Research Article
A Retrospective Analysis of Complications of Pelvic Exenteration
- A Single Institution Experience of 6 Years
*1Subbiah Shanmugam, 2Murali Kannan, 3Arul Murugan
1,2,3Centre for Oncology, Government Royapettah Hospital & Kilpauk Medical College, Chennai, India
INTRODUCTION
Pelvic exenteration is performed for advanced cancers of (2014) and varies based on the primary diagnosis. This
cervix, urinary bladder, vagina, rectum and post chemo aim of this study is to analyse the morbidity and mortality
radiation residue or recurrences that are localised to associated with pelvic exenteration procedures in our
pelvis. Distant metastasis is considered as a centre.
contraindication for the procedure. It involves radical
enbloc removal of pelvic organs including recto sigmoid
and urinary bladder and uterus and tubes. Pelvic
exenteration surgery may be anterior (uterus and urinary
bladder), posterior (uterus and rectum) or total (rectum,
uterus and urinary bladder) and patients require diversion
of urine or faeces or both depending on the type of
exenteration (ileal conduit/colostomy and wet colostomy –
common stoma for both urine and faeces). This can be
performed with a curative intent and sometimes for
palliation. The postoperative morbidity patterns change *Corresponding Author: Subbiah Shanmugam;
based on the type of exenteration and the diversion Professor and Head, Centre for Oncology, Government
procedures being performed. It is well known that, pelvic Royapettah Hospital & Kilpauk Medical College, Chennai,
exenteration is a highly morbid procedure, with metabolic, India. Email: subbiahshanmugam67@gmail.com, Tel:
gastrointestinal and urinary complications affecting most 9360206030;
patients. In spite of all these, the 5 year survival after pelvic Co-Authors Email: 2drmjmuralikannan@gmail.com;
exenteration procedures is 30-60% as per Westin et al 3
drarulramalingam@gmail.com
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years
Shanmugam et al. 031
Table 4: Comparison of complications between ileal It has been done traditionally as a curative procedure for
conduit/colostomy and Wet colostomy locally advanced and recurrent pelvic malignancies
Complications PE +IC/c PE + WC P- including that of cervix, vagina, urinary bladder, and
(n=26) (%) (n=21) (%) value* rectum. The contraindication doesn’t just stop with distant
Hypokalemia 26(100) 10(19.6) 0.11 metastasis, but, Bhangu A et al. (2013) elaborated poor
Urine leak 8(15.6) 3(5.88) 0.29 performance status, bilateral sciatic nerve involvement
Sepsis 8(15.6) 5(9.80) 0.68 and circumferential bone involvement also. Relative
Mortality 2(3.92) 1(1.96) 0.70 contraindications like vessel encasement and pelvic side
*Chi-square test wall involvement are to be managed with laterally
PE – pelvic exenteration; ic – ileal conduit; wc – wet extended endopelvic resections as described by Höckel M
colostomy; c-colostomy (2008). Patient’s performance status, physiological age,
diversion procedures, radiation exposure and the primary
Table 5: Morbidity and Mortality of Pelvic Exenteration in disease are the major factors that determine the morbidity.
various studies The most common indication for pelvic exenteration was
Series [2] Year No. of Morbidity Mortality carcinoma cervix post chemoradiation residue and
patients (%) (%) recurrence.
Benn et al 2011 54 44 -
Maggioni et al. 2009 106 - 0 Pelvic Exenteration remains the only curative procedure
for patients with recurrent cervical cancer after nonsurgical
Marnitz et al. 2006 55 38 6
treatment (Radiation with or without Chemotherapy) (Tixier
Goldberg et al. 2006 103 25 1
et al. 2010). Another condition where Pelvic Exenteration
Sharma et al. 2005 48 45 4
is appropriate is primary ovarian cancer in which resection
Berek et al. 2005 75 45 4 of the bladder and/or rectum is necessary to achieve free
Poletto et al. 2004 96 15.6 19.8 margins or optimal cytoreduction. Also, uterine cancer
Lke et al 2003 45 77.8 14.3 (Khoury-Collado et al. 2012) sometimes presents as a
Wiig et al 2002 47 38.29 13 locally recurrent neoplasia in which some irradiation of the
Our series 2019 51 33.3* 5.8 pelvis has already been performed as part of the primary
*major morbidity only treatment and for which a radical surgical approach is
necessary to pursue a curative treatment. Most of the
complications after Pelvic Exenteration are related to the
DISCUSSION pre-irradiated tissue condition. Pelvic Exenteration’s
postoperative mortality is described as less than 5%, but
This analysis brings out that the major morbidity and with a high morbidity rate (around 50%). Cases with
mortality following pelvic exenteration are 33% and 5.5.% involvement of the pelvic bone have classically been
respectively. Described for the first time by Brunschwig in considered as inoperable, although (Milne et al. 2013;
1948 (Botoncea et al. 2017), Pelvic exenteration Dobrowsky and Schmid 1985; Milne et al. 2014; Solomon
procedures were palliative in advanced gynaecological et al. 2014) reported 37 cases in which it was required.
malignancies. Later, it was considered to be curative in They achieved a 40% Overall Survival at 5 years
certain circumstances with a reasonable survival benefit. compared with an OS of 4% for chemo-radiotherapy.
Major advances happened when separate stoma for faecal
and urinary diversion were made. Laparoscopic assisted In our analysis of 51 patients, the most common cancer for
procedures improved postoperative wound morbidity. which it was done was that of cervix (72.5%) and post
Despite these developments, pelvic exenteration remains chemoradiation (49.01%) patients. Some of the
a high morbid procedure with significant complication both complications that were studied included hypokalemia,
intraoperatively and postoperatively. The mortality rates surgical site infections, urine leak and sepsis. The
are however around 5%. percentage of patients who had hypokalemia was 82.3%
overall. The surgical site infections were more common in
Pelvic exenteration refers to radical excision of the pelvic the Total pelvic exenteration with ileal conduit (66.6%) and
organs including internal reproductive organs, urinary mortality of 10% was seen in anterior pelvic exenteration
bladder, recto-sigmoid as described in Pawlik et al (2006). patients as a result of sepsis.
The major morbidity and mortality were 33.3% and 5.8% the only available surgical option in advanced stage
respectively in our study and was comparable with the disease. Sepsis has been the most common cause of
other studies such as Berek et al. and Marnitz et al. which mortality. Laparoscopy may improve outcomes but this
had a morbidity of 45% and 38% respectively and a needs larger studies for validation. It is important to stratify
mortality rate of 4% and 6% respectively. and select patients so as to minimize the degree of
morbidity and mortality associated with this procedure.
Hypokalemia was managed by oral and intravenous
potassium supplementation. Any patient who had a serum
potassium levels between 3 and 3.5 mmol/L was treated Source of Funding: None
with oral potassium (40 to 100 mmol of oral potassium per
day) and patients with serum potassium levels less than 3 Conflict of Interest: None
mmol/L were treated with intravenous potassium(20 to 40
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