Pelvic exenteration is a radical surgical procedure designed to remove all or most of the organs from the pelvic cavity. This extensive operation is reserved for patients with advanced or recurrent pelvic cancers that have not spread to distant sites. It is used when less aggressive treatments, such as radiation or chemotherapy, have failed. The goal is to achieve a complete, curative resection of the tumor and the surrounding structures it has invaded.
Medical Conditions Requiring Pelvic Exenteration
The primary indication for this procedure is a locally advanced or recurrent cancer confined to the pelvis. This means the tumor has grown into nearby organs but remains isolated from other parts of the body. Cancers of the female reproductive system, such as cervical, vaginal, and uterine cancer, are common reasons, especially after previous radiation therapy has been unsuccessful.
Other indications include locally advanced rectal cancer and certain bladder cancers that have invaded the pelvic floor. For a patient to be a candidate, physicians must confirm there are no signs of metastasis (distant spread), as the surgery’s intent is curative. The procedure is often the only option for achieving a clear surgical margin and long-term disease control in these complex cases. Eligibility determination involves extensive imaging and testing to ensure the disease is fully contained within the pelvic region.
Scope of the Surgery: Understanding the Types
The term pelvic exenteration describes a spectrum of procedures, with the extent of organ removal depending on the tumor’s location and spread. Surgeons aim to remove only the organs necessary to achieve a clean margin around the cancer. The surgical approach is categorized into three types based on which visceral compartments of the pelvis are removed.
An Anterior Pelvic Exenteration involves removing the organs in the front of the pelvis, primarily the bladder and the entire reproductive tract. In female patients, this includes the uterus, cervix, and vagina, while the rectum and lower bowel are spared. This type necessitates a new pathway for urine to exit the body.
A Posterior Pelvic Exenteration is performed when cancer has invaded the back portion of the pelvic cavity, requiring removal of the rectum and reproductive organs. The bladder is left intact during this operation. This procedure requires creating a permanent diversion for stool, as the final portion of the bowel is removed.
The most extensive operation is the Total Pelvic Exenteration, which involves the removal of all organs from the pelvis, including the bladder, rectum, and reproductive structures. In women, this means the uterus, cervix, and often the entire vagina are removed. In men, the prostate and seminal vesicles are included. This removal is performed when the cancer has spread across all three pelvic compartments, requiring both urinary and fecal diversions.
Urinary and Bowel Diversions
The removal of the bladder and/or rectum requires creating new systems to manage the body’s waste, known as ostomy formation or surgical diversion. When the bladder is removed, a urostomy is performed to create a path for urine to exit the body. The most common method is the ileal conduit, which uses a short segment of the small intestine (ileum) to channel the ureters to an opening on the abdominal wall called a stoma.
This stoma is a small, pink, moist opening through which urine continuously drains into a specialized external collection pouch worn on the abdomen. If the rectum is removed, a colostomy or ileostomy is created to divert stool. A section of the large or small intestine is brought through the abdominal wall to form another stoma, which requires an external appliance to collect waste.
In some patients undergoing anterior exenteration where the rectum remains, surgeons may attempt a restorative procedure for the urinary tract. This can involve creating an internal pouch or neobladder from a section of the intestine connected to the urethra. This allows urine to be managed internally, though it often requires intermittent self-catheterization to empty the pouch. Internal diversions are not always possible, particularly following total exenteration or in patients who have received extensive radiation.
Recovery and Long-Term Adjustments
Pelvic exenteration is a major operation, and the initial hospital stay is typically longer than for most surgeries, often lasting one to three weeks. Patients are closely monitored for signs of infection or complications during post-operative care. The recovery timeline extends for many months, with full physical recovery often taking six months or more.
Recovery involves intensive education on managing the new ostomies, provided by specialized wound and ostomy care nurses. Patients learn how to clean the stomas, change the collection pouches, and manage any skin irritation. Sitting can be difficult for several weeks after surgery due to the extensive tissue removal and reconstruction in the pelvic floor.
Long-term adjustment focuses on integrating the diversions into daily life, including adapting clothing, managing nutrition, and addressing changes to body image. While the procedure presents significant physical and psychological challenges, most survivors experience a return to their baseline quality of life within six months. The focus shifts to rehabilitation, allowing patients to resume most normal activities with necessary practical adjustments.