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10.1245/ASO.2006.03.082
Annals of Surgical Oncology 13:612-623 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Pelvic Exenteration for Advanced Pelvic Malignancies

Timothy M. Pawlik, MD, MPH, John M. Skibber, MD and Miguel A. Rodriguez-Bigas, MD

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Unit 444, P.O. Box 301402, Houston, Texas 77230-1402

Correspondence: Address correspondence and reprint requests to: Miguel A. Rodriguez-Bigas, MD; E-mail: mrodbig{at}mdanderson.org

Key Words: Pelvic exenteration • Rectal cancer • Pelvic malignancy • Morbidity • Outcome • Review


   INTRODUCTION
TOP
 INTRODUCTION
INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
For many patients with bulky, locally advanced primary or recurrent pelvic malignancy, aggressive surgical extirpation is the best treatment option. To remove large pelvic tumors that invade adjacent organs without compromising curability, an en-bloc excision of the tumor and adjacent organs is often required. Total pelvic exenteration—the removal of all pelvic organs, including the rectum, bladder, and reproductive organs—has traditionally been associated with a high rate of complications and few long-term survivors.1–7 However, since 1948, when Brunschwig8 reported the first series of pelvic exenterations for advanced pelvic malignancies, the practice of pelvic exenteration in the treatment of advanced gastrointestinal, gynecological, and urinary malignancies has significantly evolved. Originally intended as a palliative procedure, pelvic exenteration for advanced pelvic malignancy today is associated with a 5-year survival rate of 20% to 60%.1,3,4,9–12 With the advent of more refined surgical techniques and improved perioperative care, the mortality and morbidity associated with pelvic exenteration have markedly decreased. As such, when indicated, pelvic exenteration for locally advanced pelvic malignancies should be considered a standard practice in major surgical centers. The purpose of this review is to discuss the role of pelvic exenteration in the management of advanced pelvic malignancies. Herein we provide an overview of the indications for pelvic exenteration, surgical technique, advances in reconstruction, and the morbidity and mortality of pelvic exenteration.


   INDICATIONS
TOP
 INTRODUCTION
 INDICATIONS
PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
Before using pelvic exenteration for treatment of regionally advanced tumors of the pelvis, the surgeon must have a thorough understanding of the indications for this operation. Because of their location and biological behavior, tumors of the rectum and cervix are the most common indications for pelvic exenteration (Table 1Go). Other pelvic malignancies, such as bladder cancer,13 ovarian cancer,14,15 prostate cancer,16 and sarcoma,17 rarely necessitate pelvic exenteration, because these malignancies can often by treated successfully with less extensive operations.


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  		TABLE 1. Most common indications for pelvic exenteration
 
Rectal Cancer
In 1970, Spratt et al.18 described a variant of colorectal cancer carcinoma that remained localized without metastasizing to lymph nodes despite being large and invading adjacent organs. More recent data suggest that approximately 10% of primary rectal carcinomas are adherent to adjacent organs without metastases at the time of exploratory laparotomy.5,19,20 In male patients with rectal carcinoma, exenterative pelvic surgery is considered when the tumor has extended through the anterior rectal wall and invaded the prostate, seminal vesicles, and bladder.5,20,21 In women, locally advanced rectal carcinoma most frequently involves the uterus, adnexa, posterior vaginal wall, and bladder.21,22 Women with rectal carcinomas and intact gynecological organs often avoid a total pelvic exenteration because the vagina and uterus form an effective barrier against anterior tumor invasion toward the bladder.23 In patients who have previously undergone hysterectomy, however, rectal tumors of the middle to upper rectum can invade directly into the vaginal cuff to invade the bladder trigone.

