Problems in pelvic cytoreduction - Hostile pelvis

Surgeons learn over time when it is appropriate to recommend an operation. This is particularly true in the management of pelvic carcinomatous disease, which often gives rise to symptoms that are debilitating and difficult to manage by non-surgical means. Radical pelvic cytoreduction, complete resection of all visible tumor, remains the established operation for the treatment of carefully selected patients with biologically favorable tumors. Complexities in pelvic surgery and pelvic cytoreduction cover the strategic evaluation, specific approaches, and management techniques. The essential principle to removal of a very advanced pelvic disease lies in the retroperitoneal surgery. The retroperitoneal approach allows for dissection of the pan-pelvic tumoral mass and deposits using the peritoneum as a pseudo-capsule while identifying vital retroperitoneal structures such as the iliac vessels and ureter. Despite the fact that there are several considerations in favor of cytoreductive surgery, overall morbidity due to its application depends not only on the extent of the surgical procedure but also on the patient's medical fitness, the experience and expertise of the operating surgeon, as well as the quality of the supportive care, particularly anesthesia and critical care. The major source of trouble is the hostile pelvis itself. The reasons are fairly clear: most patients have had incomplete 'in-line' resective attempts, irradiation, and inflammation due to prior overhealing. Many of the complications of the procedure can be ameliorated or eliminated by careful attention to patient preparation, intraoperative meticulous technique, and post-cytoreductive intensive care. Achieving success and safety with these cytoreductive techniques requires extensive knowledge of pelvic anatomy, the use of special techniques of exposure and methods of dissection, a clear understanding of the objectives of the operation, and a flexibility of mind.