What Is Pelvic Exenteration

There are 3 main types of pelvic exenteration surgery. Which type of surgery a patient undergoes is dependent on where the cancer is found within the pelvis. The main types of pelvic exenteration are as follows:

• Anterior pelvic exenteration – This surgery involves the removal of the organs found in the front part of the pelvis – the reproductive organs (listed above) and the bladder 
• Posterior pelvic exenteration – This surgery involves the removal of the organs found in the back part of the pelvis – the reproductive organs (listed above) and parts of the intestines (parts of the colon, rectum, and sometimes the anus)
• Total pelvic exenteration – This surgery involves the removal of all the organs in the pelvis – this includes all the organs listed above (from the reproductive, digestive and urinary systems). Depending on how far the cancer has spread, this surgery could also involve the removal of pelvic muscles, bones, blood vessels and nerves

Who is eligible for pelvic exenteration?

Cancerous conditions

Pelvic exenteration is most commonly used to cure cancers of the reproductive system and those that have spread only within the pelvis (also known as locally-advanced). Also, this surgery can be used to treat cancers which keep recurring in the pelvis.³

It is important to note that, before recommending pelvic exenteration, doctors will try other, simpler treatments to treat locally-advanced or recurring pelvic cancers. These types of treatments include radiotherapy, chemotherapy, and other surgeries which remove smaller parts of the pelvis (just one or two organs) such as a hysterectomy. If such treatments do not work and the cancer has not been cured and keeps recurring within the pelvis area, then pelvic exenteration is the best option. 

Pelvic exenteration is not appropriate for cancers that have spread outside of the pelvis (known as metastatic cancers). This surgery is also not suitable for any cancer in the pelvis that is unresectable (that cannot be removed with any surgery).⁴ 

Radiation necrosis

A non-cancerous condition which pelvic exenteration can treat is radiation necrosis. This condition consists of the development of a type of tissue called scar tissue in the place where a tumour originally was, after a cancer patient has undergone radiotherapy (such as pelvic radiotherapy). However, such scar tissue that forms is dying, and is affecting nearby cells, leading to the premature death of healthy tissues. When radiation necrosis occurs within the pelvis, pelvic exenteration can be used to stop this.⁵  

Preoperative evaluation

Prior to pelvic exenteration, doctors will do a thorough examination of the patient, to check that they are a suitable candidate for this surgery. For patients to be confirmed to undergo this treatment, they must fit the following¹ criteria:

• Must not have any signs of metastatic cancer disease (cancer that has spread to other parts of the body besides the pelvis)
• Patient must be fit overall, to make sure they can endure such an extensive surgical procedure

To assess patients to see whether they fit the above criteria, doctors will order a series of imaging tests, including:

• MRI and CT scans of the pelvis – These images will give the doctors a clear picture of where the tumour is in the pelvis (and whether it is solely within the pelvis). They will also use these images to plan the surgery⁴ 
• CT scans of the chest and abdomen – These images check that the cancer has not spread to these areas of the body⁴
• Angiography – This test takes clear pictures of the blood vessels surrounding the pelvis. These will also help the doctors plan the surgery¹ 

Multidisciplinary approach

Considering how many organs will potentially be removed from the patient during this surgery, pelvic exenteration requires a large team of specialist doctors from the preoperative stages of the procedure until post-operative. This team includes various specialist surgeons responsible for different areas of the pelvis, urologists, chronic pain specialists, critical care physicians and anaesthesiologists. Following all the preoperative assessments, this team will discuss the surgery plan. This type of approach to a surgery is called a multidisciplinary approach.¹ 

What happens during pelvic exenteration?

Typically during the pelvic exenteration procedure, a patient will be given general anaesthetic through a vein in their arm, and they’ll be put to sleep – this ensures the patient feels no pain and is calm throughout this intensive procedure. The surgery consists of specialist surgeons making several cuts into the patient’s body to remove the relevant organs. Once all the tumour-compromised organs have been taken out, the surgeons will then explore the surrounding organs to check no cancer remains.⁵  

Reconstruction after pelvic exenteration 

After pelvic exenteration, the organs that have been removed from the patient need to be reconstructed. A team of plastic surgeons are in charge of this. This can be done both during and after the pelvic exenteration.¹ There are various different procedures they can do to reconstruct the missing organs: 

