Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year experience at UCLA

doi:10.1016/j.ygyno.2005.05.034

Gynecologic Oncology

Volume 99, Issue 1, October 2005, Pages 153-159

https://doi.org/10.1016/j.ygyno.2005.05.034 Get rights and content

Abstract

Objective.

To retrospectively assess the outcome of patients undergoing pelvic exenteration for recurrent or persistence gynecologic malignancy and the clinical features associated with outcome and survival.

Methods.

A review was conducted of patients who underwent pelvic exenteration over a 45-year period (1956–2001) at the UCLA Medical Center. Numerous clinical variables were analyzed, including time to relapse, type of exenteration and reconstructive operation, early (<60 days) and late (>60 days) morbidity, and survival. Variables were analyzed by chi-square and life-table analysis.

Results.

Seventy-five patients (ages 26–74 years) had persistent cervical and vaginal (67) and uterine (8) cancer. Forty-six patients underwent total exenteration, 23 anterior, and 6 posterior. Sixty-nine (92%) patients underwent urinary diversion or neocystoplasty, 54 (72%) patients had a simultaneous neovagina created, and 43 of 52 (83%) patients who had a low colon resection had a primary reanastomosis. Twenty-nine patients died from recurrent malignancy, 28 were alive without disease, 11 were alive with disease, and 7 died from other causes at last follow-up. Survival for patients with cervical and vaginal cancer was 73% at 1 year, 57% at 3 years, and 54% at 5 years. Survival for patients with uterine cancer was 86% at 1 year, 62% at 3 and 5 years. The most frequent early morbidity was urinary tract infection, wound infection, and intestinal fistula; the most frequent late morbidity was urinary tract infection and intestinal obstruction.

Conclusion.

Pelvic exenteration in patients with recurrent cervical and vaginal malignancy is associated with a durable > 50% 5-year survival. Simultaneously performed pelvic reconstructive operations with a continent urinary diversion, the creation of a neovagina, and the reanastomosis of the colon with the formation of a J-pouch is now our standard; and these operations tend to improve the outcome of patients. Based on our initial experience, recurrent uterine corpus cancer in young women (< 55 years) should be included as an indication for the surgery.

Introduction

Pelvic exenteration was first reporteds in 1948 as a palliative operation for advanced pelvic carcinoma by Dr. Alexander Brunschwig, whose initial manuscript noted that, of 22 patients studied, 5 died from the operation itself [1]. More recent operative mortality data of 0–5.3% are due to improvements in patient selection, surgical techniques and reconstructive measures, perioperative and postoperative care, blood product use, antibiotic availability, and intensive medical management [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17].

The classical indication for pelvic exenteration is the intent to cure persistent or recurrent cervical malignancy after prior pelvic radiation therapy. Fundamentally, the disease must be confined to the central pelvis such that it appears to be completely resectable and there are no distant metastases [14]. The 5-year survival rates following pelvic exenteration performed with curative intent are 20–73% [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]. Significant clinical factors affecting survival include the length of time from the initial radiation therapy to exenteration, the size of the central tumor, and the presence of pelvic sidewall fixation based on clinical examination [10], [14].

Techniques for pelvic reconstruction have evolved over the past several decades to include the performance of continent urinary conduits, the primary reanastomosis of the rectosigmoid colon, and creation of a neovagina via various operations [14], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33]. The goal is to afford the patient the opportunity to have a reasonable quality of life in addition to providing the chance for a cure [29], [30], [31], [32], [33].

The purpose of this retrospective analysis of pelvic exenteration is to determine the factors associated with morbidity and survival over a 45-year period at the UCLA (University of California at Los Angeles) Medical Center.

Section snippets

Methods

Medical records and pathology were reviewed for all patients accessible by the UCLA Tumor Registry, the Departments of Medical Records and Pathology, who underwent pelvic exenteration at UCLA from 1956 to 2001. Approval for this retrospective study was given by the UCLA Medical Institutional Review Board. Our search found 75 patients who had undergone pelvic exenteration with curative intent for cervical, vaginal, and endometrial cancers. Ovarian cancer patients were not included. Cervical and

Results

Seventy-five patients from 1956 to 2001 underwent pelvic exenteration for persistent cervical (53), vaginal (14), and uterine (8) cancers (Table 1). Fourteen patients were ages 26–39 years, 17 were 40–49 years, 13 were 50–59 years, 18 were 60–69 years, and 5 were over 70 years, with the eldest at age 74 years. Prior to developing recurrent disease, 17 patients had stage I cancers, 23 had stage II, 18 had stage III or IV, and 17 patients had an unknown stage. Forty-six (61%) patients underwent

Discussion

Pelvic exenteration has long been used as a “last option” surgical therapy, classically for recurrent or persistent cervical cancer in the central pelvis after less radical surgery and radiation have failed. Our findings of a 54% 5-year survival in these patients over 45 years at the UCLA Medical Center are consistent or better than the published survival data [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17].

Pelvic exenteration is a suitable operation for

Acknowledgment

Supported by a grant from the UCLA Women's Reproductive Cancer Program.

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^☆: Presented at the Society of Pelvic Surgeons, 53rd Annual Meeting, Pittsburgh, PA, November 2003.

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Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year experience at UCLA☆

Abstract

Objective.

Methods.

Results.

Conclusion.

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgment

Am. J. Obstet. Gynecol.

Am. J. Obstet. Gynecol.

Am. J. Obstet. Gynecol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Am. J. Obstet. Gynecol.

Gynecol. Oncol.

Gynecol. Oncol.

Complete excision of pelvic viscera for advanced carcinoma

Cancer

Major morbidity after pelvic exenteration: a seven year experience

Obstet. Gynecol.

Anterior pelvic exenteration

Gynecol. Oncol.

Pelvic exenteration, University of Michigan, 100 patients at 5 years

Obstet. Gynecol.