Difference between revisions of "Pelvic exenteration"
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A pelvic exenteration is a radical procedure in which multiple organs are removed from the pelvis as a curative or palliative measure for recurrent or locally advanced locally invasive pelvic cancers (vaginal, uterine, cervical, vulvar, rectal, urethral, prostate). A total pelvic exenteration includes a en-bloc resection of the reproductive organs as well as the pelvic sections of the gastrointestinal tract and genitourinary tract. These include the sigmoid colon, rectum, anus, bladder, and urethra. In males, reproductive organs include the prostate and seminal vesicles. In females, this includes the uterus, fallopian tubes, ovaries, cervix, vagina, and possibly the vulva.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2015|isbn=978-1-4511-7660-5|location=Philadelphia, PA|pages=781-786}}</ref> | |||
In female patients a pelvic exenteration can be anterior (removal of reproductive organs and urinary tract, sparing the rectum) or posterior (removal of reproductive organs and gastrointestinal tract, sparing the urinary system).<ref>{{Citation|last=Grimes|first=W. R.|title=Pelvic Exenteration|date=2026|url=http://www.ncbi.nlm.nih.gov/books/NBK563269/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=33085416|access-date=2026-03-11|last2=Dunton|first2=Charles J.|last3=Stratton|first3=Michael}}</ref> | |||
This procedure often results in an end colostomy (to descending colon to anus anastomosis is sometimes possible), a continent or incontinent urinary diversion, and a muscle flap for perineal and/or vaginal reconstruction.<ref>{{Cite web|title=UpToDate|url=https://www.uptodate.com/contents/exenteration-for-gynecologic-cancer?search=pelvic%20exenteration&source=search_result&selectedTitle=1~18&usage_type=default&display_rank=1|access-date=2026-03-11|website=www.uptodate.com}}</ref> | |||
As the aim of this procedure is curative, the procedure may be aborted if the initial exploratory laparotomy finds the tumor burden to be too extensive for resection, or if positive lymph nodes are found.<ref name=":0">{{Cite journal|last=Carvalho|first=Filipe|last2=Qiu|first2=Shengyang|last3=Panagi|first3=Vasia|last4=Hardy|first4=Katy|last5=Tutcher|first5=Hannah|last6=Machado|first6=Marta|last7=Silva|first7=Francisca|last8=Dinen|first8=Caroline|last9=Lane|first9=Carol|last10=Jonroy|first10=Alleh|last11=Knox|first11=Jon|date=2023-01-01|title=Total Pelvic Exenteration surgery - Considerations for healthcare professionals|url=https://www.sciencedirect.com/science/article/pii/S0748798322006187|journal=European Journal of Surgical Oncology|volume=49|issue=1|pages=225–236|doi=10.1016/j.ejso.2022.08.011|issn=0748-7983}}</ref> | |||
== Preoperative management == | == Preoperative management == | ||
| Line 18: | Line 24: | ||
!System | !System | ||
!Considerations | !Considerations | ||
|- | |||
|Airway | |||
|Prior intubations, airway evaluation | |||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Hx of stroke, carotid artery disease, seizures | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Exercise tolerance, CAD, CHF, prior cardiotoxic chemotherapy | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Hx of smoking, lung disease, sleep apnea, prior chemotherapy | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |Nutritional status | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Anemia of chronic disease | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Urinary continence, CKD | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Diabetes, steroid use | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* CBC | |||
* CMP | |||
* Type and Cross | |||
* Cancer marker if relevant | |||
* EKG or TTE if cardiac concern | |||
* CXR if concern for pulmonary disease | |||
* CT for evaluation of extent of tumor burden, vascular involvement of masses | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Arterial line pressure bag and tubing | |||
* Ultrasound for arterial line and IVs (optional) | |||
* Videoscope for potentially challenging airway or history of cervical spine procedures | |||
* Blood transfusion tubing and warmer | |||
Procedure may be done open, laparoscopically, or robot assisted. Confirm approach with surgical team. | |||
Procedure involves several surgical teams including gynecological oncology, colorectal, and urology | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
Midazolam 2 mg IV | |||
- Consider holding for patients >75 years of age | |||
Tylenol 1g for patients without renal impairment | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Consider pre-operative lumbar epidural placement for intra-operative and post-operative pain management | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* Standard monitors | |||
* Arterial line | |||
* Two large bore peripheral IVs | |||