• Plastic surgeons can use pieces of skin, muscle and fat from other parts of the body, such as the thighs, shape them into the appropriate shape of the missing organ, and stitch this reconstructed organ into place.¹ 

• If the bladder has been removed, a urostomy can be done as an alternative for draining urine out of the patient’s body. This consists of connecting the kidney and the ureters (tubes which carry urine) to a small opening on the patient’s abdomen. From this opening, either a bag is inserted to collect and dispose of the urine, or a tube known as a catheter is fitted into the hole, and this drains the urine out of the body⁶ 
• If the colon, rectum and anus have been removed, a colostomy can be done as an alternative for allowing faeces out of the body. This consists of connecting the remaining intestine to a small opening on the patient’s abdomen. A bag is then attached to this opening to collect and dispose of faeces⁶ 

Postoperative complications, recovery and rehabilitation  

Once having undergone pelvic exenteration, a patient will likely stay in hospital, in an intensive care unit, for a long time, in order to remain under the close supervision of healthcare professionals. There are various immediate risks and complications that could occur in a patient post-pelvic exenteration. These include infections, severe bleeding, and any swelling, irritation or opening of any of the cuts made during surgery. Therefore, it is important for the patient to stay in hospital for an extended period of time post-surgery, so healthcare professionals can act quickly if any of these complications occur, as well as to be able to relieve any pain the patient may feel with appropriate medications.³ 

Once a patient is allowed to go home from the hospital, it is imperative that they rest and avoid physical activity of any kind for several weeks. This means they need help with bathing, dressing and moving themselves. Some patients may even find it difficult to sit for several weeks to months post-procedure. This is because various organs which used to provide structure in the abdomen of these patients have been removed. After the first few weeks post-procedure, in order to start to be able to sit down and move about independently, the patient can then start physical therapy exercises in order to improve their own physical strength. Many patients tend to join rehabilitation programmes, as well as psychological support groups, in order to connect with other people who have experienced the same surgery.³ 

During the months following surgery, patients will have regular check-ups with healthcare professionals to monitor their postoperative progress and check for any potential complications. It is imperative for patients to visit their doctor immediately if they are experiencing any of the following symptoms:³

• Swelling, redness or bleeding near any cuts made during surgery, as well as any accompanying fever - this could be a sign of infection
• Severe pain in the abdominal area
• Nausea and vomiting
• Constipation
• Urinary incontinence (no production of urine)

Potential long-term complications

There are a number of long-term risks that could occur to someone after having undergone pelvic exenteration. The following are common examples:³

• Bowel obstruction – Such as when the intestines become blocked and food cannot pass through normally
• Problems with the small openings made to allow faeces and urine to pass through ≠ Examples include recurring infections, or no faeces and urine can pass through
• Sexual dysfunction – This is when someone is experiencing difficulties at any stage during a sexual activity
• Fistulas – This is when an opening occurs between two parts of the body or a part of the body and the skin, which are not typically connected⁷

Prognosis of pelvic exenteration

Although there are various complications, both postoperative and long-term, that could occur, there is a very little chance of dying from this surgery. In fact, if the goal of the surgery is completed (the cancer has been entirely resected from the patient), then there is a good chance of the patient being cured from their locally-advanced or recurring cancer (over 60%).⁵ Moreover, the quality of life of patients can greatly improve after pelvic exenteration, as the surgery has relieved any pelvic pain the patient may have felt prior to surgery.⁸ Hence, the surgery has an overall good prognosis, and has been shown to improve long-term survival in patients.  

Summary

Pelvic exenteration consists of the surgical removal of organs from the pelvis (typically the reproductive organs, and sometimes parts of the urinary and digestive systems). This procedure is done in patients who have locally-advanced and/or recurring cancer in their pelvis, whose cancer does not respond to other treatments (such as radiotherapy and chemotherapy). This surgery is however not suitable for patients whose cancer has spread outside of their pelvis. The purpose of pelvic exenteration is to remove all cancer found in the pelvis, to cure the patient’s cancer. Although this procedure has a good prognosis, it is important to be aware of the risks involved with this operation. Therefore, it is crucial to discuss this surgery in detail with a specialist healthcare provider, in order to assess whether this surgery is right for you.