Pelvic exenteration

Overview

Pelvic exenteration is a major surgical procedure that involves removal of the vagina, cervix, ovaries, and uterus, and may also include removal of the bladder, anus, and part of the intestine. This surgery may be recommended by your healthcare provider if your cancer recurs or doesn’t respond to other treatments.

Healthcare providers usually attempt other cancer treatments, including chemotherapy, radiation, and tumor removal surgery, before considering this major surgery. While pelvic exenteration can relieve pain and potentially cure cancer, this surgery is major and carries risks, with a challenging recovery process.

Types

The type of pelvic exenteration procedure varies depending on where the cancer has spread. It has three main types:

• Anterior pelvic exenteration: Removal of the bladder., along with the reproductive organs.
• Posterior pelvic exenteration: Part of the intestines is removed along with the reproductive organs.
• Total pelvic exenteration: The reproductive, urinary, and digestive organs are all removed.

Each type involves removing reproductive organs, such as:

• Uterus: Where a baby grows during pregnancy.
• Ovaries: Which produces and releases an egg every month throughout the menstrual cycle, or period.
• Fallopian tubes: Which connect the ovaries to the uterus and are the pathway for eggs to reach the uterus.
• Cervix: Which is the entrance to the uterus.
• Vagina: A muscular canal that connects the vulva to the cervix.

Organs that are affected by total pelvic exenteration, include:

• Rectum: The final segment of the large intestine.
• Colon: The largest portion of the large intestine.
• Urethra: The tube that expels urine from the body.
• Bladder: The muscular sac that stores urine.
• Anus: The opening through which stools exits the body.

Reasons for undergoing the procedure

Pelvic exenteration is used to treat gynecological cancers, such as cancer of the vagina, uterus, cervix, or vulva, that do not respond to other treatments, like radiation, chemotherapy, or previous surgeries, or if cancer has spread to multiple organs in the pelvis.

Pelvic exenteration can also be performed on men to treat recurring pelvic cancers like urethral cancer. In this procedure, healthcare providers remove the bladder, rectum, anus, part of the intestine, as well as the prostate, seminal vesicles, and urethra.

Risks

As with any major surgeries, pelvic exenteration also carries certain risks, such as:

• Infection
• Sepsis, a condition where an infection enters the bloodstream.
• Severe bleeding
• Blood clots
• Incisional swelling, redness, irritation, or opening
• Vaginal fistula, which is a hole that develops between the vaginal region and other internal organs like the bladder
• Bowel obstruction, which occurs when food is unable to move through the intestinal tract normally
• Issues with the ostomies, the new openings created to allow urine and waste to exit the body
• Death, although rare

Before the procedure

One can ask their healthcare provider about the necessary preparations for the surgery. Usually, prior a pelvic exenteration, these may be expected:

• Comprehensive examination
• Imaging tests (MRI and CT scan) to view pelvic organs and plan the surgery
• Possible need to stop certain medications, like blood thinners
• No eating or drinking the night before surgery

During the procedure

Pelvic exenteration generally lasts around 12 hours. The specifics of the surgery depend on the type of pelvic exenteration recommended by the healthcare provider.

The surgery usually consists of:

• Making several incisions to remove reproductive organs and other necessary organs, with a minimally invasive approach possibly using smaller incisions
• If the bladder and urethra are removed, establish a new method for urine excretion, either by constructing a new bladder from a segment of the intestine or by creating a urostomy to connect the kidneys and ureters to a small opening in the abdominal wall. Urine can either collect in a bag, or you may be able to use a catheter inserted into the hole to remove waste.
• If the colon, rectum, and anus are removed, create an alternative pathway for feces disposal, typically by forming a colostomy with the remaining intestine attached to the abdominal wall. A bag is attached to the new opening to collect and manage feces.

After the procedure

Some individuals who undergone pelvic exenteration may opt for a vaginoplasty to reconstruct the vagina immediately after the surgery.

To ensure successful recovery, the healthcare provider will give instructions on caring for incisions and, if applicable, managing a colostomy or urostomy.

Hospital stays after pelvic exenteration can be lengthy, often lasting several weeks, during which the healthcare provider will monitor health and manage pain with medications.

Outcome

Generally, pelvic exenteration is effective in alleviating pelvic pain caused by recurring cancer and may cure reproductive organ cancer when other treatments have been unsuccessful, or the cancer has returned.

Depending on the type of procedure performed, one may be unable to sit for up to eight weeks or sit up straight for several months or even years because the surgery removes many organs and tissues that previously supported the abdomen. They may also find standing or walking for extended periods challenging.

One will require assistance from a family member or friend for bathing, dressing, and moving around until they recover. Resting and refraining from physical activity for several weeks is recommended after the surgery. One should consult their healthcare provider about which activities to avoid and when they can resume them.

Physical therapy and exercises to enhance core strength can be beneficial, and seeking counseling or joining support groups may offer additional help.

Regular follow-up appointments are necessary after the surgery. It is also important to monitor one’s condition for potential complications. Seek immediate medical attention if any of the following is experienced:

• Infection symptoms, such as fever, redness and swelling near the incision
• Bleeding or swelling in the abdominal area
• Intensepain in the abdominal area
• Issues with urinary or fecal incontinence, or difficulties with waste elimination
• Constipation
• Nausea and vomiting