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Our experience of 76 pelvic exenterations for advanced pelvic malignancies is presented, with emphasis on the results and complications. The overall operative mortality rate of 14% is acceptable, and a five-year survival rate of 20% has been achieved. The procedure has a definite role to play in the management of advanced but otherwise localized pelvic malignancies.
After pelvic exenteration for cancer, the gracilis muscles, skin, and subcutaneous fat from the inner aspect of both thighs may be raised as a pedicle flap and tunneled under the skin into the pelvic space to create a neovagina. We reviewed nine pelvic CT examinations in six patients to evaluate the CT appearance of this procedure and its complications. Five patients are alive and without complications. One patient died 6 months after surgery and had a small-bowel fistula to the neovagina. Normal CT findings included air in the vaginal canal in six of nine examinations, gracilis muscle atrophy in two patients who had early and late CT studies, and early separation of the anterior and posterior approximation of the flaps in one patient. Abnormal findings were seen in two patients: one had an abscess near the vaginal apex that was drained per vagina; the other had extraluminal air in the retropubic and subcutaneous fatty tissues due to a small-bowel fistula into the vagina.
Pelvic exenteration, although performed most frequently for recurrent squamous cell carcinoma of the cervix and vagina, has been used in selected patients with pelvic sarcoma. Nine patients with various histologic types of sarcoma treated by pelvic exenteration are reported. During this 23-year time period, 46 patients with sarcoma were evaluated for possible exenteration. Patients with embryonal rhadomyosarcoma (sarcoma botryoides) were excluded because these pediatric tumors are now treated with less radical operative procedures, plus radiation and chemotherapy. Six patients had exenteration as primary treatment, and three patients had exenteration as secondary treatment. Four patients developed recurrent disease (mean 5.2 months), and all four died of disease. Five patients were alive at 5 and 10 years, for an absolute survival of 55%. All three patients with mixed mesodermal tumors died of recurrent disease, compared with 83% survival for patients with other sarcoma types. Pelvic exenteration may play a limited but important role in the therapy of pelvic sarcoma.
Our experience with 18 patients undergoing pelvic exenteration for advanced primary or recurrent pelvic malignancies is presented. Only one postoperative death was noted, and morbidity was minimal despite the advanced age and high incidence of radiotherapy failures seen in our patients. Although no improvement in cure of malignancy has been seen in this small series, appreciable periods of symptom-free life have been achieved in patients who were previously incapacitated by extensive pelvic pain, fistulas, sepsis, hemorrhage and urinary-fecal incontinence. Because of the symptomatic palliation obtained in our experience, with minimal morbidity and mortality, we have developed a liberal attitude toward the use of pelvic exenteration in the management of selected patients with extensive pelvic malignancy, even when cure is not anticipated.
Pelvic exenteration entails extensive radical surgery with evisceration of pelvic organs involved with central recurrence of pelvic cancer. It may occasionally be indicated as a primary surgical procedure. A tumour arising from any pelvic organ may require this surgery but those from the cervix and vulva primarily are particularly amenable to such surgery. Certain ovarian tumours with involvement of the rectum and large pelvic masses not responsive to previous surgery or chemotherapy may also be considered for exenterative type surgery as a type of salvage operation. Strict criteria must be observed to exclude either distal spread or local fixation in the pelvis with consequent lymphatic or vascular involvement. For patients with recurrent cervical cancer, 50% of those referred were rejected at examination under anaesthetic as being inoperable: 20% overall were surgically suitable for the procedure at exploratory laparotomy. The final decision to proceed is made at laparotomy with frozen section assessments to ensure adequate clearance of tumour. Urinary diversion by means of an ileal conduit and also terminal colostomy will be required after total pelvic exenteration. Anterior or posterior exenteration will require diversion only of either the urinary or gastrointestinal tract. Large vulvar tumours may require simultaneous musculocutaneous flaps in order to obtain adequate closure of large defects with satisfactory skin coverage. 52 such procedures have been performed over the last five years. 25 of these have been for extensive ovarian carcinomas as a salvage procedure following previous failed surgery and chemotherapy. A median survival of two years six months as opposed to 10 months in an inoperable but comparable group was obtained. 12 patients with recurrent cervical cancer and 8 with advanced vulvar cancer were also operated on. The mean age was 59 years with a range of 30-76 years. The operative mortality following this extensive and radical procedure was 6% with 3 deaths occurring at 24 hours, one month and three months post surgery. A 20% morbidity occurred with varied complications including haemorrhage (3 patients) and fistulae (2 patients). The overall survival at 3 years was 48% with 75% survival for patients with carcinoma of the vulva and 60% with carcinoma of the cervix. No patients with involved lymphadenopathy survived. With a combined team approach to the careful selection and management of suitable cases, a 50% five year survival may be obtained with patients undergoing pelvic exenteration for advanced pelvic cancer.
