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424
S. Amarnath
Appropriate IORT dosing can also help reduce
the risk of peripheral neuropathy.
Recognition
Patients may present with delayed wound healing
or wound healing complications, leg swelling,
numbness, tingling, or pain in a pelvic nerve
distribution.
Management
Wound healing issues may need a referral for
specialized wound care or plastic surgery. HBOT
may also be helpful in appropriately selecting
patients [37]. Patients at high risk for lymphedema should be referred to lymphedema physical therapy early for compression stocking tting,
massage, and other mitigation techniques [38].
Peripheral neuropathy may require management
with medications that help with neuropathic pain.
References
1. Nicholas S, Chen L, Choet A, Fader A, Guss Z,
Hazell S, etal. Pelvic radiation and normal tissue toxicity. Semin Radiat Oncol. 2017;27(4):358–69.
2. Bentzen SM.Preventing or reducing late side effects
of radiation therapy: radiobiology meets molecular
pathology. Nat Rev Cancer. 2006;6(9):702–13.
3. Eifel PJ, Jhingran A, Bodurka DC, Levenback C,
Thames H.Correlation of smoking history and other
patient characteristics with major complications of
pelvic radiation therapy for cervical cancer. J Clin
Oncol. 2002;20(17):3651–7.
4. Maruyama Y, Van Nagell JR, Jr., Utley J, Vider ML,
Parker JC.Radiation and small bowel complications
in cervical carcinoma therapy. Radiology.
1974;112(3):699–703.
5. van Nagell JR Jr, Parker JC Jr, Maruyama Y, Utley
J, Luckett P.Bladder or rectal injury following radiation therapy for cervical cancer. Am J Obstet Gynecol.
1974;119(6):727–32.
6. Mikkelsen TB, Sorensen B, Dieperink KB.Prediction
of rehabilitation needs after treatment of cervical cancer: what do late adverse effects tell us? Support Care
Cancer. 2017;25(3):823–31.
7. Wo J, Taghian A.Radiotherapy in setting of collagen vascular disease. Int J Radiat Oncol Biol Phys.
2007;69(5):1347–53.
8. Willett CG, Ooi CJ, Zietman AL, Menon V, Goldberg
S, Sands BE, etal. Acute and late toxicity of patients
with inammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Radiat
Oncol Biol Phys. 2000;46(4):995–8.
9. Chorbinska J, Krajewski W, Zdrojowy R.Urological
complications after radiation therapy-nothing ventured, nothing gained: a narrative review. Transl
Cancer Res. 2021;10(2):1096–118.
10. Levenback C, Eifel PJ, Burke TW, Morris M,
Gershenson DM. Hemorrhagic cystitis following radiotherapy for stage Ib cancer of the cervix.
Gynecol Oncol. 1994;55(2):206–10.
11. Marks LB, Carroll PR, Dugan TC, Anscher MS.The
response of the urinary bladder, urethra, and ureter to
radiation and chemotherapy. Int J Radiat Oncol Biol
Phys. 1995;31(5):1257–80.
12. Wit EM, Horenblas S. Urological complications
after treatment of cervical cancer. Nat Rev Urol.
2014;11(2):110–7.
13. Zelefsky MJ, Levin EJ, Hunt M, Yamada Y, Shippy
AM, Jackson A, et al. Incidence of late rectal and
urinary toxicities after three-dimensional conformal
radiotherapy and intensity-modulated radiotherapy
for localized prostate cancer. Int J Radiat Oncol Biol
Phys. 2008;70(4):1124–9.
14. Oscarsson N, Arnell P, Lodding P, Ricksten SE,
Seeman-Lodding H.Hyperbaric oxygen treatment in
radiation-induced cystitis and proctitis: a prospective
cohort study on patient-perceived quality of recovery.
Int J Radiat Oncol Biol Phys. 2013;87(4):670–5.
15. Chuang YC, Kim DK, Chiang PH, Chancellor
MB.Bladder botulinum toxin A injection can benet
patients with radiation and chemical cystitis. BJU Int.
2008;102(6):704–6.
