Salvage pelvic surgery and pelvic exenteration

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who, and the MDT Locally advanced or recurrent pelvic cancer that can be removed with a clear margin and in a patient who can survive the operation and live with two stomas: rectal cancer recurring after chemoradiotherapy, cervical cancer recurring centrally after radiotherapy, bladder or prostate cancer fixed to the rectum, and the irradiated pelvis with an intractable fistula. The decision belongs to a specialist exenteration MDT with colorectal, urological, gynaecological, plastic and vascular surgeons, oncologists, radiologists, anaesthetists and a stoma nurse in the room. Curative intent means an R0 resection is achievable on the imaging; palliative intent means the aim is symptom control and is said so. Staging is CT of chest, abdomen and pelvis, pelvic MRI and PET-CT, and metastatic disease outside the pelvis is the usual bar.
2. Planning the sidewall The pelvic MRI is read compartment by compartment: anterior, central, posterior and lateral, with the sacrum. Central disease with bladder and rectum together is a total exenteration; disease confined to bladder, uterus and vagina is an anterior exenteration with the rectum kept. The lateral compartment decides resectability: tumour at the internal iliac vessels can be taken with them, tumour on the obturator internus and the pelvic sidewall fascia can be taken with the muscle, tumour encasing the external iliac vessels needs a vascular surgeon and a graft, and tumour at the sciatic notch or the lumbosacral trunk is the edge of what can be done. The sacrum below S2 can be taken with a spinal surgeon. The ureters are mapped, and the kidneys checked for obstruction and function.
3. Position, incision and the stoma sites The stoma nurse marks both sites the day before with the patient sitting, standing and lying: the urostomy on the right and the colostomy on the left, each on the summit of the rectus and away from creases, scars and the belt. Lloyd-Davies position with the legs in stirrups and the arms tucked, padding at every pressure point because the operation is long, a warming blanket, arterial and central lines, an epidural or a spinal with morphine, and blood cross-matched in quantity. Antibiotics with anaerobic cover and thromboprophylaxis. A long midline incision from the xiphisternum to the pubis, the abdomen explored for peritoneal or liver disease that would stop the operation, and a fixed ring retractor set.
4. The en bloc dissection The principle is that the tumour is never seen, entered or handled: the dissection runs outside every plane the tumour occupies, and the specimen leaves in one piece. The sigmoid is divided with a stapler at the level the colorectal surgeon chooses, the ureters are found at the brim and divided high with a clip so they can be sent for a frozen section of the margin, and the plane is developed along the pelvic sidewall on both sides, lateral to the internal iliac vessels if they are to be taken. The peritoneum is incised around the pelvis and the bladder, uterus and rectum are mobilised as one block from front and sides toward the pelvic floor. Anything the tumour touches comes with it.
   where it bites: the dissection never enters the tumour; a plane that opens into it is a positive margin and an operation that has lost its purpose.
5. The pelvic sidewall and the internal iliac vessels The common iliac artery is followed to its bifurcation and the external iliac artery and vein are cleared and protected on a sling. The internal iliac artery is ligated and divided beyond the origin of the superior gluteal branch where it can be spared, or at its origin where the tumour demands, and the internal iliac vein is taken between ligatures with its tributaries, the bloodiest part of the day: the veins are thin and tear toward the sacrum. The obturator nerve is preserved if it is free of tumour and sacrificed if it is not, with the patient warned about adduction. The lumbosacral trunk and the sciatic nerve are the posterior limit. The sidewall muscle comes with the specimen where the tumour is on it.
   where it bites: the internal iliac vein and its tributaries tear toward the sacrum and the pre-sacral plexus; control is proximal ligation and packing, not a clamp put on blind.
6. The perineal phase A second team works from below while the abdominal team finishes the pelvic floor: an elliptical incision around the anus, in a woman taking the vaginal introitus and in a man the perineal skin to the bulb of the urethra, deepened through the ischiorectal fat to the levators, which are divided from below and meet the abdominal dissection at the pelvic floor. The urethra is divided at the membranous level from below or above. The specimen is delivered through the perineum or the abdomen, oriented, marked and sent fresh. The perineal wound is the size of a hand and will not close on its own in irradiated skin, which is why the flap has been planned before the incision was made.
7. Reconstruction: conduit and colostomy The urological reconstruction is an ileal conduit in nearly every case: fifteen centimetres of ileum taken twenty centimetres from the ileocaecal valve, the ureters spatulated and joined end-to-side over single-J stents, Bricker fashion, or as a Wallace plate, with the left ureter brought under the sigmoid mesentery, and the stoma everted at the right-sided mark. Irradiated ileum near the pelvis is avoided and a segment from higher up, or transverse colon, is used instead. The colorectal surgeon brings out an end colostomy on the left. Where the rectum has been preserved in an anterior exenteration a defunctioning stoma is still usual. The stents and the drains are labelled, because two stomas, two stents and three drains become confused on the ward.
8. Filling the pelvis An empty irradiated pelvis fills with small bowel that adheres, obstructs, fistulates and perforates, and its perineal wound breaks down; the dead space is therefore filled at the same operation. The vertical rectus abdominis myocutaneous flap on the inferior epigastric pedicle is the usual choice, raised from the side that will not carry a stoma, tunnelled through the pelvis and inset into the perineum, giving bulk below and skin at the wound. Where the rectus has been used or is needed, gracilis flaps from the thighs or an omental pedicle are the alternatives, and a mesh or a biological sling across the pelvic inlet holds the bowel out. The abdomen is closed with the stomas matured last.
   where it bites: small bowel that drops into an irradiated, empty pelvis obstructs and fistulates; the pelvis is filled at the operation, not at the reoperation.
9. After Critical care for the first days: fluid, transfusion, the epidural, hourly urine from the conduit, and the stents flushed if they block. Stomas are checked for colour twice a day, because a dusky conduit is an ischaemic one. Nutrition is started early. The perineal flap is inspected daily for colour and the drains stay until dry. The stents come out at ten to fourteen days, the drains after them, and a loopogram is done if there is doubt about a uretero-ileal join. Histology and margins go back to the MDT. The patient meets the stoma nurse daily, the physiotherapist for the leg if the obturator was taken, and a psychologist, because two stomas and a perineal scar are a different life.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance