A pelvic exenteration is a major surgical procedure that may be done to treat advanced or recurrent cancer in the pelvis.
Why is pelvic exenteration done
- to treat metastatic or recurrent gynecological cancer (including cervical, uterine, vaginal and vulvar cancers)
- It may also be used as a salvage surgery in women with ovarian, Fallopian tube or uterine cancer who did not have a successful first surgery and who did not respond to radiation therapy.
- to treat advanced or recurrent rectal cancer that has spread to nearby organs
- to prevent the spread of gynecological or rectal cancer to other organs of the pelvis
How pelvic exenteration is done
Exenteration surgery is done in two stages: resection (exenteration) and reconstruction.
Resection (exenteration)
A cut (incision) is made into the lower abdomen and pelvis during surgery. The inside lining of the abdomen (peritoneum), organs inside the abdomen and lymph nodes in the pelvis and around the abdominal aorta are examined closely. Lymph nodes may be removed to see if they contain cancer. Biopsies or washings of the abdomen may be done to see if cancer is present. Tissue samples (frozen section) can be sent to the pathology laboratory to be examined while the person is still in the operating room.
- If the tissue samples contain cancer, the operation is stopped.
- If cancer is not found, the surgeon removes the female or male reproductive organs, pelvic lymph nodes and other supporting tissues in the pelvis, along with the bladder, rectum or both.
A laparoscope may also be used to view the inside of the abdomen and take biopsies. Laparoscopy has a much shorter recovery time than laparotomy (open surgery).
There are 3 types of pelvic exenteration. With all types, the reproductive organs (ovaries, Fallopian tubes, uterus and cervix in women; prostate gland and seminal vesicles in men) are removed along with the lymph nodes in the pelvis. The bladder or rectum may or may not be removed.
- An anterior exenteration removes the bladder but not the rectum, if there is no cancer in the rectum.
- A posterior exenteration removes the rectum but not the bladder, if there is no cancer in the bladder.
- A total exenteration removes both the bladder and rectum.
Reconstruction
Reconstruction helps restore urinary and bowel function when the bladder and rectum are removed during pelvic exenteration. If the bladder is removed, a urostomy may be needed. If the rectum is removed, a colostomy may be needed. An ostomy is a surgically created connection from an internal structure in the body to a stoma on the outside of the body.
Reconstruction can also help to restore the structure of the vagina if it is removed during pelvic exenteration.
Urinary diversion
If the bladder is removed, the surgeon has to create a new way for the body to store and get rid of urine. This is often done using a piece of intestine (bowel). Urinary diversions can be either incontinent or continent.
With an incontinent diversion, the person does not have control of urination. An incontinent diversion uses an ileal conduit which consists of a piece of small intestine (ileum). The piece of small intestine is used as a passageway (conduit) for urine to travel out of the body.
The ureters are surgically attached to the conduit. One end of the conduit is closed off and the other end is used to create a stoma called a urostomy. Urine drains from the kidneys, through the ureters, then into the conduit. The conduit carries the urine through the urostomy. The urine is collected in a small bag worn on the outside of the body.
A continent diversion allows a person to have control over their urinary function. An internal reservoir, or pouch, is created to store urine. It is created using a piece of intestine that is connected to the abdominal wall (urostomy) or the urethra. The urine collects in the reservoir instead of going into a bag.
If the internal reservoir is connected to the abdominal wall, urine can be drained at regular times by putting a tube (catheter) into the urostomy.
If the internal reservoir is connected to the urethra, a person can urinate in the regular way. A stoma is not needed in this case.
Colostomy
If the rectum is removed, the surgeon has to create a new way for the person to get rid of stool. This is often done by attaching the end of remaining intestine to the abdomen, creating a colostomy. Stool passes through the colostomy into a small plastic bag worn on the front of the abdomen.
Low rectal anastomosis
Sometimes the surgeon removes the rectum but is able to spare the anus and reconnect the remaining intestine to it. This is called a low rectal anastomosis. It allows a person to have a bowel movement in the usual way. A colostomy is not needed in this case.
Vaginal reconstruction
If the vagina is removed in women, a new vagina may need to be built. This is called vaginal reconstruction. The vagina is often reconstructed at the same time as the pelvic exenteration. Many women have vaginal reconstruction, especially if they want to continue to have sexual intercourse or feel it is important for their body image and quality of life.
There are different ways to rebuild the vagina. Skin grafts, pieces of intestine, flaps of muscle from the abdominal wall or, most commonly, flaps of muscle and skin from the inner thighs may be used. The surgeon shapes the flaps and skin and sews them into the area where the vagina was. The newly created vagina is much the same size and shape as the woman's original vagina once it heals.
A reconstructed vagina does not make the natural lubricants that a normal vagina does. These natural lubricants help keep the vagina clean and also help moisten the vagina during sex. So a woman will need to use a douche to clean the vagina, which helps prevent odours and discharge. The healthcare team will give the woman advice on what kind to use, how often to douche and what else to do to help with vaginal dryness.
It may take 6 months or longer for a person to recover fully from a pelvic exenteration.
What happens after pelvic exenteration
The doctor will decide whether further tests, procedures, follow-up care or additional treatment are needed.
Side effects can occur with any type of treatment, but not everyone has them or experiences them in the same way.
Side effects of surgery will depend mainly on the:
- extent of the pelvic exenteration
- person’s overall health
Short-term side effects
Short-term side effects can happen during, immediately after or a few weeks after a pelvic exenteration. They are usually temporary.
- blot clots in the leg (deep vein thrombosis) or the lung (pulmonary embolism)
- bleeding
- infection
- leakage at the site where structures are joined together (anastomotic leak)
- fistula formation in the remaining urinary tract structures or bowel
- lung problems
- lung infection (pneumonia)
- buildup of fluid in the lungs (pulmonary edema)
Long-term side effects
Long-term side effects can show up long after a pelvic exenteration is done and can last a long time.
- lymphedema (because lymph nodes in the pelvis are removed)
- changes to body image
- sexual dysfunction
- Men may experience impotence if the nerves controlling erections have been damaged or cut in order to remove the cancer.
- All women will be infertile (not able to get pregnant) because their uterus has been removed.
- Some women may also experience:
- blockage of the bowel (bowel obstruction) or partial blockage caused by bands of scar tissue (adhesions)
- fistula in the remaining urinary tract structures or bowel
- kidney infection (pyelonephritis)
- blockage of the urinary system (urinary obstruction)