Exenteration for gynecologic cancer
- Ken D Hatch, MD
Ken D Hatch, MD
- Professor of Obstetrics & Gynecology
- University of Arizona College of Medicine
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
Exenteration refers to an ultraradical surgical procedure consisting of an en bloc resection of the female reproductive organs, lower urinary tract, and a portion of the rectosigmoid. Although rarely performed, it may be offered as a last hope of cure to women with recurrent or advanced gynecologic cancer with extensive central pelvic disease that cannot be resected with a lesser procedure, and in whom radiation is not an option. If the disease is truly confined to the pelvis, then this extended surgical resection offers a chance of cure: five-year survival rates are approximately 50 percent [1,2].
This topic review will discuss the indications and operative technique for exenterative surgery of the female pelvis. The evolution of pelvic exenterative surgery can be found elsewhere [3-13].
Total exenteration refers to removal of the uterus, tubes, ovaries, parametrium, bladder, rectum or rectal segment, vagina, urethra, and a portion of the levator muscles. In an anterior exenteration, the rectum is spared, while in a posterior exenteration, the bladder and urethra are preserved. A perineal phase, resecting the anus, urethra, and portions of the vulva, may also be required (figure 1).
There is no "standard" exenteration. The choice of procedure is based upon the location of the cancer, difficulties that may arise during surgery, type and location of previous radiotherapy, anatomy, and the patient's postoperative goals and expectations.
The potential for cure by exenterative surgery requires that the patient's cancer be resected in its entirety with adequate margins. Thus, diseases that spread by lymphatic, blood, or peritoneal pathways early in their course will rarely lend themselves to ultraradical resection.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA. Gynecol Oncol 2005; 99:153.
- Goldberg GL, Sukumvanich P, Einstein MH, et al. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003). Gynecol Oncol 2006; 101:261.
- BRUNSCHWIG A. Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer 1948; 1:177.
- Bricker EM. The evolution of the ileal segment bladder substitution operation. Am J Surg 1978; 135:834.
- BRICKER EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950; 30:1511.
- Orr JW Jr, Shingleton HM, Hatch KD, et al. Urinary diversion in patients undergoing pelvic exenteration. Am J Obstet Gynecol 1982; 142:883.
- Hancock KC, Copeland LJ, Gershenson DM, et al. Urinary conduits in gynecologic oncology. Obstet Gynecol 1986; 67:680.
- Kock NG, Nilson AE, Nilsson LO, et al. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol 1982; 128:469.
- Montie JE, MacGregor PS, Fazio VW, Lavery I. Continent ileal urinary reservoir (Kock pouch). Urol Clin North Am 1986; 13:251.
- Penalver MA, Bejany DE, Averette HE, et al. Continent urinary diversion in gynecologic oncology. Gynecol Oncol 1989; 34:274.
- Mannel RS, Braly PS, Buller RE. Indiana pouch continent urinary reservoir in patients with previous pelvic irradiation. Obstet Gynecol 1990; 75:891.
- Hatch KD, Gelder MS, Soong SJ, et al. Pelvic exenteration with low rectal anastomosis: survival, complications, and prognostic factors. Gynecol Oncol 1990; 38:462.
- BARBER HR, BRUNSCHWIG A. PELVIC EXENTERATION FOR EXTENSIVE VISCERAL NECROSIS FOLLOWING RADIATION THERAPY FOR GYNECOLOGIC CANCER. Obstet Gynecol 1965; 25:575.
- Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol 2006; 7:837.
- Phillips B, Buchsbaum HJ, Lifshitz S. Pelvic exenteration for vulvovaginal carcinoma. Am J Obstet Gynecol 1981; 141:1038.
- Boronow RC, Hickman BT, Reagan MT, et al. Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations. Am J Clin Oncol 1987; 10:171.
- Rotmensch J, Rubin SJ, Sutton HG, et al. Preoperative radiotherapy followed by radical vulvectomy with inguinal lymphadenectomy for advanced vulvar carcinomas. Gynecol Oncol 1990; 36:181.
- Morris M, Alvarez RD, Kinney WK, Wilson TO. Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecol Oncol 1996; 60:288.
- Barakat RR, Goldman NA, Patel DA, et al. Pelvic exenteration for recurrent endometrial cancer. Gynecol Oncol 1999; 75:99.
- Eisenkop SM, Nalick RH, Teng NN. Modified posterior exenteration for ovarian cancer. Obstet Gynecol 1991; 78:879.
- Stanhope CR, Symmonds RE. Palliative exenteration--what, when, and why? Am J Obstet Gynecol 1985; 152:12.
- Popovich MJ, Hricak H, Sugimura K, Stern JL. The role of MR imaging in determining surgical eligibility for pelvic exenteration. AJR Am J Roentgenol 1993; 160:525.
- Donati OF, Lakhman Y, Sala E, et al. Role of preoperative MR imaging in the evaluation of patients with persistent or recurrent gynaecological malignancies before pelvic exenteration. Eur Radiol 2013; 23:2906.
- Lai CH, Huang KG, See LC, et al. Restaging of recurrent cervical carcinoma with dual-phase [18F]fluoro-2-deoxy-D-glucose positron emission tomography. Cancer 2004; 100:544.