Although total pelvic exenteration is performed for central recurrent or persistent uterine cervical carcinoma, the patient is damaged both physiologically and psychologically by its massive surgical procedure and complications as well as the loss of the vagina. Vaginal reconstruction at the time of surgery brings much advantageous satisfaction to the patient's future life and a strong bond with her husband. Furthermore, a new reconstructed vagina occuping the pelvic cavity prevents intestinal herniation and is available for bimanual examination in the follow-up to surgery. A case of recurrent cervical carcinoma is presented, with reconstruction of the vagina and conduit using the sigmoid colon in total pelvic exenteration.
Between September 1969 and January 1, 1986, 143 pelvic exenterations for recurrent cervical cancer were performed by the gynecologic oncologists at the University of Alabama at Birmingham. Of this group, 78 patients underwent total pelvic exenteration, 63 patients had anterior exenteration, and two had posterior exenteration. The overall operative mortality rate was 6.3%, mostly associated with total pelvic exenteration. The 5-year survival rates were 50% overall, 63% with anterior exenteration and 42% with total exenteration. Univariate and multivariate analyses were performed to identify clinical and histopathologic factors predictive of prolonged survival. Using three clinical factors (duration from initial radiation therapy to exenteration, size of the central mass, and presence of preoperative sidewall fixation), low-, intermediate-, and high-risk groups were constructed; the 5-year survival rates for these groups were 82, 46, and 0%, respectively. Inclusion of one histopathologic factor (margin status of the surgical specimen) added to the ability to predict 2- and 5-year survival rates. The best candidates for cure by pelvic exenteration were those with recurrent small (less than 3 cm), mobile central masses who were a year or longer from the time of their previous radiation therapy. Attempts to resect bulky pelvic recurrences that impinge on the pelvic sidewall, especially in the case of persistent or early recurrent disease (within 6 months), or continuation of exenterative procedures in women known to have nodal metastases or extrapelvic spread, are generally futile. For those women falling between the two extremes, sound clinical and operative judgment is imperative in regard to selecting the treatment offering the best quality of life.
Subgrouping of pelvic exenterations as supralevator (type I), infralevator (type II), with vulvectomy (type III), and, an added category, extended can be helpful to facilitate communication when referring to these patients. It also can facilitate a more detailed analysis of operative risk factors, complications, and results and can increase our knowledge of the indications and limitations of the different exenterative procedures.
Between 1966 and 1986, 99 patients underwent total pelvic exenteration at the Ellis Fischel State Cancer Center. Fifty-eight per cent of these were done for recurrence of carcinoma of the cervix uteri after radiation. The second most common type of malignant condition treated with total pelvic exenteration was localized advanced adenocarcinoma of the rectum. Fourteen of 99 patients died prior to discharge and after five years, 36 of 80 patients had survived. Seven deaths after discharge were attributed to the operation. There were 97 complications in 64 of the 99 patients after total pelvic exenteration prior to discharge. Between 1976 and 1981, one out of 14 patients undergoing total pelvic exenteration for locally advanced recurrent carcinoma of the cervix uteri died prior to discharge. Eight of 13 of the patients who survived that operation lived for five years. Total pelvic exenteration should be strongly considered in selected patients with locally advanced malignant lesions of the pelvis.
Continent ureteral diversion at the time of pelvic exenteration avoids an external appliance and allows patients to retain "bladder" reservoir function. The technical difficulty of this procedure requires meticulous attention to operative and perioperative care, particularly after pelvic irradiation. A patient with recurrent stage IIIB carcinoma of the cervix underwent total pelvic exenteration with reconstructive procedures including low rectal anastomosis, neovagina formation, and ileocecal (Indiana) continent diversion. Early catheterization of the reservoir began 2 weeks postoperatively. One week later cecal rupture occurred, not related to suture line (technical) failure. Because of the high wall tension and reduced compliance in the irradiated cecum, we do not recommend catheterization of the urinary reservoir before 4-6 weeks. In order for continent diversion to become the standard diversion in exenteration patients, the major complication rate must remain comparable to that of noncontinent diversion.
Six cases of pelvic exenteration, performed between 1 January 1987 and 30 June 1989 in the Obstetric-Gynecological Division of the Ospedali Riuniti of Bergamo are reported. Indications, surgical methods and complications are analysed in comparison to published data. From an analysis of our data it may also be concluded that pelvic exenteration has a role in the treatment of persistent and recurrent gynecological tumors, provided that patients are carefully selected.
Twenty patients underwent a supra levator total pelvic exenteration with low rectal anastomosis for recurrent or persistent cervical carcinoma following radiotherapy. Fourteen (70%) had complete healing. Five of 9 patients with protective colostomies had complete healing while 9 of 11 without protective colostomies healed. Three of 7 patients with a rectal stump length of less than 6 cm healed while 11 of 13 whose rectal stump was 6 cm or greater experienced complete healing. Overall, 13 of the 20 patients are clinically free of disease and 8 (61%) of those enjoy life with excellent bowel continence. A low rectal anastomosis should be attempted in those patients undergoing a supralevator total pelvic exenteration.
