Overview
Definition:
Pelvic exenteration is a radical surgical procedure involving the en bloc removal of all pelvic organs (bladder, rectum, uterus, cervix, vagina, ovaries, fallopian tubes, and supporting structures) for advanced or recurrent pelvic malignancies
A urinary conduit, typically an ileal conduit, is a common form of urinary diversion created during this procedure, where a segment of the ileum is used to create a stoma for urine drainage.
Epidemiology:
Pelvic exenteration is performed for locally advanced or recurrent pelvic cancers, most commonly cervical, vaginal, vulvar, anorectal, and bladder cancers, often after failure of primary treatment
The incidence is relatively low, reflecting the advanced stage of disease requiring such extensive surgery.
Clinical Significance:
This is a complex, life-altering surgery reserved for patients with locally advanced or recurrent pelvic cancers where curative intent is still possible
It offers a chance for survival in otherwise untreatable situations
Understanding the procedure, its indications, complications, and the creation of urinary diversion is critical for surgical residents preparing for DNB and NEET SS examinations, as well as for managing these complex patients postoperatively.
Indications
Absolute Indications:
Locally advanced or recurrent pelvic malignancies (e.g., cervical, vaginal, vulvar, anorectal, bladder) involving multiple pelvic organs, with no distant metastases and a reasonable expectation of achieving negative surgical margins.
Relative Indications:
Certain benign conditions with extensive pelvic involvement and intractable symptoms, such as severe radiation necrosis of pelvic organs, although this is less common.
Contraindications:
Distant metastases, unresectable local disease, significant comorbid conditions precluding major surgery, patient refusal or poor performance status.
Preoperative Preparation
Patient Assessment:
Thorough medical evaluation including cardiopulmonary assessment, nutritional status optimization, and assessment of comorbidities
Detailed discussion with the patient and family regarding the extent of surgery, potential outcomes, and quality of life implications.
Imaging:
CT scan of the chest, abdomen, and pelvis with intravenous contrast to assess tumor extent, involvement of adjacent structures, and rule out distant metastases
MRI pelvis for detailed local staging and assessment of pelvic sidewall involvement.
Bowel Preparation:
Aggressive bowel preparation with clear liquids, laxatives, and sometimes oral antibiotics for several days prior to surgery to minimize fecal contamination.
Stoma Site Selection:
Careful identification and marking of appropriate stoma sites (both urinary and potentially fecal if a colostomy is also created) by an experienced ostomy nurse, considering patient anatomy, clothing habits, and future mobility.
Nutritional Support:
Preoperative nutritional supplementation may be beneficial for malnourished patients.
Procedure Steps
Surgical Approach:
Typically performed via a laparotomy incision, often a midline vertical incision
Robotic-assisted or laparoscopic approaches are increasingly being used for less extensive exenterations or in specialized centers.
Organ Removal:
En bloc resection of involved pelvic organs
This may involve anterior exenteration (bladder, uterus, vagina), posterior exenteration (rectum, uterus, vagina), or total exenteration (all pelvic organs)
Dissection extends to the pelvic sidewall, perineum, and retroperitoneum as needed.
Lymphadenectomy:
Pelvic and/or para-aortic lymphadenectomy may be performed depending on the primary malignancy and nodal status.
Urinary Diversion:
Creation of an ileal conduit: A segment of the ileum (typically 15-20 cm) is isolated, with its blood supply preserved via mesenteric vessels
The proximal end is closed or anastomosed to the proximal small bowel, and the distal end is brought out through the abdominal wall as an ileostomy
The ureters are then anastomosed to the isolated ileal segment
Other conduit types exist (e.g., colon conduit, jejunal conduit) but ileal is most common.
Reconstruction:
Depending on the extent of resection and patient factors, pelvic floor reconstruction or vaginal reconstruction may be considered, often using myocutaneous flaps.
Postoperative Care
Monitoring:
Intensive care unit (ICU) monitoring postoperatively
Close observation for hemodynamic stability, urine output, electrolyte balance, and signs of infection
Pain management is crucial.
Fluid Management:
Aggressive intravenous fluid resuscitation to maintain adequate hydration and urine output
Monitoring of electrolytes and renal function closely, especially for potential metabolic acidosis from prolonged ureteroileal contact.
Nutritional Support:
Parenteral nutrition initially, with gradual transition to enteral feeding as bowel function returns
High-protein diet is encouraged for wound healing.
Stoma Care:
Early stoma management by an ostomy nurse to ensure proper appliance fit, prevent skin irritation, and educate the patient on self-care.
Mobilization:
Early mobilization to prevent deep vein thrombosis (DVT) and pulmonary complications.
Complications
Early Complications:
Hemorrhage, infection (wound, pelvic abscess, UTI), anastomotic leaks (bowel or ureteroileal), ileus, fistulas (vesicovaginal, rectovaginal, ureteroileal), wound dehiscence, thromboembolism (DVT, PE), stoma complications (necrosis, retraction, prolapse).
Late Complications:
Stomal stenosis or retraction, parastomal hernia, ureteroileal stricture, chronic electrolyte imbalances (e.g., hyperchloremic metabolic acidosis), renal dysfunction, chronic pain, lymphedema, psychological distress, sexual dysfunction, incisional hernia, bowel obstruction.
Prevention Strategies:
Meticulous surgical technique, careful patient selection, aggressive bowel preparation, judicious use of prophylactic antibiotics, early and aggressive mobilization, skilled stoma care, close postoperative monitoring for early detection and management of complications.
Prognosis
Factors Affecting Prognosis:
Histological type of cancer, stage of disease at presentation, nodal status, achievement of negative surgical margins (R0 resection), patient's overall health and performance status, presence and management of complications.
Outcomes:
For selected patients with locally advanced or recurrent pelvic cancers, pelvic exenteration offers a chance for cure or long-term survival
However, it is a high-morbidity surgery with significant impact on quality of life
Survival rates vary widely based on the specific cancer and stage.
Follow Up:
Long-term follow-up is essential, typically involving regular physical examinations, imaging (CT scans), and laboratory tests to monitor for cancer recurrence, stoma-related issues, and metabolic complications
Psychological and sexual support are also crucial components of long-term care.
Key Points
Exam Focus:
Understand the indications for total, anterior, and posterior exenteration
Know the principles of ileal conduit creation
Be prepared to discuss common early and late complications and their management
Recognize the importance of multidisciplinary care and stoma siting.
Clinical Pearls:
Achieving R0 resection is paramount for cure
A well-functioning ileal conduit requires meticulous surgical technique and diligent postoperative care
Multidisciplinary team involvement (gynecologic oncologist, colorectal surgeon, urologist, stoma nurse, nutritionist, psychologist) is vital for optimal outcomes.
Common Mistakes:
Inadequate preoperative assessment
Incomplete tumor resection
Poor stoma site selection
Delayed recognition and management of postoperative complications
Insufficient postoperative patient education regarding stoma care and fluid/electrolyte balance.