Exenteration





Definition

Exenteration is a major operation during which all the contents of a body cavity are removed. Pelvic exenteration refers to the removal of the pelvic organs and adjacent structures; orbital exenteration refers to the removal of the entire eyeball, orbital soft tissues, and some or all of the eyelids.


Purpose

The pelvis is the basin-shaped cavity that contains the bladder, rectum, and reproductive organs. The internal reproductive organs include the ovaries, fallopian tubes, uterus, and cervix for women, and the prostate and various ducts and glands for men. Pelvic exenteration is performed to surgically remove cancer that involves these organs and that has not responded well to other types of treatment.

A large abdominal incision exposes abdominal and pelvic contents for pelvic exenteration (A). Contents of the lower abdominal cavity, including the rectosigmoid colon, prostate and seminal vesicles (if male), bladder, and any pelvic tumors are removed (B). (Illustration by GGS Inc.)
A large abdominal incision exposes abdominal and pelvic contents for pelvic exenteration (A). Contents of the lower abdominal cavity, including the rectosigmoid colon, prostate and seminal vesicles (if male), bladder, and any pelvic tumors are removed (B). (
Illustration by GGS Inc.
)
Pelvic exenteration is also indicated when cancer returns after an earlier treatment. In women, the operation is performed mostly for advanced and invasive cases of endometrial, ovarian, vaginal, and cervical cancer; for aggressive prostate cancer in men; and rectal cancer in either sex.

Orbital exenteration is performed to remove the eye and surrounding tissues when cancer of the orbital contents cannot be controlled by simple removal or irradiation. It is often the only course of treatment for advanced cancers of the eyelid, eyeball, optic nerve, or retina.

Exenteration is a major operation for both patient and surgeon; it is technically very challenging because it involves elaborate reconstructive surgery. Although it is a radical surgical procedure, exenteration often provides the only opportunity available for patients to eliminate the cancer and to prevent it from recurring.


Demographics

No data are available regarding the demographic nature of patients undergoing exenteration, given the numerous conditions that may warrant it. Cancer affects individuals of any age, sex, race, or ethnicity, although incidence may differ among these groups by cancer type.


Description

Both pelvic and orbital exenterations are considered to be major surgery and are performed under general anesthesia. The exact surgical procedure performed depends on the type of exenteration.


Pelvic exenteration

Pelvic exenterations start with an incision in the lower abdomen. Blood vessels are clamped and the organs specified by the procedure are removed. The site of incision is then stitched up. There are three types of pelvic exenteration: anterior, posterior, and total.

ANTERIOR EXENTERATION. This operation is called anterior exenteration because it removes organs toward the front of the pelvic cavity. It usually involves the removal of the female reproductive organs, bladder, and urethra. (In males, an operation that removes the bladder and prostate is called a cystoprostatectomy). Patients selected for this operation have cancers in areas that allow the rectum to be spared.

A new method for excreting urine must be created. One common approach, called an ileal conduit, diverts the ureters to a pouch made of small intestine, which is then connected to the abdominal wall. Urine exits the body through a small opening called a stoma, and collects in a small bag attached to the body. Vaginal reconstruction may also be performed during the exenteration, or in a later procedure.

POSTERIOR EXENTERATION. Posterior exenteration removes organs that are located in the back part of the pelvic cavity. These include the reproductive organs, plus the lower part of the bowel; the bladder and urethra are kept intact. A patient who has undergone posterior exenteration will require a colostomy , a procedure that connects the colon to the abdominal wall; waste exits the body through a stoma and is collected in a small bag.

TOTAL PELVIC EXENTERATION. This operation removes the bladder, urethra, rectum, anus, and supporting muscles and ligaments, together with the reproductive organs. Total pelvic exenteration is performed when there is no opportunity to perform a less extensive operation, because of the location and size of the cancer. A urinary stoma and a colostomy stoma will be created to collect waste.


Orbital exenteration

This operation removes the eyeball and surrounding tissues of the orbit. (Since the eye is surrounded by bone, orbital exenteration is often easier to tolerate than pelvic exenteration.) Orbital exenteration with partial preservation of eyelids and conjunctiva can sometimes be achieved. After the surgical site has healed, patients can be fitted with a temporary ocular prosthesis (plastic eye), although many patients prefer to wear an eye patch. Later, facial prostheses can be attached to the facial skeleton.