Recurrent rectal cancer is also an indication for total pelvic exenteration. Despite aggressive resection of primary rectal carcinomas, including total mesorectal excision,24,25 local recurrence rates for rectal cancer range from 4% to 35%.26 In a study by Cass et al.,27 the incidence of local recurrence was related to the original modified Dukes’ stage of the primary tumor, ranging from 15% for B1 to 52% for C2 disease. Patients who have recurrence after a low anterior resection are more likely to present with nonfixed, surgically resectable recurrent disease than are patients who have recurrence after an abdominoperineal resection.9 Recurrent disease can present a technical challenge because the normal anatomical planes have been disrupted; therefore, the complication rate is higher for pelvic exenteration performed for recurrent rectal carcinoma than for pelvic exenteration performed as initial therapy.9,28 The increased morbidity and mortality associated with pelvic exenteration for recurrent rectal disease have caused some authors to question the utility of pelvic exenteration for the treatment of recurrent rectal cancer.4,28,29

Cervical Cancer
The most common disease treated with pelvic exenteration is recurrent cervical cancer of the central pelvis. Landoni et al.30 reported that among patients treated for stage IB to IIA cervical cancer, as many as 25% experienced disease recurrence after therapy. Most patients with untreated cervical carcinoma die of advanced local disease, which can cause obstructive uropathy or peritonitis; only 25% of patients with untreated cervical carcinoma have distant metastases.31 Although radiotherapy may be considered for advanced local disease, the cure rates with radiotherapy for advanced carcinomas of the cervix are lower than those for less advanced-stage disease.32,33 In addition, the higher total radiation dose required for treatment of a large tumor volume, especially after previous operation, can often result in prohibitive morbidity.32,34 For this reason, pelvic exenteration remains the best chance for cure in patients with locally advanced cervical cancer.

Palliative Treatment
Although pelvic exenteration was originally intended as a palliative procedure,8 its use for palliation remains controversial.35,36 Because of the high morbidity and operative mortality rates associated with the procedure, some authors do not believe in the use of total pelvic exenteration for palliation.1,3,4,17,20,37–40 Other authors, however, believe that pelvic exenteration can improve the quality of life of patients with advanced disease and, therefore, is occasionally indicated for palliation.41–43 Pelvic exenteration has been proposed as palliative treatment for pelvic pain, tumor abscess, recurrent hemorrhage, bowel obstruction, and enterourinary or genitourinary fistulas.35,41,44

Patient selection is critical if pelvic exenteration is to be justified as a palliative procedure.45,46 For example, radicular pain must be distinguished from pelvic pain due to sepsis or tenesmus, because only the latter can be ameliorated by radical surgery.47 In a group of carefully selected patients, Yeung et al.48 reported a 67% improvement in pain control after pelvic exenteration. Complete extrication of the tumor mass is critical, however, because others have reported that symptom relief is possible only if all gross tumor in the pelvis is resected.43 In a review from the Fox Chase Cancer Center,41 88% of patients had improvement in their quality of life after palliative pelvic exenteration. In other series,36 in which morbidity and mortality rates were high, the effective palliation was poor. In particular, survival was short and quality of life was poor if extensive tumor was left behind.5,37,42 These data emphasize that palliative exenteration should be considered only in a small, select group of patients for whom all other palliative procedures have already been explored.32,36


   PREOPERATIVE EVALUATION
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
Patients with advanced pelvic tumors can present with a wide range of symptoms. Tumor involvement of surrounding pelvic structures can lead to symptoms including pain, constipation, tenesmus, recurrent urinary tract infections, vaginal or rectal bleeding, hematuria, and pneumaturia.47 Initial evaluation should consist of a thorough history and physical examination. Because well-selected elderly patients have outcomes similar to those of younger patients after pelvic exenteration,49,50 age is not an absolute contraindication to the procedure. Rather, the patient’s overall physiologic status dictates his or her appropriateness as a candidate for resection. The history therefore should focus on identifying any comorbidities, including hypertension, diabetes, coronary artery disease, and poor nutritional status. Patients with significant medical comorbidities are not suitable candidates for pelvic exenteration.51,52

A meticulous physical examination is a crucial component of the preoperative assessment. The regional lymph node basins, including the supraclavicular and inguinal areas, need to be examined. Palpable adenopathy suggestive of metastasis should be investigated by using fine-needle aspiration to rule out distant metastatic nodal disease.47 A digital rectal examination, bimanual examination (in women), and rigid proctoscopy provide critical information for planning the operative approach and need to be performed before the operation.47 The distance of the pelvic mass from the anal verge, the orientation of the tumor and its association with adjacent bony structures, and whether the mass is mobile or fixed should be ascertained. Accurate assessment of the pelvic mass on physical examination can be difficult, especially in patients with recurrent tumor and in patients previously treated with radiotherapy. For this reason, the preoperative assessment should include a complete radiological evaluation.

