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.