16. Caero F, Gipponi M, Peressini A, Bertoglio S,
Lionetto R. Preliminary analysis of a randomized
clinical trial of adjuvant postoperative RT vs. postoperative RT plus 5-FU and levamisole in patients
with TNM stage II-III resectable rectal cancer. J Surg
Oncol. 2000;75(2):80–8.
17. Yamada T, Ishihara S, Kawai M, Itoh Y, Naganawa
S, Ikeda M.Analysis of late adverse events and their
chronological changes after radiation therapy for cervical cancer. Nagoya J Med Sci. 2018;80(4):487–96.
18. Wang Y, Kong W, Lv N, Li F, Chen J, Jiao S, etal.
Incidence of radiation enteritis in cervical cancer patients treated with denitive radiotherapy
versus adjuvant radiotherapy. J Cancer Res Ther.
2018;14(Supplement):S120–S4.
19. Shadad AK, Sullivan FJ, Martin JD, Egan
LJ. Gastrointestinal radiation injury: prevention and treatment. World J Gastroenterol.
2013;19(2):199–208.
20. Vistad I, Kristensen GB, Fossa SD, Dahl AA, Morkrid
L.Intestinal malabsorption in long-term survivors of
cervical cancer treated with radiotherapy. Int J Radiat
Oncol Biol Phys. 2009;73(4):1141–7.
21. Shejul J, Chopra S, Ranjan N, Mahantshetty U, Mehta
S, Patil P, etal. Temporal course of late rectal toxicity & impact of intervention in patients undergoing radiation for cervical cancer. Indian J Med Res.
2021;154(2):375–82.
22. Elad S, Cheng KKF, Lalla RV, Yarom N, Hong C,
Logan RM, et al. MASCC/ISOO clinical practice
37 Pelvic Radiation Therapy
425
guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423–31.
23. McQuestion M. Evidence-based skin care management in radiation therapy: clinical update. Semin
Oncol Nurs. 2011;27(2):e1–17.
24. Williams JA Jr, Clarke D, Dennis WA, Dennis EJ 3rd,
Smith ST.The treatment of pelvic soft tissue radiation necrosis with hyperbaric oxygen. Am J Obstet
Gynecol. 1992;167(2):412–5; discussion 5–6.
25. Gothard L, Cornes P, Brooker S, Earl J, Glees J, Hall
E, etal. Phase II study of vitamin E and pentoxifylline
in patients with late side effects of pelvic radiotherapy. Radiother Oncol. 2005;75(3):334–41.
26. Dion MW, Hussey DH, Doornbos JF, Vigliotti AP,
Wen BC, Anderson B.Preliminary results of a pilot
study of pentoxifylline in the treatment of late radiation soft tissue necrosis. Int J Radiat Oncol Biol Phys.
1990;19(2):401–7.
27. Grifths MJ, Winship AL, Hutt KJ. Do cancer therapies damage the uterus and compromise fertility?
Hum Reprod Update. 2020;26(2):161–73.
28. Baiocchi G, Vieira M, Moretti-Marques R, Mantoan
H, Faloppa C, Damasceno RCF, etal. Uterine transposition for gynecological cancers. Int J Gynecol
Cancer. 2021;31(3):442–6.
29. Wallace WH, Anderson RA, Irvine DS. Fertility
preservation for young patients with cancer: who
is at risk and what can be offered? Lancet Oncol.
2005;6(4):209–18.
30. Wallace WH, Thomson AB, Saran F, Kelsey
TW.Predicting age of ovarian failure after radiation
to a eld that includes the ovaries. Int J Radiat Oncol
Biol Phys. 2005;62(3):738–44.
31. Morice P, Castaigne D, Haie-Meder C, Pautier P, El
Hassan J, Duvillard P, et al. Laparoscopic ovarian
transposition for pelvic malignancies: indications and
functional outcomes. Fertil Steril. 1998;70(5):956–60.
32. Brand AH, Bull CA, Cakir B. Vaginal stenosis in
patients treated with radiotherapy for carcinoma of
the cervix. Int J Gynecol Cancer. 2006;16(1):288–93.
