aiming to prevent infection and nutritional complications linked to sepsis (a life-threatening condition caused by the body’s response to an infection) and malnutrition, policies have been put into place. These policies include administering antibiotics for 5 days after surgery, and providing complete nutrition intravenously (through a vein) until the digestive system starts working normally.

What Else Should I Know About Pelvic Exenteration?

Pelvic exenteration is a major operation where the organs from the pelvic area are removed. This operation has been used to treat severe illnesses, such as cancer. Fortunately, since the mid-1900s, the number of people who die from this operation has significantly decreased from approximately 23% to only 1-2% in specialized centers. The main goal of this operation is to completely remove all the cancer (an R0 resection). This is the key to surviving in the long run. In fact, for people with advanced primary or recurring pelvic cancer, having surgical removal is the only possible cure. Surgery has resulted in a survival rate of 50% or more after three years, and R0 resections can be achieved in about 70% of patients chosen appropriately.

In recent times, pelvic exenteration is now done more often for diseases that have come back rather than primarily removing tumors. The use of this operation for advanced cervical, vaginal, and vulvar cancers has decreased, thanks to improved response to current chemotherapy and radiation techniques.

When pelvic exenteration is used as a palliative treatment (to relieve symptoms but not cure the disease), the percentage of patients who die in the hospital is about 6.3%, and the average survival time is 14 months. Due to the high rates of complications and limited survival time, using pelvic exenteration as a palliative treatment remains controversial. Some studies even show limited evidence that this operation improves symptoms and quality of life. The quality of life for patients who chose pelvic exenteration as a palliative treatment has been controversial and compared to those who experienced a rapid improvement in their quality of life after two to nine months following curative surgery.

Medical professionals are continually developing minimal invasive techniques associated with pelvic exenteration which could be less traumatic for patients. Studies have shown that these less invasive techniques are possible for pelvic exenteration resulting in less bleeding during the operation and shorter hospital stays. However, we still need more extensive studies on these techniques.

Frequently asked questions

1. What organs will be removed during the pelvic exenteration surgery? 2. What are the potential risks and complications associated with pelvic exenteration? 3. How successful is pelvic exenteration in completely removing all cancerous tissue? 4. Will I need additional treatments, such as chemotherapy, after the surgery? 5. What is the expected recovery time and what can I expect in terms of quality of life after the surgery?

Pelvic exenteration is a surgical procedure that involves removing multiple organs and tissues in the pelvis, including the urinary, reproductive, and digestive systems. This procedure is typically performed to treat advanced or recurrent cancer in the pelvis. The extent of the surgery depends on the location and spread of the cancer, and it may involve removing additional structures such as bones, blood vessels, nerves, and muscles.

You would need pelvic exenteration if you have cancer that is localized to the pelvic area and the surgeon believes that they can remove all of the cancerous cells from your body. This procedure is typically done with the intention of curing the disease. However, in some cases, it may also be considered as a palliative approach to ease symptoms, such as uncontrollable openings in the body, large skin tumors, or severe pain. It is important to note that the effectiveness of pelvic exenteration on patients with cancer that has spread to other organs is uncertain, and it is not recommended for patients who cannot receive additional cancer treatments following the surgery.

Pelvic exenteration should not be pursued if the surgeon believes that they will not be able to remove all cancerous cells from the body. Additionally, the procedure can result in significant discomfort and may not significantly improve the patient's quality of life, especially if it is done as a palliative approach without the intention to cure the disease.

The recovery time for Pelvic Exenteration can vary depending on the individual and the specific circumstances of the surgery. However, it is generally a major surgery with a complex recovery process. Patients may experience health problems ranging from mild to severe, and complications can occur in 20% to 80% of cases. Some patients may require further procedures to manage complications, and policies are in place to prevent infection and nutritional complications.

To prepare for Pelvic Exenteration, the patient undergoes evaluations such as cystoscopy, vaginal exam, and lower GI endoscopy to determine the involvement of pelvic organs. CT scans and PET scans are performed to check for cancer cells in the body. The patient's heart and lung health are assessed, and preparations are made for potential complications. Additionally, physical therapists and enterostomal therapists may be involved in the preparation process.

The complications of Pelvic Exenteration include health problems in 20% to 80% of cases, with more than half of patients experiencing issues while in the hospital and a 6.3% mortality rate during their stay. Patients who have undergone radiation treatment and previous surgeries are at a higher risk of urinary complications, with a 9% to 24% occurrence rate. Urine leakage can occur in 7% to 16% of patients, and there is a 6% chance of leakage at the site of surgical stitching. In some cases, leakage can occur in up to 54% of patients. Pelvic abscesses or enteric fistulas can occur in up to 15% of patients with irradiated and empty pelvises. Further procedures are often required for one-third of patients to manage complications. Policies have been implemented to prevent infection and nutritional complications, including administering antibiotics for 5 days after surgery and providing complete nutrition intravenously until the digestive system recovers.

Symptoms that require Pelvic Exenteration include severe pain, bleeding, infection, blockages, and fistulas associated with advanced or recurrent pelvic cancer. These symptoms may also be present due to previous radiation treatment.

Based on the information provided, there is no specific mention of the safety of pelvic exenteration in pregnancy. However, it is important to note that pelvic exenteration is a major surgical procedure with potential risks and complications. Given the extensive removal of organs in the pelvic region, including the reproductive system, it is unlikely that pelvic exenteration would be performed during pregnancy unless there is a life-threatening situation for the mother. Each case would need to be evaluated individually by a medical team to assess the risks and benefits for both the mother and the fetus.

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

We care about your data in our privacy policy.