Exenteration

DEFINITION: Exenteration is a major surgical procedure in which the entire contents of a body cavity, such as the pelvis or the orbit (eye socket), are totally removed.

Cancers treated: In female patients, cancer of the reproductive organs such as the uterus, cervix, and Fallopian tubes. In male patients, cancer of the prostate and certain ducts and glands. For both genders, cancer of the rectum and cancers of the eye and surrounding tissues

Why performed: Exenteration of the pelvis in female patients is performed when less radical surgery, chemotherapy, and radiotherapy have failed in the management of advanced or invasive cases of vaginal, rectal, uterine, and cervical cancer. Most often, previously treated patients with recurrent cervical cancer undergo the procedure. Cancer that has spread or metastasized is rarely treatable with exenteration. Because of characteristic distant metastasis, ovarian cancer does not lend itself to the procedure. In male patients, pelvic exenteration is indicated when prostate or rectal cancer is unresponsive to radiation and hormonal therapy and when biopsy demonstrates recurrent cancer and ultrasound shows rectal involvement. Orbital exenteration is indicated for large orbital tumors, or the extension of intraocular tumors, most commonly when squamous cell carcinoma and basal cell carcinoma affect the orbit and its contents are unmanageable by simple removal or irradiation.

Patient preparation: For exenteration of the pelvis, patients undergo laboratory tests and a physical evaluation with pelvic and rectal exams. Imaging procedures include rectal and liver ultrasound, computed tomography (CT) scans, chest X-rays, bone scans, and magnetic resonance imaging (MRI) to determine the extent and spread of the cancer. A biopsy may confirm a recurrence of cancer. Immediately preceding the operation, the patient is given a bowel prep and antibiotics to prevent postsurgical infection.

In orbital exenteration, a physical exam, history, laboratory tests, and imaging methods, such as ultrasound, CT scans, angiography (to examine the orbital blood vessels), and biopsy are employed. Patients may undergo preoperative radiation and chemotherapy.

Steps of the procedure: Total pelvic exenteration is an ultraradical surgery comprising total (removal) of female reproductive organs (cervix, uterus, tubes, ovaries, and vagina), part of the lower urinary tract (urethra and bladder) and rectum, as well as the muscles that form the pelvic floor.

The process commences with a generous midline (vertical) incision in the abdomen, allowing exploration. During the operation, biopsies may be taken to assess the presence of cancer. If a tumor cannot be found or if pathology shows that the cancer has spread to the pelvic sidewall or has metastasized to the lymph nodes, then the procedure should be discontinued.

If the process continues, pelvic blood vessels are clamped, and the organs are removed. Before the incision is closed, a urostomy and a colostomy may be performed. A urostomy diverts urine to a small pouch created from the small intestine, which is then connected to the abdominal wall so urine can pass through a stoma (small opening) for collection. A colostomy attaches the colon to the abdominal wall so fecal waste may exit the body via a stoma for collection in a small bag.

Variations of pelvic exenteration include anterior exenteration, in which the rectum is left intact, and posterior exenteration, in which the bladder and the urethra are spared. In male patients, the removal of the bladder and prostate is called a cystoproctectomy.

In orbital exenteration, all the contents of the globe, including the eyeball, surrounding tissues, and part of the bony orbit, are removed. In certain patients, the eyelids and conjunctiva may be spared. Less radical procedures include evisceration, which spares the extraocular muscles, and enucleation, in which the eye is removed while all other orbital structures are spared.

After the procedure: With pelvic exenteration, a drainage tube is placed into the incision site. Discharge, bleeding, and significant tenderness and pain are common for at least a few days. While side effects vary, they often include difficulty with urination, particularly if catheterization is involved. Stitches are removed before the patient is sent home, and pain medication is prescribed.

After orbital exenteration, most patients experience a headache for several days, which may dissipate with pain medications. An ocular ointment containing antibiotics and steroids may also be prescribed.

Risks: With pelvic exenteration, morbidity and mortality depend on the specific procedure and the condition of the patient. Older adults and those with comorbidities are most affected. Some complications, such as kidney failure, fistulas formation, and bowel obstruction, may occur during or after the procedure. Between 60 and 90 percent of patients experience at least a minor complication following pelvic exenteration, and around 60 percent experience a significant complication. The success of rectal anastomosis depends on the degree of resection and concurrent reconstructive procedures. Complications such as leaks and fistulas may occur in 30 to 50 percent of cases. Overall, a poor prognosis is associated with recurrence of cancer, a tumor larger than 3 centimeters, involvement of the resection margin or pelvic sidewall, and nodal metastasis.

With orbital exenteration, there may be ear pathology, sinusitis, chronic orbital pain that throbs, orbital cysts, and recurrence of cancer. A five-year survival rate of 55 to 65 percent has been observed.

Results: While pelvic exenteration may often be a lifesaving measure, patients should be made aware of postoperative sequelae to attenuate the psychological distress related to lifestyle changes such as dealing with permanent catheterization, a colostomy or urostomy, and loss of sexual functions. The services of a psychologist and sex therapist may be required. Additionally, various postoperative reconstructive procedures are available to support the pelvis or create a neovagina in female patients. Orbital exenteration requires that the patient adapt to a dramatic change in appearance and loss of eyesight in the affected eye. Wearing an eye patch is a popular option for many patients. After the site has healed, a temporary prosthesis, such as a plastic eye, may be used. Later, a permanent prosthesis may be attached.

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