33. Flay LD, Matthews JH.The effects of radiotherapy
and surgery on the sexual function of women treated
for cervical cancer. Int J Radiat Oncol Biol Phys.
1995;31(2):399–404.
34. Damast S, Jeffery DD, Son CH, Hasan Y, Carter J,
Lindau ST, etal. Literature review of vaginal stenosis and dilator use in radiation oncology. Pract Radiat
Oncol. 2019;9(6):479–91.
35. Denton AS, Maher EJ. Interventions for the physical aspects of sexual dysfunction in women following pelvic radiotherapy. Cochrane Database Syst Rev.
2003;2003(1):CD003750.
36. Viswanathan AN, Lee LJ, Eswara JR, Horowitz
NS, Konstantinopoulos PA, Mirabeau-Beale KL,
et al. Complications of pelvic radiation in patients
treated for gynecologic malignancies. Cancer.
2014;120(24):3870–83.
37. Moen I, Stuhr LE. Hyperbaric oxygen therapy and
cancer—a review. Target Oncol. 2012;7(4):233–42.
38. Warren AG, Brorson H, Borud LJ, Slavin
SA.Lymphedema: a comprehensive review. Ann Plast
Surg. 2007;59(4):464–72.
Pelvic Exenteration for Central Pelvic Cancer
DesmondP.Barton, OwenM.Heath,
RasheedShahnawaz, QiuSheng, ThompsonAlan,
andKumarPardeep
38
Introduction
Pelvic exenteration (PEx) was rst described by
Brunschwig in 1948 as a palliative procedure. He
published on extended radical surgery for locally
advanced gynaecological cancer (mainly primary
and recurrent cervical cancer) where less radical
surgery and/or radiation therapy had failed [1].
There was signicant mortality and morbidity in
his series, albeit 75years ago. Most PEx are now
performed with curative intent. To achieve cure
there must be 1) no metastatic disease outside the
operative eld and 2) negative margins [2–4].
More extensive and longer operations are
associated with increased morbidity [5]. Higher
volume centres/surgical teams performing PEx
have lower costs and intensive care usage [6].
During long-term follow-up, the postoperative
complications and quality of life (QoL) can
change. Obesity in the surgical population is an
important confounding factor [7]. The impact of
early postoperative complications include pro-
D. P. Barton (*) · O. M. Heath
Department of Gynaecological Oncology, The Royal
Marsden Foundation Trust, London, UK
e-mail: desmond.barton@rmh.nhs.uk
R. Shahnawaz · Q. Sheng
Department of Colorectal Surgery, The Royal
Marsden Foundation Trust, London, UK
T. Alan · K. Pardeep
Department of Uro-oncology, The Royal Marsden
Foundation Trust, London, UK
longation of hospital stay, delayed recovery,
compromised QoL (which may not improve),
increased costs and compromised survival [8].
Palliative exenteration is associated with
increased morbidity and mortality, such that
many question its role [9, 10]. As pelvic exenteration is associated with signicant morbidity and
mortality, case selection for such surgery with
palliative intent is critical to avoid surgeryassociated deterioration in QoL.
For gynaecological cancers, the most common
indication for exenteration is recurrent cervical
cancer following radiation therapy (RT)
(Fig.38.1). Most large surgical oncology centres
perform these operations for a range of pelvic
cancers. Traditionally pelvic exenteration was
considered where there was no involvement of
the pelvic sidewall, such as neuro-vascular structures and/or muscles/bone. Although these, socalled laterally extended or “out of the box”
operations can be performed for pelvic sidewall
recurrent pelvic cancers, their complications are
beyond the scope of this article (see Chap. 39).
In colorectal practice, the main indications for
PEx are locally advanced or recurrent rectal adenocarcinoma and anal squamous cell carcinoma.
