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. 1. Introduction 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
References
[1]
A. Brunschwig, “Complete excision of pelvic viscera for advanced carcinoma; a one-stage,” Cancer, vol. 1, no. 2, pp. 177–183, 1948.
[2]
E. M. Bricker, “Bladder substitution after pelvic evisceration,” Surgical Clinics of North America, vol. 30, no. 5, pp. 1511–1521, 1950.
[3]
H. J. Buchsbaum and A. J. White, “Omental sling for management of the pelvic floor following exenteration,” American Journal of Obstetrics and Gynecology, vol. 117, no. 3, pp. 407–412, 1973.
[4]
M. Hockel, “Laterally extended endopelvic resection,” Gynecologic Oncology, vol. 91, pp. 369–377, 2003.
[5]
M. Hockel and P. G. Knapstein, “The combined operative and radiotherapeutic treatment (CORT) of recurrent tumors infiltrating the pelvic wall: first experience with 18 patients,” Gynecologic Oncology, vol. 46, no. 1, pp. 20–28, 1992.
[6]
M. Hockel, K. Sclenger, and H. Hamm, “Five-year experience with combined operative and radiotherapeutic treatment of recurrent tumors infiltrating the pelvic wall,” Cancer, vol. 77, no. 9, pp. 1918–1933, 1996.
[7]
A. Schneider, C. Kohler, and E. EErdemoglu, “Current developments for pelvic exenteration in gynecologic oncology,” Current Opinion in Obstetrics & Gynecology, vol. 21, pp. 4–9, 2009.
[8]
M. H？ckel and N. Dornh？fer, “Pelvic exenteration for gynaecological tumours: achievements and unanswered questions,” The Lancet Oncology, vol. 7, no. 10, pp. 837–847, 2006.
[9]
F. Landoni, A. Maneo, A. Colombo et al., “Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer,” The Lancet, vol. 350, no. 9077, pp. 535–540, 1997.
[10]
J. S. Berek, C. Howe, L. D. Lagasse, and N. F. Hacker, “Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA,” Gynecologic Oncology, vol. 99, no. 1, pp. 153–159, 2005.
[11]
G. L. Goldberg, P. Sukumvanich, M. H. Einstein, H. O. Smith, P. S. Anderson, and A. L. Fields, “Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003),” Gynecologic Oncology, vol. 101, no. 2, pp. 261–268, 2006.
[12]
S. Marnitz, C. K？hler, M. Müller, K. Behrens, K. Hasenbein, and A. Schneider, “Indications for primary and secondary exenterations in patients with cervical cancer,” Gynecologic Oncology, vol. 103, no. 3, pp. 1023–1030, 2006.
[13]
K. D. Hatch, M. S. Gelder, S. J. Soong, V. V. Baker, and H. M. Shingleton, “Pelvic exenteration with low rectal anastomosis: survival, complications, and prognostic factors,” Gynecologic Oncology, vol. 38, no. 3, pp. 462–467, 1990.
[14]
K. A. McLean, W. Zhang, R. F. Dunsmoor-Su et al., “Pelvic exenteration in the age of modern chemoradiation,” Gynecologic Oncology, vol. 121, no. 1, pp. 131–134, 2011.
[15]
S. Marnitz, S. Dowdy, M. Lanowska, A. Schneider, K. Podratz, and C. K？hler, “Exenterations 60 Years after first description; Results of a survey among US and German gynecologic oncology centers,” International Journal of Gynecological Cancer, vol. 19, no. 5, pp. 974–977, 2009.
[16]
F. Khoury-Collardo, M. H. Einstein, B. H. Bochner, et al., “Pelvic exenteration with curative intent for recurrent uterine malignancies,” Gynecologic Oncology, vol. 124, pp. 42–47, 2012.
[17]
M. Morris, R. D. Alvarez, W. K. Kinney, and T. O. Wilson, “Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration,” Gynecologic Oncology, vol. 60, no. 2, pp. 288–291, 1996.
[18]
D. Forner and B. Lampe, “Pelvic exenteration in the treatment of Stage III/IV vulvar cancer,” Gynecologic Oncology, vol. 124, pp. 87–91, 2012.
[19]
J. Rotmensch, S. J. Rubin, H. G. Sutton et al., “Preoperative radiotherapy followed by radical vulvectomy with inguinal lymphadenectomy for advanced vulvar carcinomas,” Gynecologic Oncology, vol. 36, no. 2, pp. 181–184, 1990.
[20]
R. C. Boronow, B. T. Hickman, M. T. Reagan, et al., “Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations,” American Journal of Clinical Oncology, vol. 10, no. 2, pp. 171–181, 1987.
[21]
H. Tixier, J. Fraisse, B. Chauffert et al., “Evaluation of pelvic posterior exenteration in the management of advanced-stage ovarian cancer,” Archives of Gynecology and Obstetrics, vol. 281, no. 3, pp. 505–510, 2010.
[22]
G. Houvenaeghel, M. Gutowski, M. Buttarelli et al., “Modified posterior pelvic exenteration for ovarian cancer,” International Journal of Gynecological Cancer, vol. 19, no. 5, pp. 968–973, 2009.
