Comments On Pelvic Exenteration

In general pelvic exenteration is considered for locally advanced or recurrent pelvic malignancy in the absence of extra-pelvic metastases.

— degree of disease spread is assessed by

• CT scan—pelvic and retroperitoneal lymphadenopathy, extra-pelvic metastases.

• PET/CT scan—detects metabolic activity in malignant tumours and is useful in localizing recurrent or metastatic disease.

Figure 7.5. Pelvic exenterations. QA|

Figure 7.5. Pelvic exenterations. QA|

— relevant malignancies are: cervical carcinoma, rectal carcinoma, anal carcinoma, soft tissue lesions [e.g. malignant fibrous histiocytoma (MFH), aggressive angiomyxoma], aggressive muscle invasive bladder cancer, and occasionally advanced endometrial, vaginal or vulval cancers.

— contraindications are significant comorbidity, distant metastases (except resectable liver metastases from a rectal carcinoma) and involvement of major pelvic vessels, nerves, side walls or sacrum (but can be resected en bloc in rectal cancer).

— preoperative adjuvant therapy may result in significant tumour regression, so much so that it may be difficult to find residual disease and lymph nodes which hyalinize. Deep spread and margins fibrose, making accurate assessment of pT stage and resection status problematic.

— surgery may be with curative intent or palliative to obviate complex and debilitating pelvic symptoms due either to spread of malignancy or as a consequence of adjuvant therapy, e.g. pain, fistulae.

— pelvic exenterations

• anterior: bladder, lower ureters, reproductive organs, draining lymph nodes and pelvic peritoneum.

• posterior: rectum, distal colon, internal reproductive organs, draining lymph nodes and pelvic peritoneum.

• total: anterior and posterior.

— principles of specimen reporting

• identify the specimen type and component organs.

• block limits, i.e. ureters, urethra, vagina and proximal/distal bowel.

• paint circumferential radial fascial margins, comment on the uterine/bladder dome/colonic/upper anterior rectal peritoneum and integrity of the mesorectum and its fascia.

• sagittal hemisection can be very useful in demonstrating the relationships between the tumour and the constituent organs. Fistulae can be cut along the line of an exploring probe. Also document the status of circumferential radial margins.

• report as per individual cancers, noting in particular the degree of locoregional spread, margin status and effect of preoperative adjuvant therapy.

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