Pelvic Exenteration

Pelvic exenteration refers to an extended en bloc multi-visceral resection of pelvic structures. The visceral components of the pelvis include gastrointestinal and genitourinary structures. The sigmoid colon, rectum, and anus are the terminus aspects of the intestinal tract. The genitourinary viscera include the seminal vesicles and prostate in males; the uterus, ovaries, and vagina in females; and the urinary bladder and urethra in both genders. A complete pelvic exenteration involves resection of the distal sigmoid colon, rectum, and anus along with the bladder, seminal vesicles, prostate, and urethra in males or the uterus, ovaries, vagina, bladder, and urethra in females. In females, partial pelvic exenterations can be performed as a modified procedure consisting of anterior resection of the gynecologic and urologic structures with preservation of the rectum and anus or posterior resection of the gastrointestinal and gynecologic structures with preservation of the bladder and urethra when indicated. Pelvic exenteration was initially described in 1948 for the palliative management of recurrent cervical carcinoma. High surgical mortalities and poor survival outcomes in the 1940s and early 1950s limited the enthusiasm for these radical resections during the latter half of the 20th century. Medical advances involving anesthesia, transfusions, imaging, critical care, and surgical techniques have combined to allow pelvic exenteration to be performed with greater safety and improved outcomes. In the 1950s and 1960s, the indications for pelvic exenteration were extended beyond palliative resections of cervical cancer and currently include curative resection of locally advanced cancers involving contiguous structures (eg, rectal, ovarian, vulvar, prostate, and pelvic sarcomas and melanomas). A nonmalignant indication for pelvic exenteration includes radiation necrosis. The primary contraindication for pelvic exenteration is the inability to achieve clear surgical margins free of malignancy (R0) in a well-informed patient. Because of the postoperative morbidity that may accompany the procedure, there is generally an unspoken consensus that exenteration should be offered only with resectable disease and with curative intent. Most cases are performed via laparotomy. However, traditional and robotic-assisted laparoscopic approaches are becoming more common. Complications of pelvic exenteration include anastomotic leaks, enteric fistulas, abscesses, fistulas, and urologic injury. Pelvic exenteration is now performed more for recurrent disease than primary tumor resections.