Pelvic exenteration: Patient information
Pelvic exenteration is a major operation during which some of the organs of the pelvis are removed. This surgery is normally offered to women who have already had treatments for their gynaecological cancer. The cancer has either returned or had not been cured by the initial treatment.
The operation is very complex and takes many hours to carry out.
There are different types of pelvic exenteration and which type is needed depends on where your cancer is situated. Some women will already have had their womb or their ovaries, or both, removed in their initial treatment. Other women will not have had gynaecological surgery but received chemotherapy and radiotherapy. Some may have had both types of treatment.
• Anterior pelvic exenteration is used if the cancer is at the front of the pelvis. The reproductive organs and the bladder are removed.
• Posterior pelvic exenteration is used if the cancer is at the back of the pelvis. The reproductive organs and the bowel are removed.
• Total pelvic exenteration is used if the cancer is in the middle of the pelvis. The bladder, the reproductive organs and the bowel are removed.
This means that it will usually be necessary for you to have one or two stomas, or bags, to collect bowel and urine contents.
Why do I need this operation?
This operation is usually carried out for people who have cancer affecting their rectum, bladder and/or prostate (in men) or urethra (in women). If you are having this treatment for cancer, the surgeon will also remove some of the healthy tissue around the tumour, to make sure all the cancer is removed.
What does the operation involve?
The operation will involve open surgery, not keyhole surgery. This involves making a cut down the centre of your abdomen (tummy). When your rectum is removed, you will no longer have an anus through which to pass a bowel motion (stool/poo/faeces). The removal of your bladder and prostate (if you are male) means you will also no longer be able to pass urine in the usual way. Your ureters (tubes from your kidneys to your bladder) will be attached to your bowel (sigmoid colon).
The surgeon will then use some of the lower part of your large bowel to create a tube (colostomy or ‘stoma’) to the outside of your abdomen. The stoma will be used to divert your urine and faeces, so it all flows out through this opening and into a secure bag. This is a type of combined stoma known as a ‘wet colostomy’. The operation will involve using a part of your abdominal muscles to cover the operated area and close the anus.
You will be encouraged to get up and move around with help, within 24-48 hours of your operation. However, you will also need to make sure you regularly rest in bed, to help you recover. You will have drips and drains attached to you, but the nurses will help you with these when you need to move. It is important that you start to walk around as soon as you can, as this will help increase your breathing and circulation. It will also help you to regain your strength, as well as reducing some of the risks associated with surgery, such as blood clots, chest infections and pneumonia.
What happens during the operation?
You will be given a general anaesthetic, which means that you will be asleep for the entire procedure. Usually, an epidural anaesthetic is used as well so that we can offer you pain relief following the procedure to make you more comfortable. The operation is carried out through a long vertical incision.
The inside of abdomen is examined to make sure that the cancer has not spread. Sometimes biopsies (small pieces of tissue and lymph glands) are taken and sent immediately to the pathologist, who examines them also to make sure there has been no cancer spread.
If the cancer has spread beyond what can be removed, the operation is stopped and the incision is closed without doing any more surgery. If the biopsies are negative and there is no spread, the operation continues.
Several doctors are involved in the surgery, including:
• a gynaecological cancer surgeon
• a bowel surgeon (sometimes called a colorectal surgeon)
• a urologist
• a plastic surgeon
• an anaesthetist.
Each of these doctors has their own responsibilities and will discuss them with you before the operation.
The length of the surgery varies from patient to patient, but it can take between eight and twelve hours to complete.
Will I have to wear a bag (stoma)?
If your bowel is removed you will need to wear a bag to collect the faeces. This may be a permanent stoma, however on some occasions this can be reversed. Sometimes the bowel can be reconnected at the time of the surgery. Your surgeon will discuss options with you.
If your bladder is removed, you may have to wear a bag to collect the urine. It may be possible to create a continent pouch (a channel connecting part of your small intestine to the wall of your abdomen) which you would need to drain with a tube. Your surgeons will discuss these options with you.