All patients being considered for pelvic exenteration should undergo preoperative chest radiography and computed tomography (CT) or magnetic resonance imaging (MRI) to evaluate the extent of local disease and to exclude extrapelvic metastasis. The accuracy of CT in the preoperative assessment has been reported to range from 55% to 72%.47,53,54 Zeiler et al.55 reported that CT had a sensitivity of 83% and 56% in detecting nodal and bladder involvement, respectively. CT often underestimates the degree of tumor infiltration, and contrast-enhanced CT understages early transmural rectal extension in as many as 23% of cases.52,56 MRI has been reported to be superior to CT in accurately predicting tumor invasion through the bowel wall.47,57 In one study, MRI was reported to have an overall accuracy of 83% in determining patient eligibility for pelvic exenteration.58 In addition, MRI was more accurate than CT in the identification of sacral bone and piriform muscle involvement. In this study, however, MRI was reported to be highly accurate only in patients with no evidence of pelvic sidewall involvement; it did not reliably distinguish radiation changes from tumor involvement in patients with pelvic sidewall abnormalities.58 The role of positron emission tomographic scanning in the preoperative assessment of patients being considered for pelvic exenteration is still evolving. Positron emission tomographic scanning may be more accurate than CT or MRI in identifying metastatic disease outside the pelvis,59,60 but further studies are needed before its routine use can be justified.

Preoperative radiologic imaging can identify a number of contraindications to pelvic exenteration (Table 2Go). Distant metastatic disease is an obvious contraindication to pelvic exenteration. Enlarged retroperitoneal or para-aortic lymph nodes detected on either CT or MRI are an absolute contraindication to pelvic exenteration in patients with a rectal malignancy, although pelvic nodal metastases in patients with recurrent gynecological cancers are considered a relative contraindication.32,61,62 Other features seen on CT or MRI that preclude resection include involvement of the proximal (S2 or higher) lumbosacral spine, encasement of the common or external iliac vessels, and tumor extension through the sciatic foramen.47 Bilateral hydronephrosis has traditionally been deemed a sign of local invasiveness beyond the limits of operability for cure.42 Complete ureteral obstruction can be due to bilateral pelvic sidewall tumor encasement of the ureters or due to central involvement of the bladder trigone. Although ureteral obstruction due to central involvement is not a contraindication to pelvic exenteration, surgery for cure is precluded in most patients with ureteral obstruction due to pelvic sidewall involvement.63


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  		TABLE 2. Contraindications to pelvic exenteration for curative intent
 

   SURGICAL PROCEDURE
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
To perform a pelvic exenteration with the least risk of morbidity, the surgeon must have a thorough understanding of the anatomy of the pelvis. Not only does the surgeon need to be familiar with the various technical aspects of total pelvic exenteration, but he or she must also be acquainted with the various available modifications of the procedure. A knowledge of postresection reconstructive options, including urinary diversion techniques and pelvic floor reconstruction, is also required.

Initial Operative Assessment
The locations of the colostomy and ileostomy are routinely marked before surgery by the enterostomal therapist. At the time of operation, an examination is performed with the patient under anesthesia. Specifically, with the patient in the supine position and the patient’s legs in the dorsal lithotomy position, a digital rectal examination and a bimanual examination (in women) are performed. After this, cystoscopy is performed to assess for bladder involvement and to facilitate placement of ureteral stents. The patient is then explored through a mid-line incision, with attention initially focused on excluding metastatic disease. Adhesions need to be taken down carefully, and any adhesion suggestive of malignancy should be resected en bloc with the specimen. Lopez and Monafo5 reported a 40% incidence of malignant adhesions, whereas others have reported rates of malignant adhesions as high as 49% to 84%.64–67 The para-aortic and superior retroperitoneal lymph nodes must be palpated to rule out lymph node metastases outside the pelvis, which would contraindicate an attempt at resection. Similarly, evaluation of the relation of the tumor to the pelvic sidewall, sacrum, and coccyx will help to define whether a curative exenteration is feasible. The region lateral to the obturator fossa and external iliac vessels is also explored to rule out tumor extension beyond the psoas muscle.32 When the tumor has been deemed resectable, the pelvic dissection can be initiated.

