Procedure in Pelvic Exenteration?

Question

Please, if anyone, list down here the steps in a total pelvic exenteration. Thank you.

Nah, no I'm not. I couldn't find any sources in the internet... sorry for my misleading way of asking.

Answer 1

Pelvic exenteration is radical surgical treatment that removes the urinary bladder, urethra, vagina, cervix, uterus, fallopian tubes, ovaries, rectum, anus, and in some cases, the vulva. The procedure leaves the patient with a permanent colostomy, where the colonic contents drain into a bag that attaches on the left side of the abdomen. The bladder is reconstructed from bowel to provide a reservoir which empties into a pouch on the abdomen.

Pelvic exenteration is most commonly used in cases of advanced or recurrent cervical cancer, vaginal cancer, and vulvar cancer when more conservative surgical options are not technically possible or would not be able to remove the extent of the tumor.

Pelvic exenteration continues to be the only curative option in certain patients with centrally recurrent cervical, vaginal, or vulvar cancers. Since Brunschwig's time, improvements in critical care, antibiotics, hyperalimentation, and thromboembolism prophylaxis, accompanied by similar advances in surgical technique, including the use of stapling devices, separate urinary conduits, and pelvic reconstruction, have improved the morbidity and mortality rates associated with the procedure. Currently, operative mortality rates are 3-5%, the major perioperative complication rate is 30-44%, and the overall 5-year survival rate in patients who successfully undergo the procedure is 20-50%.

The first steps in the approach to treating a patient with a biopsy-proven central recurrence are an exhaustive search for distant metastatic disease and evaluation for comorbid conditions. The initial surgical exploration involves a further search for disseminated disease and necessitates a complete assessment of intraperitoneal and retroperitoneal areas that would preclude proceeding with exenteration. This task can be accomplished by laparoscopy in selected patients.

Problem: Cancers arising in the pelvis are often treated with multimodality therapies, including surgical resection and radiation. When these cancers recur, many may be locally advanced but still limited to the pelvis; however, prior treatment with high doses of radiation makes limited surgical resection a difficult undertaking fraught with complications. Furthermore, the response of tumors to chemotherapy within a previously radiated field is extremely poor. In some instances, the only opportunity for cure may lie in complete resection.

Pelvic exenteration is a salvage procedure performed for centrally recurrent gynecologic cancers. To a greater or lesser degree, the procedure involves en bloc resection of all pelvic structures, including the uterus, cervix, vagina, bladder, and rectum. Most candidates for this procedure have a diagnosis of recurrent cervical cancer that has previously been treated with surgery and radiation or radiation alone. In some cases, patients with recurrent uterine, vulvar, or vaginal cancers may benefit from pelvic exenteration. In general, patients with ovarian cancer are not candidates because of the distant pattern of spread associated with ovarian cancers.

Clinical: Patients with recurrent cervical cancer after radiation therapy usually present with bleeding, hematuria, or pelvic pain. In some cases, the first sign of recurrence is the discovery of hydronephrosis or abnormal cytology on routine follow-up. Before proceeding with the surgical procedure, confirming a recurrence with a pathologic specimen obtained by biopsy is essential. In patients who have previously had high doses of pelvic radiation, physical examination is notoriously unreliable, and bleeding and pain may be related to radiation changes rather than recurrent disease. The clinical triad of leg edema, ureteral obstruction, and leg pain is almost pathognomonic for disease extending to the pelvic sidewall and is generally considered a contraindication to surgery.-

Answer 2

Jed, you are scary. I hope you aren't planning on doing one yourself.