How long will I be in hospital?
The average length of stay in hospital is about 10-14 days; however, this can vary considerably from person to person, depending on how well you recover and whether you have any other medical requirements.
What are the risks?
There are risks associated with any surgical procedure. Your surgeon will explain these risks to you before you sign the consent form. This form confirms that you agree to have the operation and understand what it involves.
Possible risks and complications from this surgery are:
• Bleeding during or after your operation: this may need to be treated with a blood transfusion.
• Blood clots: you will be given a month’s supply of anticoagulant injections to decrease your chances of acquiring a blood clot. You will be taught how to give these to yourself or a carer or district nurse can give them to you.
• Problems caused by having a general anaesthetic: Having an anaesthetic for further information about the risks and side effects of anaesthesia.
• Infections: You will be given antibiotics to help prevent this.
• Your wound could be slow to heal, or breakdown due to poor healing caused by previous treatments. If this occurs, the surgeon will see you and decide with you the best course of action.
• The joining inside of the bowel or stoma could come apart.
• The joining from the ureters (tubes coming from the kidneys) could come apart.
• A hole called a fistula can occur in the pelvis or abdomen due to having cancer treatments.
• The bowel could obstruct.
• Your kidneys could start to fail.
• Blockage to your ureters could occur.
• Reconstruction tissue may begin to break down. You will be monitored closely in hospital and if this starts to happen, measures will be taken to prevent or deal with it.
• Patients can have altered sensation following this surgery if they have any reconstruction of tissue from elsewhere in their body.
This is a long list of risks and complications, however not all of these occur with every patient. If you develop any of these complications, you will be seen by your medical team and a course of action discussed with you. This may lead to an extended period in hospital.
These complications are usually rare, but you must be aware of them. As with any operation, there is a risk of death, although this is very rare. Please talk to your doctor about any concerns you have before your operation.
What happens after my operation?
The following information is a guide as to what may happen after your operation. Everyone recovers at a different pace, but if you have any concerns, please talk to your doctors or nurses.
When you wake up you will have:
• an oxygen mask on your face to help you breathe after the general anaesthetic
• a drip in your arm to give you fluids
• a small clip on your finger to check your oxygen levels
• a temporary bladder catheter, as you will feel sleepy and not be able to get out of bed to pass urine. The catheter also gives an accurate measurement of your urine
• one or more drains coming from your wound.
You may also have a tube down your nose which goes into to your stomach. This is in case you feel or are sick after the surgery.
Depending on your surgery, you may have a stoma (colostomy) to help you pass stool (poo), a stoma (urostomy or ileal conduit) to help you pass urine, or you may have a newly reconstructed vagina or tissue to cover where the vagina was. If skin is used to cover the vagina, you will no longer have a vagina. You will have discussed your options in regards to this with your consultant and plastic surgeon before the surgery. The counsellor and your nurse specialist will talk to you about how this may feel for you after the surgery.
You might have a pain relieving pump. There are two types:
• An epidural pump, which delivers painkillers into your back you to desensitise the pain nerves (this may make your legs feel heavy and numb, temporarily); or
• A PCA (patient controlled analgesia) pump, which delivers a dose of painkiller into your vein whenever you press a button, allowing you to control when you receive a dose. Your nurse will explain how to use this pump.
The anaesthetist will discuss these options with you in more detail before you have your surgery.
You will feel very tired and it is important that you do not have too many visitors in the first few days after your operation. The nursing staff will help you if you need anything.
Will I be able to have sex?
Usually after a pelvic exenteration, most of the vagina is removed. By using skin from the abdominal wall it is generally possible to restore the vagina to normal, although the skin is not the same as normal vaginal skin. If this is the case then you would be able to have sexual intercourse. Your nursing team can explain to you about the use of dilators and intercourse to keep the vagina open.