Exenterative Phase
Four types of pelvic exenteration are commonly performed: total, anterior and posterior (modified), and composite. The surgical procedures for each type are outlined in the following paragraphs.

Total Pelvic Exenteration
Total pelvic exenteration is defined as removal of the rectum, distal colon, bladder, lower ureters, internal reproductive organs, draining lymph nodes, and pelvic peritoneum (Fig. 1Go). After exploration of the abdomen, the pelvic dissection is begun at the level of the aortic bifurcation. In patients with rectal carcinoma, the inferior mesenteric artery is transected at its origin to facilitate a wide lymphadenectomy. The sigmoid colon is mobilized and transected. Sharp dissection is performed in the plane between the fascia propria of the mesorectum and the parietal layer of the endopelvic fascia as far distal in the pelvis as possible. In some situations, mainly in patients with recurrent cancer, the dissection is performed in the plane under the endopelvic fascia. The ureters are identified, and their course is traced both proximally and distally toward the pelvis, with care taken not to skeletonize them. The ureters are not transected until late in the procedure because this represents the point of no return. The bladder is mobilized anteriorly from the retropubic space, and laterally the superior and inferior pedicles of the bladder are ligated and transected. The dissection is performed anteriorly by dividing the puboprostatic ligaments, the dorsal vein of the penis, and the urethra, thereby leaving the bladder and prostate attached to the main specimen. The prostate is not dissected from the rectum but is left in situ for the en-bloc resection. In female patients, the ovaries and the ureters are mobilized from their ligamentous attachments, and the uterus and vagina can be resected en bloc with the specimen. After abdominal dissection, a perineal dissection is performed that encompasses the entire sphincter musculature and urogenital diaphragm. Once the peritoneal and abdominal dissection planes meet, the specimen can be removed en bloc.


Figure 1
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  		FIG. 1. Total pelvic exenteration is defined as removal of the rectum, distal colon, bladder, lower ureters, internal reproductive organs, draining lymph nodes, and pelvic peritoneum.

 
Modified Pelvic Exenteration
Modified pelvic exenterations are divided into anterior and posterior.23,68–70 In an anterior pelvic exenteration (Fig. 2Go), the pelvic peritoneum, lower part of the ureters, reproductive organs, bladder, and draining lymph nodes are removed. Because the posterior vaginal wall and uterus serve as the margin of resection, an en-bloc anterior pelvic exenteration resection maintains the rectum in situ. Similar to what is done during an abdominoperineal resection, the rectovaginal septum is developed by maintaining traction on the uterus or vagina and incising the peritoneum between the vagina and the rectum. The retrorectal space and the lateral rectal ligaments are left undissected in this procedure. Anterior pelvic exenteration is most commonly used in the treatment of anterior pelvic tumors involving the cervix, vagina, or bladder.23


Figure 2
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  		FIG. 2. In an anterior pelvic exenteration, the pelvic peritoneum, lower part of the ureters, reproductive organs, bladder, and draining lymph nodes are removed. Because the posterior vaginal wall and uterus serve as the margin of resection, an en-bloc anterior pelvic exenteration resection maintains the rectum in situ.

 
A posterior pelvic exenteration requires removal of the uterus, adnexa, cervix, posterior wall of the vagina, and rectum (Fig. 3Go). The bladder is preserved. In some patients with a rectal tumor located in the middle or upper rectum, a primary anastomosis can be created. Patients requiring an excision to below the level of the levator ani muscle, however, require a permanent colostomy because the sphincter complex is excised.


Figure 3
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  		FIG. 3. A posterior pelvic exenteration requires removal of the uterus, adnexa, cervix, posterior wall of the vagina, and rectum. The bladder is preserved.

 
Composite Pelvic Exenteration
Composite pelvic exenterations are those that involve bony resections, including portions of the sacrum-coccyx, ischium, pubic symphysis, and ischial pubic rami.32,71–74 When sacral involvement is identified, the extent of the tumor must be clarified early in the course of the dissection, because tumor proximal to the S1/S2 level is considered unresectable by most surgeons.72,73,75 For composite pelvic exenterations, the area of limited tumor fixation to the bone is left intact until the perineal portion of the dissection is nearly complete.32 In general, after the soft tissue and musculature has been divided, an oscillating saw or osteotome is used to transect the bony structures to perform an en-bloc resection.

