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A pelvic exenteration is surgery to remove certain reproductive organs along with lymph nodes in the pelvis. It is a major surgical procedure that may be done to treat advanced cancer or recurrent cancer (cancer that has come back) in the pelvis.
Why a pelvic exenteration is done
A pelvic exenteration may be done to:
- treat advanced or recurrent cancers of the female reproductive organs (gynecological cancers), including cervical, uterine, ovarian, vaginal and vulvar cancers
- treat advanced or recurrent colorectal cancer that has spread to nearby organs
Types of pelvic exenteration
There are 3 types of pelvic exenteration. With all types, certain reproductive organs are removed along with the lymph nodes in the pelvis.
In women, the reproductive organs removed are the ovaries, fallopian tubes, uterus, cervix and vagina. The vulva (the outer female sex organs, including the clitoris and vaginal lips) may be removed in some women with cervical cancer.
In men, the reproductive organs removed are the prostate gland and seminal vesicles.
The 3 types of pelvic exenteration are defined by whether or not the bladder, rectum or both are also removed.
- An anterior exenteration removes the bladder but not the rectum. It is done if there is no cancer in the rectum.
- A posterior exenteration removes the rectum but not the bladder. It is done if there is no cancer in the bladder.
- A total exenteration removes both the bladder and rectum.
Before a pelvic exenteration
Before surgery, your healthcare team will give you in-depth information about the surgery. They will also help prepare you for changes to your body and life after surgery. Treatment centres will usually offer counselling and other services that provide emotional support to you and your family before and after the surgery.
The healthcare team needs to gather a lot of information to see if someone is a candidate for a pelvic exenteration. You will have medical tests, such as blood tests and heart and lung function tests, to help your doctor decide if you are healthy enough to have the surgery. You will also have imaging tests, such as a CT scan or an MRI, to see if the cancer has spread outside the pelvis. If cancer is found outside the pelvis, then a pelvic exenteration may not be done. Find out more about tests and procedures that may be done before a pelvic exenteration.
Sometimes chemotherapy or radiation therapy may be given before a pelvic exenteration. These treatments help shrink the tumour to make it easier to remove.
During a pelvic exenteration
A pelvic exenteration is done in 2 stages. The first is exenteration, or resection. The second is reconstruction.
Before the exenteration, the surgeon may make a few small incisions, or surgical cuts, in the abdomen. The surgeon can use a laparoscope (a thin, tube-like instrument with a light and lens) to look inside the abdomen. This allows the surgeon to examine the organs in the abdominal cavity, the peritoneal cavity and the walls of the abdomen and pelvis.
The surgeon may collect tissue samples so they can be examined under a microscope to see if they contain cancer. These tissue samples are sent to the lab to be examined while the person is in the operating room. If the tissue samples contain cancer, the operation is stopped. If cancer is not found, the surgery can continue.
During the extenteration, the surgeon makes a large cut in the lower abdomen and pelvis. The surgeon will look at the inside of the abdomen to see if there are any signs of cancer in areas that would prevent the surgery from continuing. The surgeon may remove or take samples from some lymph nodes to see if they contain cancer.
If the surgeon thinks that the tumour can be removed completely, the pelvic exenteration begins. The surgeon removes the reproductive organs, pelvic lymph nodes and other supporting tissues in the pelvis. The surgeon may also remove the bladder, rectum or both. Sometimes part of the colon is also removed. The surgeon may have to make another cut in the perineum (the area between the genitals and the anus) to remove some of these organs.
Reconstruction is the second stage of the surgery. It is done to help restore urinary and bowel function if the bladder, rectum or colon is removed during the pelvic exenteration. Different types of reconstruction are done depending on which organs were removed.
Urinary diversion is a reconstruction technique that creates a new way for the body to store and get rid of urine if the bladder is removed. A urinary diversion is created using a piece of the person’s small intestine. Then the surgeon directs urine to the pouch and out of the body through an artificial opening, or stoma, in the abdominal wall. This is called a urostomy. Another option is to connect the piece of intestine to the urethra (the tube that carries urine from the bladder to the outside of the body). Find out more about urinary diversion.
A colostomy is a surgical procedure that creates an artificial opening, or stoma, from the colon to the outside of the body through the abdominal wall. A colostomy creates a way for stool, or feces, to leave the body if the rectum, part of the colon or both are removed. The surgeon attaches the end of the remaining colon to the opening in the abdomen. Stool can pass through the colostomy into a small plastic bag worn on the front of the abdomen. Find out more about colostomy.
In some cases, the surgeon can attach the cut end of the colon to the rectum or anus. This type of reconstruction is called an anastomosisanastomosisIntervention chirurgicale qui consiste à joindre des segments sains de structures tubulaires du corps humain (comme le gros intestin) pour créer un nouveau passage ou une dérivation.. When this is done, a colostomy isn’t needed and the person can have bowel movements in the usual way.
Vaginal reconstruction is needed if a woman’s vagina is removed during a pelvic exenteration. This reconstruction is often done at the same time as the pelvic exenteration. The new vagina (called the neovagina) is built using skin, muscle or intestine. Find out more about vaginal reconstruction.
After a pelvic exenteration
Your doctor will decide which tests, procedures, follow-up care or additional treatments you need after a pelvic exenteration. Your healthcare team will make sure that you know how to care for yourself after the surgery.
- It may take 6 months or longer to recover from a pelvic exenteration. It can take a year or more to adjust to changes in your body. Your healthcare team can arrange for care and support to help you and your family adjust to changes in your body and life.
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:
- which organs and structures are removed during the pelvic exenteration
- your 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. Short-term side effects of a pelvic exenteration include:
- blood clots in the leg (deep vein thrombosis, or DVT)
- blood clots in the lung (pulmonary embolism, or PE)
- poor wound healing
- leaking where structures are joined together (anastomotic leak)
- lung infection (called pneumonia)
- buildup of fluid in the lungs (called pulmonary edema)
Tell your healthcare team if you have any of these side effects. They will prescribe drugs for managing pain and can help you manage these side effects.
Long-term side effects
Long-term side effects can develop months or years after a pelvic exenteration and can last a long time. Long-term side effects of a pelvic exenteration include:
- a buildup of lymph fluid in the limbs (called lymphedema) that happens when lymph nodes in the pelvis are removed
- changes to self-esteem, body image and sexuality
- sexual problems
- partial or complete blockage of the intestine (called bowel obstruction) caused by bands of scar tissue (called adhesions)
- fistula, or an abnormal opening, in the remaining structures in the urinary tract or intestine
- kidney problems, such as infection (called pyelonephritis) or failure
- urinary obstruction, which is blockage of the ureters (the tubes that carry urine from the kidney to the bladder)
- death of the tissues (called necrosis) used to reconstruct the vagina or to make a stoma
Because the reproductive organs are removed during a pelvic exenteration, men and women who have this surgery can have sexual problems. Men may experience impotence if the nerves controlling erections are damaged or cut to remove the cancer. All women will be infertile (not able to become pregnant) because their uterus has been removed. Some women may also experience sexual problems because of scar tissue or narrowing of the vagina. They may experience treatment-induced menopause because the ovaries are removed, which can include vaginal dryness and other menopausal symptoms. Find out more about sexual problems for men, sexual problems for women and treatment-induced menopause.