* Nasogastric tube | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
General endotracheal anesthesia | |||
Standard induction | |||
* IV opioid (fentanyl, dilaudid, methadone) | |||
* Lidocaine | |||
* Propofol | |||
* Paralytic | |||
Consider ketamine for pain adjunct | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
Modified lithotomy | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
Antibiotics: Ancef, metronidazole (if anticipating gastrointestinal resection) | |||
Anesthetic maintenance: Preferentially use TIVA, particularly in female patients due to increased risk of PONV | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
Plan for emergence if patient is hemodynamically stable has good oxygenation and ventilation status and is appropriately responsive. | |||
Consider leaving patient intubated if they are: | |||
* Hemodynamically unstable | |||
* Requiring a high FiO2 | |||
* Hypercarbic | |||
== Postoperative management == | == Postoperative management == | ||
| Line 71: | Line 125: | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
IV opiates | |||
* Fentanyl | |||
* Dilaudid | |||
* Methadone | |||
Lumbar epidural | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --><ref name=":0" /> === | |||
* Bleeding | |||
* PONV | |||
* Bowel obstruction | |||
* Ileus | |||
* Stoma breakdown | |||
* Vaginal fistula | |||
* Ureteral stricture | |||
* Infection | |||
* Venous thrombosis | |||
* PE | |||
* Positional nerve damage | |||
* Hypotension due to fluid shifts | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
| Line 80: | Line 155: | ||
! | ! | ||
!Variant 1 | !Variant 1 | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | |Case may be aborted tumor burden is considered irresectable on initial inspection | ||
|- | |- | ||
|Position | |Position | ||
| | |Modified lithotomy | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |8-12 hours | ||
|- | |- | ||
|EBL | |EBL | ||
| | |1200-4000 ml | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
| | |ICU | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |IV opiates, epidural anesthesia | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | |bleeding, infection, dehiscence, ileus, bowel obstruction, fistula | ||
|} | |} | ||
Latest revision as of 19:30, 10 March 2026
Pelvic exenteration
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
2-3 Large bore IVs, Arterial line |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Volume shifts and bleeding |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A pelvic exenteration is a radical procedure in which multiple organs are removed from the pelvis as a curative or palliative measure for recurrent or locally advanced locally invasive pelvic cancers (vaginal, uterine, cervical, vulvar, rectal, urethral, prostate). A total pelvic exenteration includes a en-bloc resection of the reproductive organs as well as the pelvic sections of the gastrointestinal tract and genitourinary tract. These include the sigmoid colon, rectum, anus, bladder, and urethra. In males, reproductive organs include the prostate and seminal vesicles. In females, this includes the uterus, fallopian tubes, ovaries, cervix, vagina, and possibly the vulva.[1]
In female patients a pelvic exenteration can be anterior (removal of reproductive organs and urinary tract, sparing the rectum) or posterior (removal of reproductive organs and gastrointestinal tract, sparing the urinary system).[2]
This procedure often results in an end colostomy (to descending colon to anus anastomosis is sometimes possible), a continent or incontinent urinary diversion, and a muscle flap for perineal and/or vaginal reconstruction.[3]
As the aim of this procedure is curative, the procedure may be aborted if the initial exploratory laparotomy finds the tumor burden to be too extensive for resection, or if positive lymph nodes are found.[4]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | Prior intubations, airway evaluation |
| Neurologic | Hx of stroke, carotid artery disease, seizures |
| Cardiovascular | Exercise tolerance, CAD, CHF, prior cardiotoxic chemotherapy |
| Pulmonary | Hx of smoking, lung disease, sleep apnea, prior chemotherapy |
| Gastrointestinal | Nutritional status |
| Hematologic | Anemia of chronic disease |
| Renal | Urinary continence, CKD |
| Endocrine | Diabetes, steroid use |
Labs and studies
- CBC
- CMP
- Type and Cross
- Cancer marker if relevant
- EKG or TTE if cardiac concern
- CXR if concern for pulmonary disease
- CT for evaluation of extent of tumor burden, vascular involvement of masses
Operating room setup
- Arterial line pressure bag and tubing
- Ultrasound for arterial line and IVs (optional)
- Videoscope for potentially challenging airway or history of cervical spine procedures
- Blood transfusion tubing and warmer
Procedure may be done open, laparoscopically, or robot assisted. Confirm approach with surgical team.