[23]
F. T. J. Ferenschild, M. Vermaas, C. Verhoef et al., “Total pelvic exenteration for primary and recurrent malignancies,” World Journal of Surgery, vol. 33, no. 7, pp. 1502–1508, 2009.
[24]
C. Fotopoulou, U. Neumann, R. Kraetschell et al., “Long-term clinical outcome of pelvic exenteration in patients with advanced gynecological malignancies,” Journal of Surgical Oncology, vol. 101, no. 6, pp. 507–512, 2010.
[25]
G. C. Guimar？es, G. Baiocchi, F. O. Ferreira et al., “Palliative pelvic exenteration for patients with gynecological malignancies,” Archives of Gynecology and Obstetrics, vol. 283, no. 5, pp. 1107–1112, 2011.
[26]
G. B. Boustead and M. R. Feneley, “Pelvic exenterative surgery for palliation of malignant disease in the robotic era,” Clinical Oncology, vol. 22, no. 9, pp. 740–746, 2010.
[27]
Y. Rezk, F. Dao, and K. Hurley, “A prospective study of quality of life in patients undergoing pelvic exenteration: interim results,” Gynecologic Oncology, vol. 116, no. 3, p. S24, 2010.
[28]
M. J. Popovich, H. Hricak, K. Sugimura, and J. L. Stern, “The role of MR imaging in determining surgical eligibility for pelvic exenteration,” American Journal of Roentgenology, vol. 160, no. 3, pp. 525–531, 1993.
[29]
A. Husain, T. Akhurst, S. Larson, K. Alektiar, R. R. Barakat, and D. S. Chi, “A prospective study of the accuracy of 18Fluorodeoxyglucose positron emission tomography (18FDG PET) in identifying sites of metastasis prior to pelvic exenteration,” Gynecologic Oncology, vol. 106, no. 1, pp. 177–180, 2007.
[30]
T. M. Pawlik, J. M. Skibber, and M. A. Rodriguez-Bigas, “Pelvic exenteration for advanced pelvic malignancies,” Annals of Surgical Oncology, vol. 13, no. 5, pp. 612–623, 2006.
[31]
J. Rock and H. Jones, TeLinde’s Operative Gynecology, Lippincott, Williams, and Wilkins, Philadelphia, Pa, USA, 10th edition, 2011.
[32]
D. E. Bejany and V. A. Politano, “Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir,” Journal of Urology, vol. 140, no. 3, pp. 491–494, 1988.
[33]
M. A. Penalver, D. Bejany, D. M. Donato, B. U. Sevin, and H. E. Averette, “Functional characteristics and follow-up of the continent ileal colonic urinary reservoir: miami pouch,” Cancer, vol. 71, supplement S4, pp. 1667–1672, 1993.
[34]
J. T. Soper, A. A. Secord, L. J. Havrilesky, A. Berchuck, and D. L. Clarke-Pearson, “Rectus abdominis myocutaneous and myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: comparison of flap-related morbidity,” Gynecologic Oncology, vol. 97, no. 2, pp. 596–601, 2005.
[35]
C. Benson, A. P. Soisson, J. Carlson, G. Culbertson, C. Hawley-Bowland, and F. Richards, “Neovaginal reconstruction with a rectus abdominis myocutaneous flap,” Obstetrics and Gynecology, vol. 81, no. 5, pp. 871–875, 1993.
[36]
P. T. Ramirez, K. M. Schmeler, J. K. Wolf, J. Brown, and P. T. Soliman, “Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer,” Gynecologic Oncology, vol. 111, no. 1, pp. 18–21, 2008.
[37]
R. K. Reynolds, W. M. Burke, and A. P. Advincula, “Preliminary experience with robot-assisted laparoscopic staging of gynecologic malignancies,” Journal of the Society of Laparoendoscopic Surgeons/Society of Laparoendoscopic Surgeons, vol. 9, no. 2, pp. 149–158, 2005.
[38]
D. S. Veljovich, P. J. Paley, C. W. Drescher, E. N. Everett, C. Shah, and W. A. Peters, “Robotic surgery in gynecologic oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging,” American Journal of Obstetrics and Gynecology, vol. 198, no. 6, pp. 679.e1–679.e10, 2008.
[39]
J. F. Boggess, P. A. Gehrig, L. Cantrell et al., “A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy,” American Journal of Obstetrics and Gynecology, vol. 199, no. 4, pp. 360.e1–360.e9, 2008.
[40]
C. Pomel, R. Rouzier, M. Pocard et al., “Laparoscopic total pelvic exenteration for cervical cancer relapse,” Gynecologic Oncology, vol. 91, no. 3, pp. 616–618, 2003.
[41]
C. Pomel and D. Castaigne, “Laparoscopic hand-assisted Miami Pouch following laparoscopic anterior pelvic exenteration,” Gynecologic Oncology, vol. 93, no. 2, pp. 543–545, 2004.