Diagnosis/Preparation

The evaluation of patients before pelvic exenteration includes a thorough physical examination with rectal and pelvic examination. Endorectal ultrasound and imaging studies such as computed tomography scans ( CT scans ) and magnetic resonance imaging (MRI) are routinely used to obtain pictures of the abdominal and pelvic areas and evaluate the spread of the cancer.

Ocular ultrasound examination, CT scan, and angiography evaluation (used to image blood vessels) are usually performed to prepare for orbital exenteration.

Some patients begin treatment with chemotherapy and/or radiation before the procedure. Surgery is typically performed approximately six weeks later.

In the case of pelvic exenteration, the patient will be given a bowel prep to cleanse the colon and prepare it for surgery. This procedure is required to lower the level of intestinal bacteria, thus helping to prevent post-surgical infections. Antibiotics are also typically given to help decrease bacteria levels in the bowel.


Aftercare

Pelvic exenteration

After a pelvic exenteration, a drainage tube is inserted at the site of the incision. There usually is some bleeding, discharge, and considerable tenderness and pain for a few days. At least a three- to five-day hospital stay is usually required. Side effects depend on the type of pelvic exenteration performed, but often include urination difficulty, especially if adjustment to a catheter is required; and a very painful lower abdomen.

Stitches are usually removed from the skin on the third day, or before the patient is sent home. A prescription for pain medication is usually given as well as instructions for follow-up care.


Ocular exenteration

After ocular exenteration, most patients have a headache for several days, which goes away with over-the-counter pain medications. An eye ointment is also prescribed that contains antibiotics and steroids to help the healing process.


Risks

As with any operation, there is a risk of complications due to anesthesia, wound infection, or injury to adjacent organs or structures.

In the case of pelvic exenteration, the following complications are also possible:

  • hemorrhage that may require a blood transfusion
  • injury to the bowel
  • urinary tract infection
  • urinary retention requiring permanent use of a catheter
  • bowel obstruction

After removal of the reproductive organs, women will no longer have monthly periods nor will they be able to become pregnant. For men, surgery involving the prostate and the nerves around the rectum may also result in the inability to produce sperm or to have an erection.

In the case of orbital exenteration, the following complications have been known to occur:

  • growth of an orbital cyst (rare)
  • chronic throbbing orbital pain
  • sinusitis (nasal stuffiness)
  • ear problems
  • reoccurrence of malignancy

Normal results

During and after recovery from exenteration, it is normal for a patient to undergo a period of psychological adjustment to the major change in lifestyle (e.g., learning to care for a urostomy or colostomy) or appearance (e.g., following orbital exenteration). It is important that all aspects of the procedure be discussed with the patient before undergoing surgery, and that any psychosocial distress that the patient experiences after exenteration be addressed.


Morbidity and mortality rates

There is a 30–44% chance of complications during pelvic exenteration, and the operative mortality rate ranges from 3–5%. About one-third of patients will experience such postoperative complications as bowel obstruction, fistula formation, inflammation or failure of the kidneys, narrowing of the ureters, or pulmonary embolism (a blood clot that travels to the lungs). The five-year survival rate after pelvic exenteration ranges from 23–61%. For patients who undergo pelvic or orbital exenteration, short- and long-term morbidity and mortality rates depend on the particular condition that required the procedure.


Alternatives

Exenteration is generally pursued only if no other less invasive options are available to the patient. Alternatives, however, include chemotherapy, radiation therapy, and more conservative surgery.

Resources

BOOKS

Yanoff, Myron, and Jay Duker. Ophthalmology, 1st ed. London: Mosby International Ltd., 1999.

PERIODICALS

Clarke, A., N. Rumsey, J. R. O. Collin, and M. Wyn-Williams. "Psychosocial Distress Associated with Disfiguring Eye Conditions." Eye 17, no. 1 (January 2003): 35–40.

Ramamoorthy, Sonia L., and James W. Fleshman. "Surgical Treatment of Rectal Cancer." Hematology/Oncology Clinics of North America 16, no. 4 (August 2002): 927.

Sevin, B. U., and O. R. Koechlie. "Pelvic Exenteration." Surgical Clinics of North America 81, no. 4 (August 1, 2001): 771–9.

Turns, D. "Psychosocial Issues: Pelvic Exenterative Surgery." Journal of Surgical Oncology 76 (March 2001): 224–36.

