The place of pelvic exenteration as a cytoreductive procedure in advanced gynaecologic malignancies

For now 60 years pelvic exenteration is in the armamentarium of pelvic surgeons for the treatment of advanced pelvic malignancies. The biology of malignant tumors originating in the pelvis locoregional tumor progression and only late stage distant spread was the basis for the development of a radical surgical technique removing the tumor en-bloc with the adjacent pelvic organs. The original procedure described by Brunschwig in 1948 comprised the resection of rectum and bladder followed by a “wet” colostomy with implantation of both ureters into the colon. Originally described for palliation of symptoms this procedure was initially afflicted with a high surgical mortality and morbidity, but on the other hand became the only surgical option offering cure for advanced stage and recurrent pelvic tumors. Over the years, improvements in perioperative management and surgical technique modified the procedure including continent reconstruction techniques for bowel and bladder making the operation more acceptable for patients. To date more than 95% of patients not only survive the procedure, but may also encounter 5-year survival rates of 40% or more depending on the individual patient selection criteria. This improvement in outcome parameters is paralleled by an increase Correspondence/Reprint request: Dr. Markus C. Fleisch, Department of Obstetrics and Gynaecology, HeinrichHeine-University, Moorenstr. 5, D-40477 Düsseldorf, Germany. E-mail: Fleisch@uni-duesseldorf.de Markus C. Fleisch et al. 180 in continent urinary and intestinal reconstruction techniques which have made pelvic exenteration in appropriately selected cases not only acceptable but indispensable for the treatment of advanced gynaecologic malignancies. Introducing the concept of pelvic exenteration The concept of pelvic exenteration (PE) goes back to the 1940s when some centers in the US developed a surgical technique to treat locally advanced or recurrent pelvic cancers. The concept was based on the observation that tumors in the small pelvis, especially cervical and rectal cancers, have common biological features. They show locoregional invasion and metatastatis but distant metastasis only occur at late stage disease as tumors only rarely spread by hematogeneous route. Tumor persistence or recurrence within the pelvis is the major cause of death in patients suffering from cervical cancer (1). Patients with advanced or recurrent disease in the pelvis frequently develop infiltration of neighbouring organs like urinary bladder, ureter or intestine resulting in urinary complications including obstruction, fistula formation, uraemia or intestinal obstruction with ileus and/or fistula formation. These observations allowed the conclusion that an ultra-radical local therapy of advanced or recurrent pelvic malignancies might not only relief symptoms or prevent complications, but might also have significant impact on patients’ prognosis. The development of the concept of PE is traditionally credited to Alexander Brunschwig (*1901-†1969) (2) who published his first report on this technique in 1948 (3). He described an en-bloc resection of the pelvic viscera including rectum and anus, urinary bladder and parts of the perineum for the treatment of recurrent cervical cancer. Intestinal and urinary deviation was provided in form of a wet colostomy. Surgical mortality (death within 30 days post surgery) of this procedure at that time was high (23%) and longterm survival was short. Over the past 60 years numerous modifications to pelvic exenteration have been introduced with respect to patient selection criteria, perioperative management, surgical technique and methods for the reconstruction of bladder and bowel function. The initial “total” pelvic exenteration had been modified into a procedure preserving either the rectum (i.e. anterior PE) or bladder (i.e. posterior PE). Still, in appropriately selected patients, pelvic exenteration is considered to be the only therapeutic option offering cure. In the following paragraphs of this chapter we are going to describe the initial surgical technique, its potential indications and modifications over time. We will summarize the published studies with special emphasis on outcome parameters and will highlight current indications and potential future Pelvic exenteration for advanced gynaecologic malignancies 181 prospects for this challenging surgical procedure. As in the field of gynaecologic oncology patients with cervical and endometrial cancers represent the largest group of patients undergoing PE this review will focus on these two entities.