PEx is performed when these cancers directly
invade adjacent structures or threaten the circumferential resection margin (CRM). PEx are performed where these cancers involve the urogenital
organs anteriorly. En bloc sacrectomy can be performed when the cancer invades beyond the TME
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_38
427
428
D. P. Barton et al.
Fig. 38.1 The extent of pelvic exenteration may be individualized in selected cases depending on tumor location, organ
function and prior treatment
38 Pelvic Exenteration for Central Pelvic Cancer
429
plane posteriorly to involve the presacral fascia
or the sacral cortex [11]. In one report on locally
advanced rectal cancer, the perioperative mortality rate for PEx was 1.5%, and the 30-day postoperative major morbidity rate was 37.8%—with
the most common being surgical site infection/
collection. The 3-year survival rate was 56.4%
with an R0 resection [12, 13].
In urological practice, the most common indications for anterior pelvic exenteration in female
patients (anterior vagina and uterus in addition to
urologic tract resection) are: muscle-invasive
transitional cell carcinoma of the bladder (usually preceded by neo-adjuvant chemotherapy),
high-grade non-invasive transitional carcinoma
following failed intravesical BCG therapy, and as
a salvage treatment following failed radiotherapy
[14, 15]. It is also used in the treatment of adenocarcinoma or squamous cell carcinoma of the
bladder, neither of which are radiosensitive. A
less common indication is for selected cases of
urethral cancer.
Assessment andAnticipation
ofSurgical Complications
Pre-Operative Considerations
Ideally, these multidisciplinary operations should
be in a high-volume centre where there is colocation of services and the expertise of pathologists
and radiologists is essential [12, 13, 17, 18]. The
importance of the decision-making process (case
selection) is emphasised in most reports on PEx.
Prevention, early recognition and comprehensive treatment of complications is an integral and
necessary standard of care. As would be expected,
patients with co-morbidities undergoing PEx have
poorer outcomes [19–21]. More extensive operations (Fig. 38.1), particularly in the lateral and
posterior compartments, are associated with an
increased rate of complications (largely neurovascular) [22]. The Charlson comorbidity index, the
POSSUM score (Physiological and Operative
Severity Score for the enUmeration of Mortality
and Morbidity) and other predictive models have
been used to predict adverse outcomes, and an
age-adjusted scoring system has been validated
[23–27].
In anticipation of the consequences (complications) of PEx, the pre-operative period is when
risk modication strategies should be implemented [16, 26]. These include:
• Revision of current medications.
• Correction of anaemia.
• Normalization of WBC and platelet counts.
• Pre-habilitation.
• Bowel preparation.
• Patients who have a pelvic stula or have had
urosepsis (with or without the presence of a
nephrostomy tube or ureteric stent) are more
predisposed to infection and a marked inam-
matory response during and after surgery. It is
unclear if “prophylactic” antibiotics before
surgery reduce the risk or severity of such
reactions.
• Consent: This must not be a rushed process.
Setting realistic expectations from PEx—in
terms of 5-year survival, complications and qual-
ity of life—is integral to the consent process.
• Psychological support may be necessary
before and after surgery—in the short and the
long term. It can be helpful to have other
patients who have been through PEx surgery
speak with those patients facing PEx [28]. It is
also evident that patient expectations from sur-
gery impact patient-reported outcomes [29].
• Multidisciplinary team (MDT) coordination:
With comprehensive planning, there should be
no surprises on the morning of surgery. There
is evidence that patients undergoing PEx for
gynecologic cancers are more obese obese
and have more comorbidities [30].
Intra-Operative Complications
WHO Checklist
This is not a perfunctory exercise and will include
patient identication, equipment checks, availability of blood and blood products and availability of surgeons from other disciplines. An
important conrmation for some PEx is the availability of two “scrub teams” for the abdominal
430
D. P. Barton et al.
and perineal phases, and two sets of equipment
including energy devices. There must also be a
sufcient number of appropriately trained assistants with the surgical teams.
(a) Anaesthetic considerations
(b) Patient positioning
Most PEx are performed through an
extended midline laparotomy and a xed
retraction system is used to keep the abdominal wall retracted. Prolonged retraction can
traumatise the inferior epigastric pedicle,
which is essential for the reconstruction of
the pelvic oor/perineum using the rectus
abdominis ap.
For laparoscopic and robotically assisted
PEx the problems of prolonged “head-down”
position and prolonged increased intraperitoneal pressure, include the compartment syndrome being more common [31]. During the
procedure, the patient is periodically taken
out of this position.
