Pelvic exenteration in gynecologic oncology: A single institution study over 20 years

Abstract

Objective

The profile of women with gynecologic malignancies treated with pelvic exenteration has changed since the initial description of this procedure. We sought to evaluate our experience with pelvic exenteration over the last 20 years.

Methods

Patients who underwent anterior, posterior, or total pelvic exenteration for vulvar, vaginal, and cervical cancer at Barnes-Jewish Hospital between January 1, 1990 and August 1, 2009 were identified through hospital databases. Patient characteristics, the indications for the procedure, procedural modifications, and patient outcomes were retrospectively assessed. Categorical variables were analyzed with chi-square method, and survival data was analyzed using the Kaplan–Meier method and log rank test.

Results

Fifty-four patients were identified who had pelvic exenteration for cervical, vaginal, or vulvar cancer. Recurrent cervical cancer was the most common procedural indication. One year overall survival from pelvic exenteration for the entire cohort was 64%, with 44% of patients still living at 2 years and 34% at 50 months. Younger age was associated with improved overall survival after exenteration (p = 0.01). Negative margin status was associated with a longer disease-free survival (p = 0.014). Nodal status at the time of exenteration was not associated with time to recurrence or progression, site of recurrence, type of post-operative treatment, early or late complications, or survival.

Conclusions

Despite advances in imaging and increased radical techniques, outcomes and complications after total pelvic exenteration in this cohort are similar to those described historically. Pelvic exenteration results in sustained survival in select patients, especially those that are young with recurrent disease and pathologically negative margins.

Introduction

Pelvic exenteration as originally described has historically been performed for recurrent gynecologic malignancies limited to the pelvis, specifically for recurrent cervical cancer. This radical procedure involves en bloc resection of the uterus, cervix, vagina, adnexa, lower urinary tract, and rectosigmoid colon depending on the extent of the disease. Although variations exist, a urinary conduit and an end colostomy are commonly created after total exenterative procedures. Even though this procedure is potentially curative, it comes with significant risks, associated morbidity and impact on quality of life. Procedure-related mortality is approximately 3–5%, and morbidity is also high with complication rates approaching 60% [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12].

Since its first description by Brunschwig in 1948, the procedure has undergone modifications and indications have changed [13], [14]. Advances such as laparoscopic evaluation for feasibility and even laparoscopic exenterations have been described [6], [15], [16], [17]. The obesity epidemic and an aging population may influence both who is a candidate for a pelvic exenteration as well as surgical and survival outcomes [3], [4], [18], [19], [20], [21]. Factors such as tumor size, nodal involvement, sidewall fixation, and margin status that have previously caused surgeons to abort exenterative procedures are now being challenged in some institutions due to suspicions that survival may still be improved even with the presence of these adverse prognostic factors [2], [4], [5], [6], [9], [18], [20], [22], [23]. Additionally, advances in bioavailable grafts and novel surgical techniques have allowed for refinements in vaginal and abdominal reconstruction [11], [12], [14], [24], [25], [26], [27], [28].

The purpose of this study was to evaluate the profile, indications, procedures, and outcomes in women with vaginal, vulvar, and cervical cancer treated with pelvic exenteration at our institution over the last 20 years.