An exenteration is a major operation during which all the contents of a body cavity are removed. Pelvic exenteration refers to the removal of all the organs and adjacent structures of the pelvis, and orbital exenteration refers to the removal of the entire contents of the ocular orbit, sometimes including the eyelids as well.
Purpose
The pelvis is the basin-shaped cavity that contains the bladder, rectum and reproductive organs. (The reproductive organs include the ovaries, uterus and cervix for women and the prostate 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. For example, pelvic exenteration might be performed for primary rectal cancer because 5%-10% of primary rectal cancers spread to nearby pelvic organs. Pelvic exenteration is also indicated when cancer returns after an earlier treatment, as rectal cancer does in some 20% of cases. In women, the operation is additionally performed mostly for advanced and invasive cases of endometrial, ovarian, vulvar, vaginal and cervical cancer, and in men for aggressive prostate cancer.
Similarly, 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 basal cell carcinoma of the eyelids, for cancers that have spread to the optic nerve, or retinoblastomas larger than 1/4 inch (0.6 cm), as well as for large tumors of the eyeball.
Exenteration is not only a major operation for a patient to undergo, it is also technically very challenging, because it involves elaborate reconstructive surgery. It is a radical surgical procedure, but it often provides the only opportunity available for patients to eliminate the cancer and to prevent cancer from recurring.
Precautions
Pelvic exenterations should not be performed on patients diagnosed with inflammation of the roots of spinal nerves, sciatica, lymphedema, liver cancer, extrapelvic disease, and obstructions of the urinary tract.
All precautions applying to major surgery apply to exenterations, whether pelvic or ocular.
After pelvic exenteration, sexual intercourse should be avoided as directed by the surgeon. This is to allow the wound to heal properly.
Description
Pelvic exenteration
There are three types of pelvic exenterations.
ANTERIOR EXENTERATION.
This operation usually removes in women the uterus, bladder, vagina, and entire urethra. Patients selected for this operation have cancers that are located so as to allow the rectum to be spared. Vaginal reconstruction is performed afterwards if required. It is called anterior because it removes organs toward the front or in front of the pelvis.
POSTERIOR EXENTERATION.
This operation removes in women the uterus, ovaries, Fallopian tubes, anus, supporting muscles and ligaments, and all the vagina except a portion of the wall that supports the urethra. In men, the bladder is also removed. It is called posterior because it removes organs located in the back part of the pelvis.
TOTAL PELVIC EXENTERATION.
This operation removes the bladder, rectum and anus, supporting muscles and ligaments, together with either the prostate in men or the gynecologic (reproductive) organs in women. 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. For women, vaginal reconstruction is performed, which also helps reconstruction of the pelvic area. In both anterior and total pelvic exenteration, a urinary tract can be constructed.
The exact surgical procedure followed depends on the type of exenteration, but generally, all 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.
Orbital exenteration
This operation removes the eyeball and surrounding tissues of the orbit. The eye is surrounded by bone, so orbital exenteration is easier to tolerate than pelvic exenteration and patients may even undergo the operation as outpatients. Orbital exenteration with partial preservation of eyelids and conjunctiva can sometimes be achieved. Within two weeks of surgery, patients are usually fitted with a temporary ocular prothesis (plastic eye). Later, facial prostheses are also attached to the facial skeleton.
Both pelvic and orbital exenterations are performed using general anesthesia.
Preparing for the operation usually depends on the type of exenteration procedure selected. Most patients receive a combination of radiation therapy and chemtherapy before the operation. Surgery is typically performed approximately six weeks later.
In the case of pelvic exenteration, patients are required to clean as much waste as possible out of the large intestine, using various laxatives or enemas. This cleaning of the colon and rectum is required so as to eliminate stool and lower the level of bacteria, thus preventing infections after surgery. Antibiotics are also typically given to help sterilize the colon.
Aftercare
Pelvic exenteration
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. This is a major operation that requires at least a three-to five-day hospital stay. Side effects depend on the type of pelvic exenteration performed, but always include urination difficulty, especially if adjustment to a catheter is required, and a very painful lower abdomen.
Some exenterations require a temporary or permanent colostomy, meaning the creation of an opening (stoma) in the abdomen to allow solid waste to leave the body. Permanent colostomy may be needed, for example, if the rectum is removed. In such cases, the patient needs time to adjust and be taught how to irrigate, empty, clean and wear the colostomy bags.
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.
Ocular exenteration
After ocular exenteration, most patients have a headache for several days which goes away using medication such as tylenol. An eye ointment is also prescribed
that contains antibiotics and steroids to help the healing process.
Risks
No surgical procedure is risk-free. Complications are always possible, especially if the operation is major. As with any operation, possible exenteration risks include possible complications due to the anesthetic and wound infection.
In the case of pelvic exenteration, the following complications are also possible:
The following considerations also apply: 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:
Deardorff, W. W. and J. Reeves. Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery. Oakland: New Harbinger, 1997.
Shields, J. A. Diagnosis and Management of Orbital Tumors. St. Louis: W. B. Saunders Publishing Company, 1989.
PERIODICALS
Kennedy, R. E., R. Frezzotti, R. Bonanni, A. Nuti, E. Polito, G.Bonavolonta, S. Evers, P. Soros, R. Brilla, H. Gerding, I. W. Husstedt, and K. W. Dolphin. "Indications and surgical techniques for orbital exenteration." Advances in Ophthalmic Plastic Reconstructive Surgery 9 (1992): 163-173.
Kersten, R. C., D. T. Tse, R. L. Anderson. "The role of orbital exenteration in choroidal melanomas." Ophthalmology 92 (1985): 436-443.
Moffat, F. L. J. and R. E. Falk. "Radical surgery for extensive rectal cancer: is it worthwhile?" Recent Results in Cancer Research 146 (1998): 71-83.
Petros, J. G., P. Augustinos, M. Lopez, J. S. Spratt, W. J. Temple, E. B. Saettler, R. E. Hautmann, D. Turns. "Pelvic exenteration for carcinoma of the colon and rectum." Seminars in Surgical Oncology 17 (October-November 1999): 206-212.
Turns, D. "Psychosocial issues: pelvic exenterative surgery."Journal of Surgical Oncology 76 (March 2001): 224-236.
OTHER
Women's Health Matters. <http://www.womenshealthmatters.ca/centres/cancer/cervical/treatment/index.html>.
Information on eye cancer: Web sites: <http://www.EyeCancerBook.com/> and <http://eyecancerinfo.com/>.
Monique Laberge, Ph.D.
Anus
—The terminal orifice of the gastrointestinal (GI) or digestive tract which includes all organs responsible for getting food in and out of the body.
Catheter
—Long thin tubes that carry urine from the kidneys to the bladder.
Conjunctiva
—A clear membrane that covers the inside of the eyelids and the outer surface of the eye.
Cyst
—Any closed cavity surrounded by a wall made up of cells joined by cementing substances and that contains liquid or semi-solid material.
General anesthesia
—Method used to stop pain from being felt during an operation. General anesthesia is the most powerful type and is generally used only for major operations, such as brain, neck, chest, abdomen, and pelvis surgery.
Ocular orbit
—Bony cavity containing the eyeball.
Resection
—The complete or partial removal of an organ or tissue.
Rectum
—The last part of the large intestine (colon) that connects it to the anus.
QUESTIONS TO ASK THE DOCTOR
Why do I need the operation?
What are the benefits of having the operation?
What are the risks of having the operation?
What if I don't have this operation?
Where can I get a second opinion?
What has been your experience in doing the operation?