(c) Haemorrhage
In what is often a heavily pre-treated pelvis (and abdomen) with prior radiotherapy
and surgery, the associated brosis, distorted
anatomical planes and abnormal anatomy
lead to an increased risk of intestinal injury
and intra-operative bleeding.
Recognition of the cause, site, amount and
rapidity of blood loss, and the stability of the
patient—assessed from dialogue between
senior members of the surgical and anaesthetic
teams—is essential. In particular, communication must include notication of those steps of
the operation where signicant blood loss might
be expected before that step is undertaken.
Pelvic packing/pressure, suturing of bleeding points, the use of haemostatic agents, and/
or sacral tacks may be needed. Often it is necessary to change tact during the operation,
apply pressure to control the bleeding area,
proceed with another step when safe to do so,
and then return to the site of bleeding. It is
preferable to leave the most hazardous step to
later in the operation when there has been
more mobilisation of the specimen and greater
access to the bleeding area. In those cases
where pre-operative assessment indicates that
vascular resection and reconstruction are
thought possible, then the vascular surgeon
should be involved in the pre-operative planning and readily available during surgery.
When a translevator (sometimes referred to as
an infralevator) PEx is being undertaken, dialogue and coordinated dissection between the
abdominal and perineal teams are important.
The abdominal phase should be completed
with as full mobilisation as possible before the
perineal phase is commenced.
Major haemorrhage is a risk of sacrectomy due to the proximity of major neurovascular structures to the resection margin, and
conned physical space hindering access.
Preoperative risk factors for major haemorrhage include large/difcult-to- access
tumours, proximity to major vessels, previous
surgery, and previous radiotherapy [32].
Blood products (pack red cells, fresh frozen
plasma, platelets, and brinogen/thrombin
agents) should be made available for use
intraoperatively. Bleeding can occur as the
result of vascular injury or generalised ooze
from raw surfaces of bone or soft tissue.
Pre-emptive vascular mobilisation and
control are essential prior to sacral resection.
The presacral venous plexus and iliac vessels
are the main sources of haemorrhage.
Presacral haemostasis can usually be achieved
by a combination of electrocautery, packing,
and haemostatic dressings. The external iliac
artery and vein are mobilised and controlled
with vascular slings. The internal iliac artery
and veins are identied and can be divided as
required to achieve oncologic resection (see
Chap. 39). In the case of urological cancers,
major haemorrhage is unusual in female
patients, even in those who have been irradiated previously, unless there is signicant
pelvic sidewall/vessel involvement. In such
cases surgery is rarely performed, even for
palliation, as the benets are minimal.
The level of sacral transection is predetermined radiologically as part of the MDT
approach to surgical planning. Sacrectomies
are classied as high or low (below the level
38 Pelvic Exenteration for Central Pelvic Cancer
431
of the S2 nerve root foramen). High sacrectomy is associated with greater morbidity and
poorer functional outcomes [34, 35]. L5, S1,
and S2 nerve roots are identied in the posterior lateral compartments. Where ‘high and
wide’ en bloc sacrectomies are performed,
excision of the sacral nerve roots and sciatic
nerve may be required to achieve an R0 margin. The resultant functional decit (e.g. foot
drop) requires intensive rehabilitation and
orthotics. However, some have reported physical QoL can return to baseline 12 months
after surgery [36]. Sacral osteotomy follows
control and selective ligation of neurovascular
structures. The height and angle of the sacral
osteotomy in relation to the sacral cortex are
determined on preoperative MRI.It is important to evaluate the level of thecal sac termination in relation to the osteotomy, as
inadvertently opening the thecal sac can result
in a CSF leak. Sacral division can be performed with an osteotome and mallet or other
devices such as a pneumatic drill. The sacral
division is usually started in the midline and
extended laterally to divide the sacrospinous
and sacrotuberous ligaments attaching the
sacrum to the pelvis (see Chap. 40).
Whilst some surgeons prefer to start the
operation with posterior dissection of the
sacrum with the patient in the prone position,
the authors’ practice is to start in the LloydDavies position to complete all abdominopelvic steps of the resection. Subsequently,
the abdomen is closed and the patient is
placed prone. The posterior aspects of the
sacrectomy are completed to meet the anterior transection margin. This can be a hazardous phase of the operation due to the limited
access to the pelvis for control of bleeding.