Two approaches have been reported for sacral transection. In 1981, Wanebo and Marcove76 described a combined abdominal-transsacral approach for resecting locally advanced rectal carcinoma involving the sacrum. In this approach, the initial dissection of the intrapelvic organs is accomplished through a standard anterior approach, and initial dissection is then followed by resection of the sacrum with the patient in the prone position. Specifically, at the completion of the pelvic dissection, a Kirshner wire is drilled through the midline of the sacrum through the intragluteal skin to mark the site of posterior transection of the sacrum.32,76 In the approach described by Temple and Ketcham,74 an osteotome is used to transect the sacrum from an anterior approach after completion of the pelvic dissection and identification of the sciatic nerves.

Reconstruction Phase
The reconstructive phase of the exenterative procedure is critical to a successful outcome because most long-term morbidity can be traced to this phase of the operation. The procedures involved in the reconstructive phase include urinary diversion, filling of the pelvic dead space, and, in female patients, reconstruction of the vagina.

Urinary Diversion
Several surgical options exist for the creation of a urinary reservoir after pelvic exenteration, including both continent and incontinent conduits. The standard incontinent ileal conduit is created by isolating a distal portion of ileum while maintaining its mesenteric vascularity.77 Intestinal continuity is restored as usual. In the creation of the standard ileal conduit, the isolated ileal segment is placed below the intestinal anastomosis. The ureters are anastomosed directly into one end of the ileum, and the other end of the ileum is brought out to the level of the skin. The urine flow is constant, and a drainage bag must be worn at all times.

In an attempt to avoid the need for patients to wear a permanent urinary ostomy bag, techniques of continent urinary diversion have been developed. Many methods of creating a continent urinary conduit have been described, including the Indiana pouch,78 Kouch pouch,79,80 Florida pouch,81 and Miami pouch.82,83 The Miami pouch is the preferred continent urinary reservoir at many centers because of the >90% overall long-term continence rates.52 The Miami pouch is constructed by using a 10-cm segment of distal ileum, the ascending colon, and part of the transverse colon.83 The transverse colon is anastomosed to the ascending colon in a U-shaped fashion to create the colonic reservoir. Antirefluxing nontunneled ureterocolonic anastomoses are then created. The segment of ileum is tapered to reduce the lumen of this segment of bowel, and the ileum is anastomosed at the level of the ileocecal valve to achieve continence. The other end of the ileum is exteriorized as a stoma to allow for self-catheterization. This technique yields a mean urinary reservoir volume of 650 mL and provides the patient with a convenient emptying frequency.83 Techniques of continent urinary diversion may be limited by extensive adhesions, prior bowel operation, or a history of irradiation.

Filling of the Pelvic Dead Space
Considerable morbidity is associated with the resultant large, empty pelvic dead space left after pelvic exenteration. The pelvic dead space predisposes patients to abscesses, fistula formation, perineal wound problems, and intestinal obstruction. To prevent these complications, pelvic floor reconstruction is critical. This can be accomplished by using synthetic absorbable mesh, Alloderm (Life Cell Corporation, Branchburg, NJ), omentum, or other autologous tissue. It has been our practice to use myocutaneous flaps to fill the pelvic dead space after pelvic exenteration, especially in patients who have previously undergone irradiation. The advantages of myocutaneous flap reconstruction of the irradiated pelvis and perineal wound include reduction of dead space, interposition of well-vascularized, nonirradiated tissue, and replacement of resected skin. Specifically, the distally based rectus abdominis flap is commonly used to fill the perineal space.84,85 Other authors have reported decreased rates of perineal complications with the use of myocutaneous flaps, such as those based on the rectus abdominis, gracilis, and gluteus maximus muscles.86–88

