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.
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- 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