Access can be improved by making a safe
perineal entry point to the pelvis prior to
prone positioning [33].
In addition to the higher risk of massive
bleeding, sacrectomy is associate with a
higher rate of wound dehiscence and perineal
ap failure [37]. This procedure is also associated with signicant long term postopera-
tive pain [38]. Therefore, appropriate patient
selection and counselling is paramount
before embarking upon this procedure.
(d) Infection risk:
Not infrequently the tumour mass is partially necrotic/infected and during surgery
there can be frequent uid shifts and the
development of a systemic inammatory
response (systemic inammatory response
syndrome—SIRS). Avoidance of peritoneal
contamination with bowel contents and/or
necrotic tumour is routine practice. With variably friable and brotic tissue, difcult access
and altered anatomy, the manoeuvres of traction and counter-traction need to be controlled and not excessive to avoid tearing the
specimen, or jeopardising surgical planes and
margins. This is not always straightforward.
Specic Intra-Operative Considerations:
Urology
Rectal injury is much less common in female
urological exenterative surgery than in males
because the vagina acts a barrier between the
bladder and the rectum. For bladder cancers
where a cystectomy with urinary diversion is
indicated, consideration needs to be given to performing an en bloc hysterectomy (and in some
cases partial vaginectomy).
The condition of the ureters (brosis) and
ileum (for an ileal conduit) are assessed intraoperatively. The ileum, if brosed, may not be
suitable as a conduit. Patients undergoing PEx
and who have a ureteric stent(s) tend to have
more brosed ureters, and post-PEx are more
likely to develop urosepsis and a ureteral anastomotic stricture [39, 40]. The incidence and severity of complications of a urinary diversion are
substantially higher in an irradiated than in a nonirradiated pelvis and it is unclear if the doublebarrelled stoma, the continent or the incontinent
urinary diversion confers long-term benet with
regards to lower risk of upper urinary tract infection and preservation of renal function [41–43].
(See Chaps. 15 and 16 for a more in-depth discussion regarding conduit complications and
continent versus incontinent conduits.)
432
D. P. Barton et al.
Specic Intra-Operative Considerations:
Colorectal
In a supralevator exenterative procedure, there
can be the option to perform a colorectal anastomosis. When an anastomosis has been made, the
recommendation is to bring out a loop ileostomy,
with the goal of reversing this some months later.
Elderly patients often have signicant diverticulosis or anal incontinence, and this may preclude
a colorectal anastomosis. The stability of the
patient, bowel preparation, and health of the
proximal and distal (and length of) bowel are
some of the factors that must be considered in
deciding whether or not to do a colorectal anastomosis (see Chap. 36). A pelvic drain must be
placed close to the anastomotic site. If possible,
an omental transposition should be performed.
Specic Considerations: Plastic
andReconstructive (See Chap. 41)
(e) Intra-operative death: Whilst the 30-day mor-
tality for PEx is often quoted as 1–2%, and
the 90-day mortality slightly higher, the literature does not always clearly distinguish
intra-operative from postoperative deaths [9,
12, 13, 20]. Obese patients and those with
extended procedures for non-central relapse
are at increased risk of serious complications
and death within 90days.
Post-Operative Complications
Immediate
Typically, the patient will be in intensive care and
many will be intubated.
The specic problems
(a) Blood loss: Primary haemorrhage may be sud-
den or gradual and revealed or concealed. If
sustained, substantial and associated with
hypotension there is no recourse but to take the
patient back to theatre. An experienced surgical and anaesthetic team should be involved in
the decision making and the operation should
ideally be by the team which performed the
PEx. As with primary haemorrhage from other
operations, often no source can be identied.
(b) Poor urine output: Where there has been a
urinary diversion, a post-renal cause includes
a blocked ureteric stent—these should be
ushed regularly.
(c) Flap ischaemia and other ap problems—
(see Chap. 41).
