What is Anterior Pelvic Exenteration?
Anterior pelvic exenteration is a major surgical procedure in which multiple organs of the pelvis, including urinary and gynecologic systems, are removed in an anterior (front) approach to treat cancers in the pelvis. The surgery involves the removal of organs at the front of the pelvis, such as the uterus (womb), cervix (neck of the womb), ovaries and fallopian tubes, vagina, urethra, and bladder affected with cancer. The surgery also involves the removal of some healthy tissue around the tumour to ensure complete removal of all cancerous tissue.
Indications for Anterior Pelvic Exenteration
Anterior pelvic exenteration surgery is usually indicated to treat cancers of the pelvis in women who:
- Have already received treatments for cancer
- Have recurrence of cancer following previous treatment
- Have had no cure from initial cancer treatment
- Have cancer confined to pelvis and has not spread elsewhere
- Want permanent relief from symptoms of cancer
Preparation for Anterior Pelvic Exenteration
Pre-procedure preparation for anterior pelvic exenteration will involve the following steps:
- A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
- You will be asked if you have allergies to medications, anaesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
- You should refrain from alcohol or tobacco at least a few days prior to surgery.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
- You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
- Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Procedure for Anterior Pelvic Exenteration
Anterior pelvic exenteration is a very complex surgery that takes several hours to complete and may involve several surgeons depending upon the organs affected with cancer. These surgeons may include:
- A colorectal surgeon who specialises in bowel cancers
- A gynaecological surgeon who specialises in female reproductive system
- A urologist who specialises in the genitourinary system
- A plastic surgeon who specialises in reconstruction
- An anaesthetist
The surgery is performed under general anaesthesia with open surgery. Your surgeon will make a long vertical incision starting at the top of the pubic hairline and going up to the belly button or umbilicus and sometimes above the umbilicus. The inside of the abdomen is carefully examined to ascertain the spread of cancer and the affected pelvic organs including the bladder, urethra, and vagina are removed accordingly. When the urethra and bladder are removed, a urinary diversion, also known as a urostomy, becomes a necessity for urine to exit the body. During urinary diversion procedure, your ureters and kidneys are attached to the urinary diversion that exits through an opening in the abdominal wall. Two types of urinary diversions with stomas (artificial opening) can be made: a urinary pouch and an ileal conduit. In a urinary pouch, a drainage catheter tube is placed in the stoma to drain the urine. In an ileal conduit, a collection bag is attached around the stoma to drain the urine. Vaginal reconstruction using skin graft and/or muscle flap from other parts of the body may also be performed. If reconstruction is not desired, the vagina will be closed with skin tissue. At the end of the procedure, the incision is closed with absorbable sutures and sterile dressings are applied.
Postoperative Care and Recovery
In general, postoperative care instructions and recovery after anterior pelvic exenteration will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
- As it is a complex surgery, you will likely require 7 to 10 days of hospital stay after surgery.
- You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
- Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
- Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
- Antibiotics are prescribed to address the risk of surgery-related infection.
- Your diet is slowly advanced post surgery. You will start with clear liquids, then progress to having normal solid foods, as tolerated.
- It is important to keep the surgical site clean and dry. Instructions on surgical site care, stoma care, urine collecting bag/pouch, and bathing will be provided.
- Refrain from smoking for a specific period of time as it can negatively affect the healing process.
- Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
- Eating a healthy diet rich in low fat and high-fibre is strongly recommended to promote healing and faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
- Most patients will need to take off work at least a month or two to rest and promote healing. Walking is a good exercise and is strongly recommended to improve your endurance.
- Refrain from driving until you are fully fit and receive your doctor’s consent. Most patients often take 2 to 4 weeks to drive.
- You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Anterior pelvic exenteration is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:
- Hematoma (accumulation of blood in the wound)
- Seroma (accumulation of clear fluid in the wound)
- Damage to surrounding soft tissue structures, such as nerves, vessels, and organs
- Post-procedure pain, requiring narcotics for relief
- Blood clots
- Heart problems
- Bladder problems
- Anaesthetic/allergic reactions
- Kidney problems