Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recur rence after prior surgery and radiotherapy. After exenteration, 5-year surv ival is 40% to 60% in patients with gynecologic cancer as compared to 25% t o 40% for patients with colorectal cancer. Physiologic age and absence of c o-morbidities appear to be more important when selecting patients for exent eration than chronological age. Careful pre-operative staging, including ei ther computed tomography (CT) scan or magnetic resonance imaging (MRI), usu ally will identify patients with distant metastases, extrapelvic nodal dise ase, or disease involving the pelvic sidewall (which,generally precludes su rgery). The recent application of intra-operative radiotherapy or postopera tive high-dose brachytherapy for patients with more advanced pelvic disease , which may include sidewall involvement, may expand the standard indicatio ns for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operativ e details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Fil ling the pelvis with large tissue flaps, usually a rectus abdominus flap, h as decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity oc curs in over 50% of patients. Restorative techniques for both urinary and g astrointestinal tracts can diminish the need for stomas and, along with vag inal reconstruction, can significantly improve quality of life for many pat ients after exenteration. These advances in surgery and radiotherapy help m ake the procedure a viable option for patients with otherwise incurable pel vic malignancy. (C) 1999 Wiley-Liss, Inc.