ORGANIZATIONS

American Academy of Ophthalmology. P.O. Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. http://www.aao.org .

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS-2345. http://www.cancer.org .

American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org .

OTHER

Husain, Amreen, and Nelson Teng. "Pelvic Exenteration." eMedicine, January 31, 2003 [cited April 5, 2003]. http://www.emedicine.com/med/topic3332.htm .

Monique Laberge, PhD Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


As exenteration is considered to be major surgery, the procedure is performed under the strict conditions that a hospital operating room affords. A team of physicians, nurses, and other health care workers are involved in the procedure. Pelvic exenteration may be performed by a gynecologist, gynecologic oncologist, urologist, and/or plastic surgeon. Orbital exenteration may be performed by an ophthalmologist and/or oculoplastic surgeon.

QUESTIONS TO ASK THE DOCTOR


  • Why is exenteration recommended in my case?
  • What organs or other structures will be removed?
  • In the case of pelvic exenteration, what methods of urinary/fecal diversion will be performed?
  • In the case of orbital exenteration, what are my options in terms of cosmetic prostheses?
  • What nonsurgical options are available to me?
  • How long after surgery may I resume normal activity?


User Contributions:

mandy gage
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May 22, 2006 @ 10:10 am
my daughter is about to have this type of operation having an early relapse form cervical cancer. I have found this article to be very informative and helpful in this very stressful time. It has answered alot of my questions and also given me questions to ask my daughters doctor. I will definately relate to this information again.
Faith Pattison
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Aug 16, 2007 @ 7:19 pm
I am potentially about to undergo the Posterior Exenteration and the results are only 4 days away now. I would like this thank the preparers of this webpage for providing such helpful information. It is a very stressful and upsetting time for me and for my family and friends and we have all been provided with detailed information which we can use to further improve our knowledge of my most likely next medical route. I suffered from Cervical Cancer last year which was treated with both radiotherapy and Chemotherapy so I am able to relate to the information written here. If I am given a choice next week of the posterior exenteration or further Chemotherapy I would certainly chose the posterior exenteration in the knowledge that I am well prepared mentally with plenty of background knowledge not only of the procedures but also of many of the risks involved in the procedure.
Thank you. F Pattison, York, UK
B. Forner
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Oct 26, 2007 @ 3:15 pm
I am surprised to read that hospital stay is supposed to be 3-5 days. To my knowledge - and I work closely together with a gynaeco-oncologic centre performing exenterations routinely - postoperative stay is 3 weeks if no major complications occur and possibly much longer in the case of severe complications.
Dr. B. Forner, gynaecologist
Remy Ellen Edwards
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Jul 8, 2008 @ 4:16 pm
The hospital stay mentioned is misleading...I do a lot of research to educate myself as a cancer patient,; and not too long ago I went in to see my doctor for follow up visit and I was told to have my cervical cancer back. Pelvic Exenteration was the only option available in my case (according to him); and I was told that hospital stay is two weeks at the least, and could be longer depending on my response to treatment. I encourage everyone to be vigilant with their own healthcare and educate themselves. You owe that to yourself and nobody else.
Karen
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Aug 20, 2008 @ 4:16 pm
I have been told that I will need a pelvic exenteration. Can someone email me back who is a woman and who has had the surgery? Please tell me what your life is like now. What are some of the questions I need to ask my doctor. What kind of cancer do you have or had. I had cervical cancer almost two years ago and it is now reappeared with a tumor on my spine.
ALICE
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Sep 26, 2008 @ 9:21 pm
i HAVE HAD A PELVIC ECENTERATION BACK IN FEB 22 2008... i HAD CERVICAL CANCER AS WELL.. I WILL NOT SUGAR COAT TO ANYONE I WILL NOT TELL PEOPLE THAT THE SURGERY IS EASY IS VERY HARD TO DEAL WITH I HAD A LOT OF SIDE EFFECTS I WAS IN THE HOSPITAL FOR A TOTAL OF 6 WEEKS i STILL HAVE A NURSE COME TO MY HOME EVERY THREE DAYS TO HAVE CARE OF MY WOUND CARE... iF I COULD TO DO THIS ALL OVER AGAIN i WOULD i SAY THIS BECAUSE THIS WAS MY ONLY CHANCE TO LIVE A LONG LIFE YES IT IS LIFE CHANGING & ITS VERY HARD AT TIMES TO DEAL WITH ALL THE CHANGES bUT i THANK GOD i AM STILL HERE FOR MY SON & THE REST OF MY FAMILY ALL MOST OF ALL FOR MYSELF... aNYBODY WHO IS ABOUT TO UNDER GO THIS SURGEY PLEASE FEEL FREE TO CONTACT ME I WOULD BE MORE THAN HAPPY TO DISCUSS THIS MATTER WITH ANYONE I HAVE ONE MORE THING TO SAY REGARDING THIS SURGEY MAKE SURE YOUR DOCTORS HAVE ALOT OF EXPEREINCE IN DOING THIS SURGEY ALSO DO YOUR HOME WORK REGARDING THE HOSPITAL YOU WILL BE HAVING THIS SURGERY IN ALSO WILL AS DO A BACKROUND CHECK ON ALL DOCTORS INVOLVED AS FAR TO MAKE SURE NONE OF THEM HAVE MILPRACTICE SUITS AGAINST THEM THIS PRODCEURE IS VERY SERIOUS SO MAKE SURE YOU TRUST YOUR DOCTORS COMPLETELY GOD BLESS
Jody
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Oct 20, 2008 @ 5:17 pm
Karen,