Vaginal Reconstruction
Reconstruction of the vagina should be attempted after pelvic exenteration, either at the time of the initial operation or as a delayed procedure. The loss of the vagina with pelvic exenteration can be psychologically difficult for women.89,90 In addition, vaginal reconstruction is an integral part of healing the perineal wound. Beemer et al.91 reported their experience with split-thickness skin grafts for vaginal reconstruction. This procedure, however, often requires a delay in reconstruction of 2 to 8 weeks while an adequate granulation bed forms. Other authors84 have advocated techniques that allow for immediate vaginal reconstruction. Myocutaneous flaps involving the gracilis and rectus abdominis muscles are frequently used to construct a neovagina at the time of the initial radical operation.84,92,93 An advantage of these flaps is that they provide extra tissue to cover the pelvis. In fact, the creation of a myocutaneous neovagina has been shown to decrease postoperative morbidity by filling the potential space left after exenteration.52,94 Jurado et al.94 found a significant decrease in pelvic abscess formation in patients who had undergone creation of a neovagina compared with patients who had not.


   PERIOPERATIVE MORBIDITY
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
Pelvic exenteration has historically been associated with a high incidence of perioperative complications, with rates ranging from 32% to 84%.1–5,28,34,39 In a recent study by Kakuda et al.,28 45% of patients required at least one readmission to the hospital, and 32% required additional operative procedures. The most common complications associated with exenteration include wound/pelvic complications, gastrointestinal or genitourinary fistulas, and small-bowel obstruction (Table 3Go). Although many complications after surgery may be considered minor, major complications are not infrequent. Specifically, serious infections of the wound/pelvis and problems with the urinary conduit are the most common serious perioperative complications.6,95–98 Rates ranging from 45% to 65% have been reported for both short-term and long-term complications of the urinary conduit.83,99–103 Early complications can occur in up to 10% of patients and usually involve problems with the urinary enteric anastomosis, such as leaks and obstruction.32 Most leaks can be managed conservatively with prolonged conduit drainage and, if needed, diversion of the urine stream with percutaneous nephrostomy tubes. Late urinary complications include stenoses and fistulas, which have been reported to develop in up to 16% of patients.104 Serious complications involving the urinary and gastrointestinal tracts are correlated with prior exposure to radiotherapy.6,95–97 In the series reported by Jakowatz et al.,105 67% of patients who had undergone radiotherapy developed postoperative complications, compared with 26% of those who had not had prior irradiation. Another rare, but life-threatening, complication that can occur after extended resection of pelvic tumors is arterioureteral fistula.106 Clinical presentation is often limited to gross hematuria, and surgical treatment must be undertaken early, even in the absence of absolute proof of diagnosis, to preclude uncontrollable massive hemorrhage.


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  		TABLE 3. Possible complications of pelvic exenteration
 

   SURVIVAL AFTER PELVIC EXENTERATION
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 
Most authors report a 5-year survival rate between 20% and 60% after pelvic exenteration (Table 4Go).1,3,4,9–12,97,107–111 In general, patients with gynecological cancers tend to have long-term survival similar to that of patients with primary rectal cancer (Table 4Go). Patients with recurrent rectal carcinoma, however, have significantly worse 5-year survival rates.37,48,75,112,113


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  		TABLE 4. Survival after pelvic exenteration
 
Whether the primary tumor is gynecological or rectal in origin, one of the most important prognostic factors after pelvic exenteration is the status of the surgical margin. Anthopoulos et al.1 reported that the most important risk factor for reduced survival was the extension of tumor laterally into the surgical margins. Talledo96 also reported that patients with lateral extension to the parametrium, pelvic fascia, or both had a decreased survival rate compared with patients with central disease. Kraybill et al.6 reported a 5-year survival rate of 25% in patients with positive margins versus 44% in patients with negative margins.