Although the ileal conduit is currently the most widely used method for urinary diversion in patients undergoing pelvic exenteration, reports continue to accumulate indicating the frequency of long-term complications. Four patients with failure of ileal urinary diversion after pelvic exenteration for invasive pelvic malignancy are presented. All four patients had either multiple pelvic surgical procedures and/or pelvic radiation. Interposition of jejunum between the proximal ureters or renal pelvises and skin was performed with satisfactory results in all four. In patients with pelvic exenteration and failure of ileal urinary diversion this technic offers the following advantages over the conventional revision of the ileal conduit: (1) eliminates use of radiated small intestine which is subject to fistula formation and/or obstruction; (2) avoids the settling of the urinary conduit in the devitalized pelvic space with potential adhesions, fistula formation, or obstruction; (3) ensures proximal jejunal loop is away from area of potential tumor recurrence and field or previous or future radiotherapy; (4) eliminates the extensive dissection of the adherent ileal conduit and subsequent risk of avascular necrosis; and (5) bypasses the radiated fibrotic distal ureters.
A series of 28 exenterations for advanced pelvic tumours is presented. The operative mortality (within 90 days) was 17.8%. The actuarial survival (expressed as a two-year disease-free interval) was 35.7%, and better in cases with negative lymph nodes. The types of urinary and bowel diversions adopted are discussed in terms of longer survival.
BACKGROUND: Advanced vulvar cancer can be treated by pelvic exenteration. METHODS: A clinical review of patients treated by exenteration surgery for vulvar cancer was performed. RESULTS: From 1950 through 1989, 19 patients underwent pelvic exenteration for advanced or recurrent squamous cell cancer of the vulva. The mean age was 53 years (median, 50 years; range, 40-74 years). The cumulative 5-year survival was 60%. Fourteen patients had posterior exenteration; 2 had anterior exenteration; and 3 had total exenteration. The survival was significantly influenced by lymph node status. When lymph nodes were not involved, 10 of 14 patients survived, whereas all 5 patients with lymph node involvement died of disease (P = 0.002). When exenteration was performed as primary therapy, 7 of 11 patients survived, whereas 3 of 8 survived when exenteration was performed for recurrent disease (P = 0.4). The extent of vulvar involvement did not influence survival (P = 0.99). There was no mortality, but ten patients had complications, including vesicovaginal fistula (three); stomal hernia (two); abscess (one); stress urinary incontinence (one); deep venous thrombosis (one); conduit leak (one); enterocutaneous fistula (one); and small intestinal obstruction (one). CONCLUSIONS: Acceptable survival for advanced or recurrent vulvar cancer can be achieved with pelvic exenteration, but the presence of metastatic disease to lymph nodes markedly decreases survival.
It has been traditional to exclude patients with radiation-recurrent carcinoma of the uterine cervix or other pelvic neoplasms, incapacitating pelvic pain, postirradiation fistulas, hemorrhage, or malodorous draining tumor necrosis from pelvic exenteration if cure of the malignant disease is not achievable. This negative attitude is a direct result of the reported high morbidity, prohibitive mortality, and low salvage rate previously associated with pelvic exenteration, the only acceptable surgical approach to these diseases. A recent experience with eighteen patients who underwent pelvic exenteration for advanced primary or recurrent carcinoma of the cervix, urinary bladder, or rectum has led us to challenge several traditional concepts regarding this operative procedure. We have observed but one operative death and our morbidity has been minimal. This may reflect our belief that an aggressive pelvic lymphadenectomy in those patients with direct visceral involvement from radiation-recurrent carcinoma of the pelvic viscera is not advantageous since no significant survival has ever been documented for patients with pathologic visceral involvement and positive lymph nodes. In addition, significant morbidity has always been associated directly with pelvic lymphadenectomy in the irradiated pelvis, and elimination of this phase of the operation in selected patients with radiation-recurrent carcinoma is indicated. Moreover, the considerable decrease in morbidity and the minimal mortality observed have led us to adopt a very liberal attitude toward preoperative selection criteria, and we regularly now use pelvic exenteration not only for cure but as intentional palliation in selected patients. We strongly believe that elimination of pain, fistulas, pelvic sepsis, hemorrhage, and malodorous areas of tumor necrosis are important for improving the quality of life for both the patient and family.
In a retrospective review of 23 pelvic exenterations performed at Miami Valley Hospital, 8 were considered to be palliative procedures because of pelvic or paraaortic lymph node metastases, pelvic peritoneal involvement, pelvic sidewall extension, or distant spread. Following palliative exenteration, morbidity and mortality were high, survival was low, and quality of life was uniformly poor. With rare exceptions, pelvic exenteration as a palliative procedure should not be deliberately performed.
Two male patients underwent supralevator pelvic exenteration, preserving their normal voiding and evacuating function. Case 1 was a 19-year-old man with pineal region tumor, and a metastatic lesion in the bottom of the rectovesical pouch, possibly through the ventriculo-peritoneal shunt. Following supralevator pelvic exenteration, the construction of double pouches, a colonic J pouch and Mainz pouch to the urethra, were performed. Case 2 was a 39-year-old man with bulky retrovesical tumor. He underwent supralevator pelvic exenteration by sigmoid colo-proctostomy and U-pouch to the urethra. Both patients achieved continent except for urinary leakage at night and were able to defecate and urinate voluntarily. Urodynamic study revealed that the pressure in their urinary pouches was low.