Did you have this surgery? I see my MD tomorrow for recurrent cervical cancer and think this might be my only chance at survival. Wanted to know how you are doing. Is there another site for this also?

Thank you,
Jody
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Jul 11, 2010 @ 9:21 pm
I recently had a pelvic exenteration in April, and like Alice says it is not an easy surgery. I just had my first urinary track infection with my urinary diversion. I too have a young child like Alice above, so I didn't give the procedure much of a second thought. Now I wish I would have gotten a third opinion, but I don't think cervical cancer doesn't give you much deciding time before it spreads elsewhere where it is much more difficult to be treated.

Hopefully this is my cure, it should be I have gone through enough in 1 year.
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Aug 17, 2010 @ 1:13 pm
I am a male of 36years young and was diagnosed with a rectal gist tumor, I have to have a pelvic excenteration eventually has it is the only cure,i was wondering if any male patint has had this operation, and what the prognosis is, and how normal life is
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Oct 11, 2010 @ 10:10 am
They are telling me that this is the next step for me. I am 59 years old female have had cancer in the anal area from a doctor leaving a hole in the area when i had surgery three years ago for cancer of the area between my legs and lymph node cancer and removal of. I am scared shitless as I dont heal well and don't like pain all that much. I say forget it and my son is flipping out my daughters think that it is a lost cause. I know the anesthesy dept wants me to have and epidural for two or three days following surgery. The doctors worry as to how to close up all the holes left from the surgery. I just don't know what to do. I have a colonosopy now and got used to it pretty well but to have the one for pee has me freaked out. Is it worth it?
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Sep 20, 2011 @ 9:21 pm
I'm a survivor of total abdominal/pelvic exenteration, I had my surgery in June, 2005, first and foremost it is a very rough surgery, I had chemotherapy and internal radiation 4 years prior to that for cervical cancer and it came back in 2005, my only option was to take chemo again and maybe give me 2 years top, the abdominal/pelvic exenteration is a 50/50 chance, you might make it and you might not, it all depends on the will power each person has. I was in good physical condition, my age at the time was 46. Instead of using a colostomy, I choice to have reconstruction done to actually use my own internal organs, my bladder was removed totally and a neobladder was reconstructed out of my large intestine, all works well. My doctor informed me to get papers ready for disability because I would not be able to work for quite some time and to get all my matters in life arranged just in case I wouldn't make it. The surgery alone took about 10 hours, I was in ICU for about 3 days and in the hospital for 42 days, I was sent home due to infections and continued with my mother's care and home health care. I came home with 5 tubes inserted in me, 3 drain tubes, catheter and stents in my kidneys until my neobladder was sealed and healed before using. I was accepted for disability, however, after 3 months I started to go back to work for 2 hours a day, then 4 hours a day, 6 hours a day and after 7 months I went back to work full time. For about 1 year after the surgery, I continued to have UTI's, and that was mainly due to the neobladder. My doctor put me on a daily antibiotic to help keep infections from continuing, however, that never really cured them. So after about a year of medications, etc. the best possible solution is to self cath. I am able to urinate on my own, however, I don't completely empty, therefore I self cath 3 times a day and have been infection free since I started catheterizing. I did lose some sensation in the pelvic area, however, I'm still able to have intercourse. In the evenings thou I need to wear diapers just because of leakage during the evening hours. My bladder only holds about 13 oz., which is the size of a can of soda, so it's not much, I don't have the sensation as to when I need to urinate, so therefore I make a mental block to go every 2 hours and have no problems with leakage, however, in the evenings, my sleep is more important then to set an alarm to go to the restroom every 2 hours. Yes, it is a change of life style, but I'm alive and living a normal life. My family, partner and doctors are the only ones that really know that I wear diapers in the evenings. I am active in sports, play softball, volleyball, golfing, fishing, etc. and yes you can liVe a normal life after this surgery. If anyone has any questions concerning this procedure, please do not hesitate to contact me via e-mail. GOOD LUCK AND GOD BLESS!!!