Early Complications—First 6Weeks
After Surgery
Within the rst week, the problems typical of
major abdominal and pelvic surgery can be seen,
but with greater frequency and severity. Those
more particularly associated with PEx include:
(a) Secondary haemorrhage: Unlike with signi-
cant primary haemorrhage, there is less need
to take a patient with secondary haemorrhage
back to theatre. With PEx and the prolonged
catabolic phase, anaemia is not uncommon.
(b) Infection: This is the most common compli-
cation after major surgery. There are a number of guidelines on surgical site infection
(SSI) [44, 45]. Although infection can be
conrmed on bacteriology, and/or on imaging, in clinical practice the actual site and
responsible organism(s) often remain elusive. The usual SSI are evident in PEx
patients and more than one site can be a
source. In particular these include urinary
tract infection, donor and recipient sites of
the reconstruction (including infected mesh),
and as part of a cluster of problems referred
to as the empty pelvis syndrome [46–48].
Patients undergoing PEx will be on perioperative antibiotics, often for some days,
and there is a risk of C. difcile “infection”.
With the often slow recovery and relative
immobility, dependent wounds (donor and
graft sites of the reconstruction) are prone to
pressure and are often moist and oedematous—all of which contribute to wound
breakdown. Given the anatomical location of
these wounds, they cannot be self-cared for.
Abdominal wound infection is more
likely if a mesh has been used in reconstruction of the anterior abdominal wall.
38 Pelvic Exenteration for Central Pelvic Cancer
433
(c) Urological problems.
Urinary leak: Leakage from a urinary diversion will be identied with low urine output, high
drain output and clinical suspicion. Urinary leakage is more common in the early postoperative
period. The use of ureteric stents has been shown
to reduce the rate of urinary leak. The serum urea
and creatinine levels will rise and the patient’s
condition can vary. Pelvic or abdominal drain
uid biochemistry will conrm there is urine
leakage. Occasionally this may manifest as leakage of uid from the perineal wound.
Nephrostomy tubes will be required in the shortterm to manage the leak.
1. Breakdown of urinary diversion. This is a rare
outcome where there is anastomotic failure,
peritonitis, and an ill patient. Contrast studies
will demonstrate the leak and its extent.
Surgical intervention is considered, generally
after a period of conservative management
with a nephrostomy tube. It is more problematic to drain the urinoma/collection percutaneously as the anatomy is altered after PEx.
2. Infection—this may not be conrmed on
urine culture as the patients are, or have very
recently been, on antibiotics.
3. Stomal problems (see below).
(d) Intestinal tract problems:
1. The development of an enteric stula, a poten-
tial consequence of the empty pelvis syndrome, has been offset to some extent by the
use of a well-vascularised (bulky) ap that
reconstitutes the pelvic oor and perineal/
vaginal/perianal defect. Although such stulae usually present in the perineum they can
also present at the abdominal wound. This is a
serious complication and can lead to chronic
abscess formation, further stulae and sepsis
[46]. Conservative and subsequent surgical
management are carefully considered [47,
48]. There is a substantial risk of prolonged
hospitalisation, intestinal failure (that is, the
patient is dependent on parenteral nutrition)
and death. It may be necessary to call on the
expertise of the “intestinal failure team”.
2. Ileus: This is a common problem of major
abdominal surgery and usually settles with
conservative management. Some centres will
routinely give parenteral nutrition after PEx.
Delayed return of bowel function can sometimes take weeks to resolve and persistence
with conservative management with parenteral nutrition usually results in resolution.
3. Bowel obstruction: This is rarely acute in
nature. A prolonged period of conservative
management including parenteral nutrition
may be required. The decision to re-operate
must not be premature, but must be
considered if there are persistent signs of
peritonitis.
4. Peritonitis—from an anastomotic leak. A leak
may be contained in a walled off collection,
which can be managed conservatively, or there
may be a diffuse leak with generalised peritonitis. Omental transposition performed during
PEx may contribute to containment of a leak. A
localised collection can be managed conservatively with drainage, antibiotics and parenteral
nutrition, whereas generalised peritoneal infection will usually require surgery. If a supralevator procedure has been performed with a
colorectal anastomosis, there is an increased
risk of anastomotic leak because of the prior
pelvic radiotherapy. A proximal diversion, typically a loop ileostomy, is recommended. A
loop ileostomy brings its own problems.