Procedure involves several surgical teams including gynecological oncology, colorectal, and urology
Patient preparation and premedication
Midazolam 2 mg IV
- Consider holding for patients >75 years of age
Tylenol 1g for patients without renal impairment
Regional and neuraxial techniques
Consider pre-operative lumbar epidural placement for intra-operative and post-operative pain management
Intraoperative management
Monitoring and access
- Standard monitors
- Arterial line
- Two large bore peripheral IVs
- Nasogastric tube
Induction and airway management
General endotracheal anesthesia
Standard induction
- IV opioid (fentanyl, dilaudid, methadone)
- Lidocaine
- Propofol
- Paralytic
Consider ketamine for pain adjunct
Positioning
Modified lithotomy
Maintenance and surgical considerations
Antibiotics: Ancef, metronidazole (if anticipating gastrointestinal resection)
Anesthetic maintenance: Preferentially use TIVA, particularly in female patients due to increased risk of PONV
Emergence
Plan for emergence if patient is hemodynamically stable has good oxygenation and ventilation status and is appropriately responsive.
Consider leaving patient intubated if they are:
- Hemodynamically unstable
- Requiring a high FiO2
- Hypercarbic
Postoperative management
Disposition
ICU
Pain management
IV opiates
- Fentanyl
- Dilaudid
- Methadone
Lumbar epidural
Potential complications[4]
- Bleeding
- PONV
- Bowel obstruction
- Ileus
- Stoma breakdown
- Vaginal fistula
- Ureteral stricture
- Infection
- Venous thrombosis
- PE
- Positional nerve damage
- Hypotension due to fluid shifts
Procedure variants
| Variant 1 | |
|---|---|
| Unique considerations | Case may be aborted tumor burden is considered irresectable on initial inspection |
| Position | Modified lithotomy |
| Surgical time | 8-12 hours |
| EBL | 1200-4000 ml |
| Postoperative disposition | ICU |
| Pain management | IV opiates, epidural anesthesia |
| Potential complications | bleeding, infection, dehiscence, ileus, bowel obstruction, fistula |
References
- ↑ Jaffe, Richard (2015). Anesthesiologist's Manual of Surgical Procedures. Philadelphia, PA: Wolters Kluwer. pp. 781–786. ISBN 978-1-4511-7660-5.
- ↑ Grimes, W. R.; Dunton, Charles J.; Stratton, Michael (2026), "Pelvic Exenteration", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33085416, retrieved 2026-03-11
- ↑ "UpToDate". www.uptodate.com. Retrieved 2026-03-11.
- ↑ 4.0 4.1 Carvalho, Filipe; Qiu, Shengyang; Panagi, Vasia; Hardy, Katy; Tutcher, Hannah; Machado, Marta; Silva, Francisca; Dinen, Caroline; Lane, Carol; Jonroy, Alleh; Knox, Jon (2023-01-01). "Total Pelvic Exenteration surgery - Considerations for healthcare professionals". European Journal of Surgical Oncology. 49 (1): 225–236. doi:10.1016/j.ejso.2022.08.011. ISSN 0748-7983.