- Burger IA, Vargas HA, Donati OF, et al. The value of 18F-FDG PET/CT in recurrent gynecologic malignancies prior to pelvic exenteration. Gynecol Oncol 2013; 129:586.
- Schneider A, Köhler C, Erdemoglu E. Current developments for pelvic exenteration in gynecologic oncology. Curr Opin Obstet Gynecol 2009; 21:4.
- Martínez A, Filleron T, Vitse L, et al. Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage? Gynecol Oncol 2011; 120:374.
- Davis MA, Adams S, Eun D, et al. Robotic-assisted laparoscopic exenteration in recurrent cervical cancer Robotics improved the surgical experience for 2 women with recurrent cervical cancer. Am J Obstet Gynecol 2010; 202:663.e1.
- Lim PC. Robotic assisted total pelvic exenteration: a case report. Gynecol Oncol 2009; 115:310.
- BRUNSCHWIG A, BARBER HR. EXTENDED PELVIC EXENTERATION FOR ADVANCED CANCER OF THE CERVIX. LONG SURVIVALS FOLLOWING ADDED RESECTION OF INVOLVED SMALL BOWEL. Cancer 1964; 17:1267.
- Stelzer KJ, Koh WJ, Greer BE, et al. The use of intraoperative radiation therapy in radical salvage for recurrent cervical cancer: outcome and toxicity. Am J Obstet Gynecol 1995; 172:1881.
- Moutardier V, Houvenaeghel G, Lelong B, et al. Colorectal function preservation in posterior and total supralevator exenteration for gynecologic malignancies: an 89-patient series. Gynecol Oncol 2003; 89:155.
- Houvenaeghel G, Moutardier V, Karsenty G, et al. Major complications of urinary diversion after pelvic exenteration for gynecologic malignancies: a 23-year mono-institutional experience in 124 patients. Gynecol Oncol 2004; 92:680.
- Ramirez PT, Modesitt SC, Morris M, et al. Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies. Gynecol Oncol 2002; 85:285.
- Karsenty G, Moutardier V, Lelong B, et al. Long-term follow-up of continent urinary diversion after pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2005; 97:524.
- Salom EM, Mendez LE, Schey D, et al. Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years. Am J Obstet Gynecol 2004; 190:994.
- Yong SM, Dublin N, Pickard R, et al. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev 2003; :CD003306.
- Rutledge FN, Smith JP, Wharton JT, O'Quinn AG. Pelvic exenteration: analysis of 296 patients. Am J Obstet Gynecol 1977; 129:881.
- Soper JT, Berchuck A, Creasman WT, Clarke-Pearson DL. Pelvic exenteration: factors associated with major surgical morbidity. Gynecol Oncol 1989; 35:93.
- Morley GW, Hopkins MP, Lindenauer SM, Roberts JA. Pelvic exenteration, University of Michigan: 100 patients at 5 years. Obstet Gynecol 1989; 74:934.
- Salom EM, Penalver MA. Pelvic exenteration and reconstruction. Cancer J 2003; 9:415.
- Ungar L, Palfalvi L, Novak Z. Primary pelvic exenteration in cervical cancer patients. Gynecol Oncol 2008; 111:S9.
- Orr JW Jr, Shingleton HM, Hatch KD, et al. Gastrointestinal complications associated with pelvic exenteration. Am J Obstet Gynecol 1983; 145:325.
- Bladou F, Houvenaeghel G, Delpéro JR, Guérinel G. Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies. J Surg Oncol 1995; 58:91.
- Rezk YA, Hurley KE, Carter J, et al. A prospective study of quality of life in patients undergoing pelvic exenteration: interim results. Gynecol Oncol 2013; 128:191.
- Shepherd JH, Ngan HY, Neven P, et al. Multivariate analysis of factors affecting survival in pelvic exenteration. Int J Gynecol Cancer 1994; 4:361.
- Numa F, Ogata H, Suminami Y, et al. Pelvic exenteration for the treatment of gynecological malignancies. Arch Gynecol Obstet 1997; 259:133.
- Shingleton HM, Soong SJ, Gelder MS, et al. Clinical and histopathologic factors predicting recurrence and survival after pelvic exenteration for cancer of the cervix. Obstet Gynecol 1989; 73:1027.
- Park JY, Choi HJ, Jeong SY, et al. The role of pelvic exenteration and reconstruction for treatment of advanced or recurrent gynecologic malignancies: Analysis of risk factors predicting recurrence and survival. J Surg Oncol 2007; 96:560.
- Cervical cancer
- Vulvar cancer
- Ovarian and endometrial cancer
- Other cancers
- PATIENT SELECTION
- Psychological issues
- Medical evaluation
- - Laboratory and imaging tests
- - Cystoscopy and sigmoidoscopy
- PREOPERATIVE PATIENT PREPARATION
- OPERATIVE TECHNIQUE
- Intraoperative biopsy
- Anterior exenteration
- Total exenteration with perineal phase
- Supralevator total exenteration with low rectal anastomosis
- Posterior exenteration
- Urinary diversion
- POSTOPERATIVE CARE
- General care
- Respiratory care
- Bowel and ostomy issues
- Body image and sexual function
- SUMMARY AND RECOMMENDATIONS