Pelvic exenteration plays an important role in the care of patients with advanced pelvic malignancies. Throughout 50 years of constant evolution, it has been labeled as the “gold standard” treatment for highly developed and not disseminated pelvic lesions. The procedure was first described by Alexander Brunschwig,1
but similar techniques were already being performed independently at hospital centers in North America. In the early 1940s, even prior to the actual technique being described and published worldwide, Eugene Bricker – who developed the earliest method of bladder substitution7
– believed that exenterative surgery would provide a better outcome when used for the treatment of rectal neoplasms instead of cervical cancer, due to fact that disease-free margins were obtained with greater ease.
In Mexico, the procedure is employed for the treatment of advanced pelvic malignancies, especially gynecologic tumors, which are a significant health issue in many Latin American countries. Colorectal and anal canal cancer occupies 30% of large bowel tumors8
and represents 2% of all malignancy-associated deaths in Mexico.9
This disease occurs in adult males beyond the sixth decade of life and presents with symptoms such as rectal bleeding and abdominal pain or discomfort.
In Mexico, PE for colorectal and anal cancer is seldom used as a means to treat a patient’s targeted lesion. This is due to the fact that these lesions should fulfill certain criteria: the neoplasm should be locally advanced, and it should present without distant metastases at the time of diagnosis. Boey11
stated: “An invasive tumor, penetrating contiguous pelvic viscera but without disseminated disease, confronts the surgeon in about 6% of large bowel cancers.”
Throughout history, PPE has been performed mainly to target anorectal malignancies. There is sufficient evidence to suggest that this exenteration type is usually used based on the specific organ of origin. A total of 51 patients were submitted to PPE (86.4%), while 10 underwent supralevator surgery, and 8 patients were submitted to TPE (14%). It is important to note that 53 patients were female (90%); this is not to suggest that colorectal and anal cancer occurs more frequently in women than men, but it clarifies the idea that this tumor type involves the female uterus, vagina, and rectum, therefore creating the ideal scenario for the use of the PPE procedure.
The primary goal of exenterative surgery is to remove the central tumor mass, despite its size. Neither cure nor palliation occurs if the tumor is left behind.12
In this series, disease-free margins were achieved in 50 patients (85%), and a remnant of the lesion was left in nine patients (15%). Futile attempts to save an adjacent organ can result in tumor transection, and incomplete resection is generally followed by prompt recurrence and death.13
Colon and rectal surgery is prone to complications, which reflect the physiologic and anatomical nature of the systems of the particular organ involved. For years, exenterative surgery has been known to account for an important number of postoperative complications. Moreover, although significant improvements in surgical techniques and in postoperative management of the patient have occurred, potential complications after PE are numerous. Reported morbidity rates vary widely in the literature, ranging from 13%-77%.14
On the other hand, while early studies reported operative mortality rates near 15%, more recent reviews report rates closer to 3%;18
this is where current improved care standards affect patient outcomes. An individual who undergoes radical pelvic surgery is at risk of early (up to 30 days after surgery) and late (later than 30 days after the surgery) complications. Our findings in this study are in line with these rates, as we obtained an overall morbidity of 49% and an overall mortality rate of 3%.
Complications related to urinary diversion are most frequently cited in the literature. Our most important complications were related with stoma and wound care; this is because PPE was the procedure performed in about 81.35% of patients in the study. PPE does not require urinary diversion; as a result, the most common complications noted among patients were wound dehiscence (15%), abscess or wound infection (12%), and stroma complications (10%). Some researchers have indicated that radiation therapy either preoperatively or post-procedurally is associated with higher morbidity rates, especially after the surgical event.16
Sixteen patients received radiation before the procedure, and eight of these patients submitted to radiation prior to the development of complications following radical pelvic surgery (50%). Of the 43 patients who received no radiation therapy at all, 21 patients developed complications (49%). We found no association between morbidity and prior radiation. There was no significant difference in the outcome of patients who underwent radiation therapy and those who did not receive such a treatment in this series; however, the effects of radiation on tissues and wound healing have been well known for years.18
Local tumor recurrence has been recorded in 20% to >50% of cases in many studies.18
In our experience, local recurrence occurred in 19% of patients, and distant recurrence occurred in 47% of patients. Positive nodes as well as tumor size were described as the most important determinants for local recurrence of colorectal cancers that have been submitted to exenterative surgery. Risk of local recurrence has been associated with regional lymph nodes in about 20%–25% of cases.21
Only one patient recurred out of the twelve patients, with palpable lymph nodes noted upon clinical examination. Local recurrence remains an issue with which surgeons are required to deal in order to achieve better survival rates.
Size, as stated previously, was defined as a determinant for local recurrence of tumors, but it has been demonstrated in recent years that size does not affect recurrence or survival unless residual tumor remains after surgery.14
At our institution, many patients arrive with huge masses and highly advanced disease. Mean tumor size of patients studied here was 6.56 cm (range, 2–14 cm), and although the literature has overlooked the value of tumor size as a determinant for survival, a large mass implies rectal penetration by tumor, nodal spread, or direct invasion of other tissues and organs, thereby directly affecting a patient’s survival rate; this is a common issue among the majority of our patients. Size, involvement of adjacent organs, previous surgery, and prior irradiation are all factors that may lead to substantial recurrence and to subsequent morbidity and mortality rates.
The primary role of radical pelvic surgery was palliation for advanced malignancies. Today, the main purpose of PE is to provide a cure; therefore, recurrence represents the most important failure of the procedure. Many authors have noted the absence of symptomatic pelvic recurrence even with visceral spread or carcinomatosis, such is the case in this series.2
The key item here is the gap in DFS. The Dukes’ classification correlates well with the latency period and OS. In this series, patients who recurred at Dukes’ B had a latency period of 34.6 months, those who recurred at Dukes’ C had a latency period of 8.21 months, and those who recurred at Dukes’ D had a latency period of 7.02 months (). Careful patient selection is imperative in order to improve outcomes.22
As was the case with recurrence rates, survival is also closely related to the disease stage, but patients with nodal disease and/or systemic spread will have a poor prognosis, and exenterative surgery is palliative, not curative.
A total of 46 patients received some type of cancer treatment in addition to surgery. While we do not have significant data pertaining to this subject, we noted that the only patients that presented with a positive OS were those who submitted to radiation after the procedure (a total of eight patients survived of the 15 who received the therapy), as opposed to patients who underwent the remaining treatments. Because the percentage of local and distant recurrence remains high, we think that this factor must be included in further discussions of PE as a standard treatment for advanced pelvic malignancies.
Pelvic sarcomas are rare tumors that originate from the stroma of pelvic viscera or from the retroperitoneum. Complete resection and tumor grade are the main prognostic factors associated with increased survival rates. In the present study, only one patient with sarcoma had undergone complete tumor resection and did not experience disease recurrence in the pelvis.25