Pelvic exenteration types and indications
Pelvic exenteration is an extensive surgical procedure performed for locally advanced cancers in the pelvis. Since the time Brunschwig described Pelvic Exenteration in 1948 for advanced cervical cancer, this procedure has evolved over decades. Traditionally a multivisceral resection in the pelvis involves total extirpation of the pelvic viscera (bladder, uterus in women and rectum) with a permanent colostomy and urinary conduit.
This procedure viz. total pelvic exenteration has been modified over the years to give rise to Posterior Pelvic Exenteration (resection of rectum, uterus and posterior vaginal wall) and Anterior Pelvic Exenteration (resection of bladder and uterus). Another modification is Supralevator Pelvic Exenteration, wherein the pelvic organs are excised at the level of levator muscles, preserving the lowest portion of the rectum and urogenital diaphragm.
Further modifications evolved with the ability to establish the bowel continuity after proctectomy so that a permanent colostomy may be avoided in Total or Posterior Pelvic Exenteration. Indeed, with further refinements of the technique, a Stoma-less total pelvic exenteration has also been described with coloanal anastomosis and orthotopic neobladder construction. At the same time, ultra-radical procedures like Extended Pelvic Exenteration (exenteration with sacrectomy) have also been described.
Indications and Outcomes
Traditionally PE has been used for centrally recurrent cervical carcinoma, both squamous and adenocarcinoma, with well-documented salvage potential. Up to 25% of women with FIGO stage IB-IIA cervical cancer may recur after initial therapy. Frequently, these recurrences may be treated with radiotherapy; however, radical surgery may offer an alternative for curative treatment. Survival rates ranging from 16 to 60% are reported for these patients.
Long-term survival is directly correlated with complete tumor resection, so establishing resectability is a key aspect of preoperative planning. Time from primary treatment, with radiation or chemoradiation, to time of PE has also been shown to be related to survival and disease-free interval, with women requiring PE for recurrence less than 2 years following primary therapy demonstrating an 8-month survival versus 33 months in women who recurred more than 2 years following initial treatment in one study, though this has not been shown in all series. PE has also been utilized as a potentially curative primary treatment for locally advanced cervical cancer (FIGO stage IVa), a practice exercised more frequently in Germany than the United States. For example, in their series, Marnitz et al. reported a 52.5% five-year survival
Cases of PE for a variety of histologic types of uterine cancer have been reported, with outcomes similar to PE for other indications. Most recurrent uterine cancers spread beyond the pelvis, given their propensity for diﬀuse abdominal or heterogenous spread, making PE appropriate intervention for only a select group of patients with recurrent uterine malignancies. Women with only locoregional recurrence, however, may be candidates for PE with curative intent.
Khoury-Collado et al. described a series of 21 women with recurrent uterine cancers who underwent PE and demonstrated a ﬁve-year survival of 40%. The study also noted varying outcomes dependent on histology, with endometrioid adenocarcinoma (50% ﬁve-year survival rate) and sarcoma (66% ﬁve-year survival rate) demonstrating improved survival over a group of women with tumors. With serous, mixed, and carcinosarcoma-histology (14%ﬁveyear survival rate).
Morris et al. reported a ﬁve-year survival rate of 45% following PE for recurrent endometrial cancer. Given the similarity of complication rates (48–60%) and survival to PE for cervical cancer, patients with locally recurrent uterine cancer may be considered candidates for the procedure.
Vulvar cancer has a propensity for regional metastases. For patients with advanced primary or recurrent vulvar cancer who do not have the option of treatment with radiation therapy, PE may be appropriate. Forner and Lampe published a series of 27 patients undergoing PE. The authors demonstrated results similar to other gynecologic malignancies, with a ﬁve-year survival of 62%.
Complete resection with no evidence of residual disease was associated with improved outcomes, a ﬁve-year survival rate of 74%, compared to 21% in patients without complete resection. Absence of tumor lymph node invasion was also associated with an improved ﬁve-year survival rate (83% versus 36%).
In contrast, combination therapy with vulvectomy and radiotherapy has been described for locally advanced vulvar cancer with the goal to spare the pelvic organs, with ﬁve-year survival in two series of 45% and 72%, and sparing of the pelvic organs in 62.5% and 89% of patients.
Given the propensity of ovarian cancer to spread throughout the abdomen, women with this disease are rarely candidates for PE with curative intent. Supralevator PE has been reported when needed for optimal cytoreduction, combined with standard staging procedures and for recurrent disease. Two series of modified posterior PE for ovarian cancer demonstrated median survival 33 and 37.4 months after initial surgery. Optimal cytoreduction was achieved in 46% and 58% of patients in the series, demonstrating this technique may be used to achieve optimal cytoreduction in patients with disease requiring rectosigmoid resection.
As vaginal cancer is rare, this review could not identify any literature specifically addressing PE for this indication. Several cases of vaginal cancer, both primary and recurrent, undergoing PE have been included in larger studies, most frequently including the results for these patients combined with results for cervical cancer. It may be hypothesized, that results following PE for vaginal carcinoma would be similar to those for cervical cancer pro-vided the same other parameters for patient selection apply.
PE has been described for palliation rather than for curative intent, most frequently in the setting of severe radiation necrosis. Indications have also included intractable hemorrhage due to tumor invasion and fistulae. Both morbidity and mortality were shown to be higher in this group of patients as opposed to those undergoing PE with curative intent, though improvements in quality of life are reported. PE is thus only considered for palliation if there is no reasonable alternative, though with the development of minimally invasive surgical technology, PE may become a more feasible option
Alternative Types of PE
Anterior PE involves the removal of the bladder and internal reproductive organs but spares the gastrointestinal tract. The rectosigmoid, anus, and lower portion of the posterior vagina are left intact. After division of the cardinal ligaments, uterine vessels, and ureters, the rectum is separated from the upper vagina. The rectumis retracted posteriorly by rectovaginal bimanual exam to ensure the space is clear of tumor and resectable. The uterosacral ligaments are dissected and divided. An incision is made into the peritoneum of the cul-de-sac, and the rectum is dissected sharply off the upper vagina. The incision into the posterior vagina at its mid portion is made. Biopsies of the vagina or margins may be sent for frozen section.
Posterior PE removes the internal reproductive organs and the rectosigmoid but spares the anteriorvagina, urinary bladder, and ureters. In previously irradiated pelves, it is important to consider the possibility of urinary fistulae developing following a posterior PE given the possibility for devascularization. The uterovesical peritoneum is incised after the paravesical and pararectal spaces have been developed. The ureters are identified and dissected as in a radical hysterectomy, and the uterine arteries and cardinal ligaments ligated. The anterior vagina is incised and dissected sharply. The perineal phase of the operation spares the urethra and the anterior vagina.
Modiﬁed posterior PE, as for cytoreduction in ovarian cancer, is a supralevator dissection. There is no perineal phase to the operation. If enough rectum remains (more than 6 centimeters), a low rectal anastomosis may be made, sparing the patient a stoma
If the tumor does not involve the vulva or lower third of the vagina, the patient may be a candidate for a supralevator PE. After the specimen is mobilized as in a total PE, an incision is made into the posterior vaginal wall below the tumor, ensuring an adequate margin. The rectum is isolated and divided with a stapling device, leaving an anorectal stump and possibility for low rectal anastomosis.
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