Pelvic exenteration. Has it a role in 1987? A six year experience

Pelvic exenteration entails extensive radical surgery with evisceration of pelvic organs involved with central recurrence of pelvic cancer. It may occasionally be indicated as a primary surgical procedure. A tumour arising from any pelvic organ may require this surgery but those from the cervix and vulva primarily are particularly amenable to such surgery. Certain ovarian tumours with involvement of the rectum and large pelvic masses not responsive to previous surgery or chemotherapy may also be considered for exenterative type surgery as a type of salvage operation. Strict criteria must be observed to exclude either distal spread or local fixation in the pelvis with consequent lymphatic or vascular involvement. For patients with recurrent cervical cancer, 50% of those referred were rejected at examination under anaesthetic as being inoperable: 20% overall were surgically suitable for the procedure at exploratory laparotomy. The final decision to proceed is made at laparotomy with frozen section assessments to ensure adequate clearance of tumour. Urinary diversion by means of an ileal conduit and also terminal colostomy will be required after total pelvic exenteration. Anterior or posterior exenteration will require diversion only of either the urinary or gastrointestinal tract. Large vulvar tumours may require simultaneous musculocutaneous flaps in order to obtain adequate closure of large defects with satisfactory skin coverage. 52 such procedures have been performed over the last five years. 25 of these have been for extensive ovarian carcinomas as a salvage procedure following previous failed surgery and chemotherapy. A median survival of two years six months as opposed to 10 months in an inoperable but comparable group was obtained. 12 patients with recurrent cervical cancer and 8 with advanced vulvar cancer were also operated on. The mean age was 59 years with a range of 30-76 years. The operative mortality following this extensive and radical procedure was 6% with 3 deaths occurring at 24 hours, one month and three months post surgery. A 20% morbidity occurred with varied complications including haemorrhage (3 patients) and fistulae (2 patients). The overall survival at 3 years was 48% with 75% survival for patients with carcinoma of the vulva and 60% with carcinoma of the cervix. No patients with involved lymphadenopathy survived. With a combined team approach to the careful selection and management of suitable cases, a 50% five year survival may be obtained with patients undergoing pelvic exenteration for advanced pelvic cancer.