What is Central, Posterior, and Total Pelvic Exenteration?
Pelvic exenteration is a major surgical procedure in which multiple organs of the pelvis are removed to treat cancers in the pelvis, such as uterine cancer, bladder cancer, cervical cancer, rectal cancer, and anal cancer. The surgery involves removal of organs in the pelvis, such as the uterus (womb), cervix (neck of the womb), ovaries and fallopian tubes, vagina, urethra, and bladder that are affected with cancer. In men, the procedure involves removal of the seminal vesicles and the prostate.
Central, posterior, and total pelvic exenterations are different types of pelvic exenteration approaches employed in the treatment of pelvic cancer.
Anterior pelvic exenteration is employed if the cancer is located at the front portion of the pelvis and involves removal of the bladder and reproductive organs. You will require a new location for urine to exit the body. Your surgeon will create a new opening called a stoma for this on your belly. This is known as a urostomy.
Posterior pelvic exenteration is employed if the cancer is located at the back portion of the pelvis and involves removal of the rectum (lower section of the large bowel) and reproductive organs. You will need a new place for stools to exit the body. Your surgeon will create a new opening called a stoma for this on your belly. This is known as a colostomy.
Total pelvic exenteration is employed if the cancer is located in the central portion of the pelvis and involves removal of the bowel, reproductive organs, and the bladder. This means that you may need 1 or 2 openings (stomas) to collect urine and stool contents. Both colostomy and urostomy are performed during this procedure.
Indications for Central, Posterior, and Total Pelvic Exenteration
Central, posterior, and total pelvic exenteration surgery is usually indicated to treat cancers of the pelvis in individuals 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 some of the symptoms associated with the cancer
Preparation for Central, Posterior, and Total Pelvic Exenteration
Pre-procedure preparation for central, posterior, and total 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 Central, Posterior, and Total Pelvic Exenteration
Central, posterior, and total pelvic exenteration is a very complex surgery that takes several hours to complete and may involve multiple 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 the 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 an 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 are removed, including the bladder, urethra, and bowel/rectum necessitating a urinary diversion, also known as a urostomy, and colostomy for the exit of urine and stools from the body. During the 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. For a urinary pouch, a drainage catheter tube is placed in the stoma to drain the urine. With an ileal conduit, a collection bag is attached around the stoma to drain the urine. During a colostomy procedure, one end of the large intestine (bowel) is brought out through the abdominal wall by making a small cut in the abdominal wall to create an opening called a stoma. Stools are then passed through the stoma and collected in a pouch attached to the skin. After these procedures, 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 and the anus will be closed with a skin tissue. At the end of the procedure, the incisions are closed with absorbable sutures and sterile dressings are applied.
Postoperative Care and Recovery
In general, postoperative care instructions and recovery after central, posterior, and total 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, and stool 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 low fat, high fibre diet is strongly recommended to promote healing and a 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 can resume driving around 2 to 4 weeks following surgery.
- 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
Central, posterior, and total 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