What is pelvic exenteration?

From the Guidelines

Pelvic exenteration is a last resort treatment for advanced or recurrent cancer in the pelvic region, offering a possibility of cure with significant impact on quality of life, high complication rates, and lengthy recovery period, with five-year survival rates ranging from 20-50% depending on cancer type and extent. This radical operation may include removal of the bladder, rectum, reproductive organs (uterus, ovaries, vagina in women; prostate in men), and surrounding lymph nodes, and is most commonly performed for persistent or recurrent cervical, rectal, vaginal, vulvar, or prostate cancers that have not spread beyond the pelvis. The surgery is classified as anterior (removing the bladder and reproductive organs), posterior (removing the rectum and reproductive organs), or total (removing all pelvic organs) 1. Following removal of these organs, reconstructive procedures are performed to create new pathways for bodily waste elimination, which may include a urostomy for urine and a colostomy for stool. Some key points to consider when evaluating pelvic exenteration as a treatment option include:

• The presence or absence of distant recurrence, as pelvic exenteration is typically only considered for patients with localized disease 1
• The extent of local organ invasion, which determines whether partial or total exenteration is indicated 1
• The patient's overall health and ability to tolerate the surgery, as well as their quality of life expectations 1
• The potential benefits and risks of the surgery, including the possibility of cure, as well as the potential for significant complications and impact on quality of life 1. It is essential to carefully evaluate each patient's individual situation and consider the potential benefits and risks of pelvic exenteration before making a treatment decision, as supported by the most recent and highest quality study 1.

From the Research

Definition and Purpose of Pelvic Exenteration

• Pelvic exenteration is a demanding and potentially curative operation for patients with advanced pelvic cancer 2.
• The procedure involves the en bloc resection of the rectum, bladder, and internal genital organs (prostate/seminal vesicles or uterus, ovaries, and/or vagina) 3.
• The goal of pelvic exenteration is to remove all tumor tissue with the aim of cure, as the place of palliative exenteration is controversial at best 2.

Indications and Patient Selection

• Pelvic exenteration is typically considered for patients with locally advanced or recurrent pelvic malignancies, including cervical, rectal, and endometrial cancer 3, 4.
• Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age 2.
• Careful pre-operative staging, including computed tomography (CT) scan or magnetic resonance imaging (MRI), is essential to identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall 2.

Surgical Technique and Outcomes

• The operative details of exenteration involve composite resection of pelvic structures in continuity with sacrectomy, and filling the pelvis with large tissue flaps to decrease morbidity rates 2.
• Total pelvic exenteration is accompanied by considerable morbidity, with major and minor complication rates ranging from 34% to 57% 3.
• The postoperative morbidity rate can be as high as 50%, with a mortality rate of 1-3% 3, 4, 5.
• Despite the risks, pelvic exenteration can provide good local control and acceptable overall survival, with 5-year survival rates ranging from 40% to 60% for patients with gynecologic cancer and 25% to 40% for patients with colorectal cancer 2, 3.

Quality of Life and Long-Term Outcomes

• Quality of life (QoL) is a crucial metric of surgical outcome, and baseline QoL is the strongest predictor of postoperative QoL 6.
• Female gender, total pelvic exenteration with or without bone resection, and positive surgical margins are associated with a reduced QoL 6.
• QoL gradually improves between 2 and 9 months post-operation in the majority of patients 6.
• The median overall survival time can range from 38.7 months, with significant improvement in long-term survival achievable if radical resection is feasible 4.