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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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
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.
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.
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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 .
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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?