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Oct 24, 2011 @ 3:15 pm
Hi, Its looking like I may now need an extenteration after undergoing radio/chemo earlier this year. Where is the best lace to go in the uk, interested in hearing more on any experiences you can share. Helen
hazel
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Jan 19, 2012 @ 7:07 am
Hi Helen
I am about to find out whether i am having an excenteration re a secondary bowel tumour that has slid it's way into my pelvis. Funnily enough the nurse just called whilst i was writing this to book scans. I am with Mr Mark George at Guys who is apparently one of the best surgeons in the country but it is colorectal so i don't know if this helps you or if i am too late with this response. Good Luck!
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May 4, 2012 @ 3:03 am
My neice just had this surgery today. All I can say is you are all so courageous and God bless each and everyone of you.
Neti
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Jan 28, 2013 @ 3:03 am
Thank you all for sharing this information God bless you and all the best to you. My sister has been told she is going to need a total pelvic exenteration she has a stage 3 cervical cancer. She did chemo and radiation with no success . I would like to know by having done the surgery did the doctor tell you that you are cancer free? or there are X amount of years to live? I was just wondering what if my sister refuses to go thru will she die . Please let me know we have to go for consultation next few days!
God bless!
Jen
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Jul 9, 2013 @ 4:16 pm
I had a total pe a year ago after my cervical cancer did not respond to radiation & chemo. I went from a 0% chance of survival with 3 months to live to an 88% survival rate one year later. If I make it another year my survival rate goes to 95% and yes the doctor says the cancer is GONE. It is a huge surgery and a huge decision to have it. hospital stay is a minimum of 2 weeks depending on complications. I was there for 2months. Total recovery time is at least 6 months depeding on complications from not only the surgery but I had effects of radiation that compounded the problem. The stomas are the hardest thing to get used to and there is lot of pain for a very long time but it is a chance for a cure where none was before.
Rich
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Nov 27, 2013 @ 9:21 pm
I'd really like to hear from a man who has had this. The doctors are telling me this is my only hope (and a very small hope at that) for a cure of prostate cancer that has spread throughout the pelvic area. To be honest, I'm incredibly scared and considering not having the surgery and moving on to extending my life as long as possible.
michelle
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Dec 10, 2013 @ 1:13 pm
I would love to thank everyone here , im scared as , just reading what you ladies have gone through , and what im about to go through ,i hope i can be as brave as you all , but in the end we dont really have much of a choice ,i dont think we would be normal if we werent scared,good luck everyone , god bless
Lora
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Aug 24, 2014 @ 4:16 pm
PE is a life saving procedure. My husband has received the best of care. Make no mistake,it is life changing,but life remains. His PE was 2012 after chemotherapy and radiation. You need family and friends for support. Radiation was 5 days a week and a chemotherapy pump. There is alot of prep,like a possible port for easy IV access,alot of scan. As a care giver you have to push nutrition,ensure and boost
you need to understand sometimes nothing goes as planned,but please remember the love and the sickness and heath vows. I have to go,plan to return soon,blessing to all
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Oct 26, 2014 @ 1:13 pm
My husband has just had a PE. He is very weak. It is definitely life changing, but life remains. He had the procedure on Oct 9th. He has a urostomy and a colostomy. He is just 2 weeks post op. He is up walking around still adjusting to his new life style. e definitely does not have an appetitie however I am pushing Boost and Ensure. He eats a little food but not much. He had chemo and radiation prior to the surgery and he had radiation during surgery. We pray that he continues to do well. God Bless all who opt for this procedure. It is definitely hard on the patient.

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