5. Stomal problems—see below.
(e) Stomal problems: Patients may struggle,
mentally and physically, with the early adaptation to the stoma(s) and self-caring can
take some weeks. The challenge can be
greatest in those who have had a rectus
abdominis ap reconstruction [49].
Stomal necrosis may develop—most
often this is supercial, above the fascia.
Endoscopic examination will reveal the level
of demarcation. In some cases a laparotomy
will be required for revision. Necrosis of a
urinary conduit is very rare.
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(f) Extensive subcutaneous oedema—rarely, a
clinical picture similar to anasarca develops.
Reduction of intravenous uid, if possible, is
important along with skilled nursing care to
avoid pressure sores. This problem contributes to delay in mobilisation. There is debate
about the use of salt-free albumen, parenteral
nutrition and enteral nutrition in managing
this problem. Extensive oedema of the vulva
and perineum can be very upsetting to the
patient and with the limited mobility and
gravitational inuences (dependent tissues),
can be difcult to reverse.
(g) Pressure sores: The particular problems of
malnourishment, immobilisation and subcutaneous oedema pre-dispose these patients to
pressure sores. Skilled nursing care is
essential.
(h) Thrombo-embolic problems: These have
been reduced by the peri-operative use of
stockings, sequential compression devices,
prophylactic anticoagulation and early
mobilisation—the last often not practical in a
PEx patient. Central line infection/thrombosis is more common in PEx. A swollen lower
limb post-PEx, whilst not unexpected, might
also indicate an underlying thrombosis and a
Doppler study is then indicated.
(i) Empty pelvis syndrome: A pelvic abscess is
one consequence of the extensive dissection
and resection, with a large residual “deadspace.” The many potential sequelae of this
are sometimes described as the “empty pelvis syndrome” [46, 47, 48]. A pelvic abscess
can present insidiously with low grade fever
or swinging pyrexia. There may be no other
clinical signs or the patient may be septic.
The usual investigations for source of infection will be needed. A CT of chest, abdomen
and pelvis will be informative, and imageguided drainage may be required, but this
can be technically difcult.
(j) High outputs from abdominal and pelvic
drains: The cause may be a urinary tract leak
and a check on drain biochemistry will conrm this. It is important to ensure there is not
blockage of the ureteric stents or drains.
(k) Body image/psychological issues: With a
midline scar(s), distorted anterior abdominal
wall, stoma(s), and resected lower genital
tract structures, body image issues are common and may become more signicant in the
long term. The features of PEx that can cause
psychological problems include baseline or
pre-operative psychological function, prolonged surgery, postoperative intubation, longer stay in intensive care, multiple medications
and distorted body image. A patient with signicant pre-morbid psychological problems
may not be considered suitable for PEx.
Psychological assessment and support should
be available. Depression (reactive) and hallucinations are not uncommon. Patients who
have been on HRT prior to surgery may have
more challenges with vasomotor symptoms
and mood swings after PEx.
Delayed Complications—In theFirst
12Months
Within the rst 6–12months after PEx some of
the problems mentioned above can manifest during this period and thereafter (50, 51). More specic problems include:
1. Stomal problems: These can relate to the
patient’s adjusting to stomas which in most
cases are permanent. Aside from stomal
retraction and stomal prolapse, PEx patients
may have troublesome bowel activity as a
result of prior radiotherapy. Abdominal wall
weakness after surgery, especially when
there has been reconstruction with a rectus
abdominis ap, can compound the situation
(see below). The presence of a stoma(s) has
been reported to adversely affect the QoL
[52].
2. Renal impairment: Associated with the risk
of infection and anastomotic stricture, renal
impairment can develop which is detectable
only on biochemical prole (which should
be checked regularly). Ureteral stenting and
nephrostomy tube drainage may be required,
followed by surgical revision- which is a
major undertaking. In urological cancers, the
rate of stricture formation is reported as
being around 2%. In patients who have had