Overview
Definition:
Pelvic exenteration is a radical surgical procedure involving the removal of pelvic organs, encompassing the rectum, anus, bladder, prostate (in males), vagina/uterus/cervix (in females), and pelvic lymph nodes, often for locally advanced or recurrent pelvic malignancies
In recurrent rectal cancer, it represents a salvage option for patients with disease confined to the pelvis after initial treatment.
Epidemiology:
Recurrence after primary rectal cancer treatment occurs in 15-30% of patients, with a significant proportion of these being locoregional
Pelvic exenteration is typically considered for a select group of these patients with resectable disease, making its incidence relatively low but critical for those who are candidates
Factors influencing recurrence include stage at diagnosis, lymph node involvement, and adequacy of initial surgery.
Clinical Significance:
Recurrent rectal cancer in the pelvis presents a significant challenge due to proximity to vital structures and prior radiation therapy
Pelvic exenteration offers the potential for cure or long-term palliation in carefully selected patients when other treatment modalities have failed
It is a complex procedure with high morbidity, demanding meticulous patient selection, multidisciplinary team management, and experienced surgical expertise.
Indications
Patient Selection:
Ideal candidates are those with symptomatic or asymptomatic locoregional recurrence confined to the pelvis, without distant metastases, and who are medically fit for major surgery
Prior history of radiation therapy is a consideration but not an absolute contraindication.
Disease Characteristics:
Resectable disease confined to the pelvis, typically after previous surgery and/or chemoradiation
Imaging confirmation of resectability is crucial, assessing involvement of adjacent organs and major vascular structures.
Symptomatic Versus Asymptomatic:
Symptomatic recurrence (e.g., rectal bleeding, pain, tenesmus, fistula formation, urinary symptoms) may necessitate urgent intervention
Asymptomatic recurrence detected on surveillance imaging can also be amenable to exenteration if resectable, aiming for curative intent.
Absence Of Distant Metastases:
The presence of distant metastases (e.g., liver, lung, peritoneum) generally precludes exenteration with curative intent, as the goal is to achieve a complete oncologic resection
Palliative measures would be more appropriate in such scenarios.
Preoperative Preparation
Multidisciplinary Assessment:
A team approach involving surgical oncologists, medical oncologists, radiation oncologists, radiologists, pathologists, stoma nurses, and rehabilitation specialists is essential for optimal patient selection and management planning.
Imaging Evaluation:
Comprehensive imaging including MRI pelvis with contrast for local staging, CT chest/abdomen/pelvis for distant metastasis assessment, and PET-CT if equivocal findings are present
Endorectal ultrasound may also be useful in some cases.
Nutritional Optimization:
Patients should be assessed for nutritional status and optimized preoperatively, often with dietary modifications and supplementation, to improve wound healing and reduce postoperative complications.
Bowel Preparation:
Mechanical bowel preparation with clear liquid diet and oral antibiotics is typically performed to reduce the bacterial load in the colon and rectum, minimizing infectious complications.
Stoma Counseling:
Preoperative counseling and marking by an experienced stoma nurse are vital to identify optimal sites for colostomy and/or urostomy creation, aiding in patient acceptance and management postoperatively.
Surgical Management
Types Of Exenteration:
Based on the organs removed, exenteration can be anterior (bladder and anterior vaginal/prostate removal), posterior (rectum and posterior vaginal/sacral removal), or total (removal of all pelvic organs)
The extent is dictated by the tumor's spread.
Surgical Technique:
A combination of abdominal and perineal approaches is often utilized
The abdominal phase involves mobilizing the bowel and pelvic organs, performing lymphadenectomy, and creating diversions (colostomy and/or urostomy)
The perineal phase involves en bloc resection of the involved organs from below.
Reconstruction Options:
Reconstruction of the pelvic floor, vagina, or perineum may be necessary using flaps (e.g., gracilis, VRAM) or other reconstructive techniques to improve functional outcomes and cosmesis
Urinary diversion can be ileal conduit or continent diversion.
Margin Assessment:
Achieving negative surgical margins (R0 resection) is paramount for oncologic success
Intraoperative frozen section analysis of margins is often employed to guide the extent of resection.
Lymphadenectomy:
Pelvic lymphadenectomy is an integral part of the procedure to remove potentially involved nodal tissue and accurately stage the disease.
Postoperative Care
Intensive Care Monitoring:
Patients typically require close monitoring in an intensive care unit initially for fluid balance, hemodynamics, pain control, and respiratory function.
Pain Management:
Aggressive pain management is crucial, often involving patient-controlled analgesia (PCA) with opioids, supplemented by non-opioid analgesics and regional blocks.
Stoma Care:
Meticulous stoma care by trained nurses is essential to prevent skin irritation, leakage, and promote patient independence in stoma management.
Nutritional Support:
Intravenous fluids are continued until adequate oral intake is established
Nutritional support may include parenteral nutrition if oral intake is insufficient or delayed.
Ambulation And Mobilization:
Early ambulation and mobilization are encouraged to prevent deep vein thrombosis, pneumonia, and aid in recovery
Physical therapy is often initiated early.
Complications
Early Complications:
Common early complications include surgical site infections, anastomotic leaks (if bowel continuity is attempted), urinary tract infections, ileus, deep vein thrombosis, pulmonary embolism, and wound dehiscence
Fistula formation (vesicovaginal, rectovaginal) can also occur.
Late Complications:
Late complications may include chronic pain syndromes, lymphedema, sexual dysfunction, psychological distress, incisional hernias, and stoma-related issues
Pelvic fibrosis and strictures can also develop.
Prevention Strategies:
Meticulous surgical technique, appropriate antibiotic prophylaxis, early mobilization, adequate hydration, and proactive management of stomas and wounds are key to preventing complications
Adherence to multidisciplinary care pathways is vital.
Prognosis
Factors Affecting Prognosis:
Prognosis is primarily determined by the achievement of R0 resection, the presence or absence of positive margins, nodal status, and the overall health of the patient
Tumor biology also plays a significant role.
Outcomes:
For patients achieving a complete resection (R0) without distant metastases, long-term survival rates can be encouraging, with 5-year survival rates reported between 40-70% in select series
However, the morbidity associated with the procedure is substantial.
Follow Up:
Regular lifelong follow-up is essential, including physical examination, tumor markers (CEA), and periodic imaging (CT scans) to detect early recurrence, either locoregional or distant
Surveillance colonoscopy may also be recommended.
Key Points
Exam Focus:
Understand indications for pelvic exenteration in recurrent rectal cancer
Differentiate between anterior, posterior, and total exenteration
Recognize the critical role of multidisciplinary teams and achieving R0 resection
Recall common early and late complications.
Clinical Pearls:
Patient selection is paramount
exenteration is not for everyone
Meticulous preoperative assessment and postoperative care are as crucial as the surgery itself
Stoma care education and support are vital for long-term patient quality of life.
Common Mistakes:
Undertreating recurrent disease by not considering exenteration when appropriate
Over-treating by offering exenteration to patients with distant metastases
Inadequate preoperative workup leading to intraoperative surprises
Poor management of postoperative complications, especially fistulas and infections.