Survival of Patients With Rectal Cancer
In patients with rectal cancer, survival is associated with the presence or absence of positive lymph nodes, the extent of local disease, whether the operation is for a primary or a recurrent tumor, and the achievement of negative margins.32,114 After pelvic exenteration, the absence of lymph node metastases is associated with improved survival.42,115–118 Specifically, the reported 5-year survival rate ranges from 47% to 82% in patients with negative lymph nodes, compared with 0% to 55% in patients with positive lymph nodes.42,115–118 Salo et al.113 reported a 5-year survival rate of 31% in patients undergoing pelvic exenteration for recurrent rectal cancer, whereas Kakuda et al.28 reported only an 11-month disease-free survival after pelvic exenteration for recurrent pelvic disease. Other authors37,72 have similarly reported that patients who present with primary disease have better 5-year survival rates than patients with recurrent disease. Hafner et al.37 reported that patients with recurrent rectal tumors had a 5-year survival rate of only 20%, compared with 43% for patients undergoing exenteration for primary disease. Despite aggressive multimodality therapy, including multivisceral resection, patients with close or positive margins also have a high rate of pelvic and distant disease recurrence.114

Survival of Patients With Cervical Cancer
Factors associated with worse outcomes after pelvic exenteration for carcinoma of the cervix include positive pelvic and para-aortic lymph nodes, a short time to recurrence, a more advanced tumor stage, and a nonsquamous histological subtype.38,52,61,119,120 Rodriguez Cuevas et al.119 reported that patients with stage I or IIA disease had a significantly better disease-free survival compared with patients with more advanced disease. Morley et al.61 noted that patients with squamous cell carcinoma of the cervix had a cumulative 5-year survival rate of 73%, compared with 22% in patients with adenocarcinoma of the cervix. Shingleton et al.120 reported that the best candidates for cure of cervical cancer by pelvic exenteration were those with recurrent small (<3 cm), mobile central masses who had completed radiotherapy at least a year earlier. In this group’s experience, attempts to resect bulky pelvic recurrences that impinged on the pelvic sidewall, especially in the case of persistent or early recurrent disease (within 6 months), and continuation of exenterative procedures in women known to have nodal metastases or extrapelvic spread were generally futile.


   ADJUVANT THERAPY
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
CONCLUSIONS
 REFERENCES
 
Preoperative radiotherapy has been shown to improve resectability in as many as 50% to 75% of patients with "unresectable" rectal tumors.121–124 The use of chemotherapy in combination with radiotherapy may enhance the effectiveness of radiation in downstaging previously unresectable disease.125–127 Minsky et al.125,126 reported that the addition of 5-fluorouracil and leucovorin to 50.4 Gy of preoperative pelvic radiation led to a higher rate of complete response and fewer regional nodes with metastases at resection than radiotherapy alone, even though the patients who received chemotherapy had more advanced disease. Because longer follow-up is still needed, the ultimate effect of a complete response and a decrease in the incidence of positive pelvic nodes on local control and survival remains to be determined. However, given the enhancement of downstaging in patients with unresectable rectal cancer, the combined-modality approach warrants further consideration and study.126,128


   CONCLUSIONS
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
REFERENCES
 
Total pelvic exenteration and its modifications need to be considered among the treatment options for patients with advanced pelvic malignancies. Recent advances in patient selection, surgical technique, and perioperative care have led to decreased morbidity. Despite this, pelvic exenteration remains a formidable procedure with the potential for both short- and long-term complications. There is abundant evidence that pelvic exenteration for primary rectal cancer and cervical cancer can lead to meaningful long-term survival; however, the prognosis after pelvic exenteration for recurrent rectal cancer is not as good. The recent introduction of combined chemoradiotherapy is likely to improve local recurrence rates and may translate into more durable long-term survival. Pelvic exenteration continues to have an important role in the multimodality approach to patients with advanced pelvic malignancies.


   FOOTNOTES
 
Timothy M. Pawlik, MD, is now at Department of Surgery, Johns Hopkins, 600 North Wolfe Street, Halsted 614, Baltimore, MD 21287-7113.

Received for publication March 18, 2005. Accepted for publication August 5, 2005.


   REFERENCES
TOP
 INTRODUCTION
 INDICATIONS
 PREOPERATIVE EVALUATION
 SURGICAL PROCEDURE
 PERIOPERATIVE MORBIDITY
 SURVIVAL AFTER PELVIC...
 ADJUVANT THERAPY
 CONCLUSIONS
 REFERENCES
 

  1. Anthopoulos AP, Manetta A, Larson JE, Podczaski ES, Bartholomew MJ, Mortel R. Pelvic exenteration: a morbidity, mortality analysis of a seven-year experience. Gynecol Oncol 1989;35:219–23.[CrossRef][Medline]
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