[42]
M. Y. Lin, E. W. Fan, A. W. Chiu, Y. F. Tian, M. P. Wu, and A. C. Liao, “Laparoscopy-assisted transvaginal total exenteration for locally advanced cervical cancer with bladder invasion after radiotherapy,” Journal of Endourology, vol. 18, no. 9, pp. 867–870, 2004.
[43]
G. Ferron, D. Querleu, P. Martel, B. Letourneur, and M. Soulié, “Laparoscopy-assisted vaginal pelvic exenteration,” Gynecologic Oncology, vol. 100, no. 3, pp. 551–555, 2006.
[44]
G. Ferron, D. Querleu, P. Martel, N. Chopin, and M. Soulié, “Laparoscopy-assisted vaginal pelvic exenteration,” Gynecologie Obstetrique Fertilite, vol. 34, no. 12, pp. 1131–1136, 2006.
[45]
S. Puntambekar, R. J. Kudchadkar, A. M. Gurjar et al., “Laparoscopic pelvic exenteration for advanced pelvic cancers: a review of 16 cases,” Gynecologic Oncology, vol. 102, no. 3, pp. 513–516, 2006.
[46]
S. P. Puntambekar, G. A. Agarwal, S. S. Puntambekar, R. M. Sathe, and A. M. Patil, “Stretching the limits of laparoscopy in gynecological oncology: technical feasibility of doing a laparoscopic total pelvic exenteration for palliation in advanced cervical cancer,” International Journal of Biomedical Science, vol. 5, no. 1, pp. 17–22, 2009.
[47]
J. F. Magrina, R. M. Kho, A. L. Weaver, R. P. Montero, and P. M. Magtibay, “Robotic radical hysterectomy: comparison with laparoscopy and laparotomy,” Gynecologic Oncology, vol. 109, no. 1, pp. 86–91, 2008.
[48]
T. N. Payne and F. R. Dauterive, “A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice,” Journal of Minimally Invasive Gynecology, vol. 15, no. 3, pp. 286–291, 2008.
[49]
A. G. Visco and A. P. Advincula, “Robotic gynecologic surgery,” Obstetrics and Gynecology, vol. 112, no. 6, pp. 1369–1384, 2008.
[50]
B. Sert and V. Abeler, “Robotic radical hysterectomy in early-stage cervical carcinoma patients, comparing results with total laparoscopic radical hysterectomy cases. The future is now?” International Journal of Medical Robotics and Computer Assisted Surgery, vol. 3, no. 3, pp. 224–228, 2007.
[51]
A. Shafer and J. F. Boggess, “Robotic-assisted endometrial cancer staging and radical hysterectomy with the da Vinci surgical system,” Gynecologic Oncology, vol. 111, no. 2, pp. S18–S23, 2008.
[52]
J. F. Magrina, R. Kho, and P. M. Magtibay, “Robotic radical hysterectomy: technical aspects,” Gynecologic Oncology, vol. 113, no. 1, pp. 28–31, 2009.
[53]
R. S. Pruthi, H. Stefaniak, J. S. Hubbard, and E. M. Wallen, “Robot-assisted laparoscopic anterior pelvic exenteration for bladder cancer in the female patient,” Journal of Endourology, vol. 22, no. 10, pp. 2397–2402, 2008.
[54]
P. C. W. Lim, “Robotic assisted total pelvic exenteration: a case report,” Gynecologic Oncology, vol. 115, no. 2, pp. 310–311, 2009.
[55]
E. M. Salom and M. A. Penalver, “Pelvic exenteration and reconstruction,” Cancer Journal, vol. 9, no. 5, pp. 415–424, 2003.
[56]
E. J. Roos, M. A. Van Eijkeren, T. A. Boon, and A. P. M. Heintz, “Pelvic exenteration as treatment of recurrent or advanced gynecologic and urologic cancer,” International Journal of Gynecological Cancer, vol. 15, no. 4, pp. 624–629, 2005.
[57]
E. J. Roos, A. de Graeff, M. A. van Eijkeren, T. A. Boon, and A. P. M. Heintz, “Quality of life after pelvic exenteration,” Gynecologic Oncology, vol. 93, no. 3, pp. 610–614, 2004.
[58]
S. Hawighorst-Knapstein, C. Fusshoeller, C. Franz et al., “The impact of treatment for genital cancer on quality of life and body image - Results of a prospective longitudinal 10-year study,” Gynecologic Oncology, vol. 94, no. 2, pp. 398–403, 2004.
[59]
K. K. S. Austin, J. M. Young, and M. J. Solomon, “Quality of life of survivors after pelvic exenteration for rectal cancer,” Diseases of the Colon and Rectum, vol. 53, no. 8, pp. 1121–1126, 2010.
[60]
T. Benn, R. A. Brooks, Q. Zhang et al., “Pelvic exenteration in gynecologic oncology: a single institution study over 20 years,” Gynecologic Oncology, vol. 122, no. 1, pp. 14–18, 2011.
[61]
A. Maggioni, G. Roviglione, F. Landoni et al., “Pelvic exenteration: ten-year experience at the European Institute of Oncology in Milan,” Gynecologic Oncology, vol. 114, no. 1, pp. 64–68, 2009.
