Difference between revisions of "Pelvic exenteration"

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{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 2-3 Large bore IVs, Arterial line
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative = Volume shifts and bleeding
| considerations_postoperative =
}}


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 ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!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<!-- 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. --> ===
* 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. --> ===
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. --> ===
Consider pre-operative lumbar epidural placement for intra-operative and post-operative pain 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. --> ===
* 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. --> ===
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. --> ===
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. --> ===
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. --> ===
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<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
ICU
=== 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). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!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 ==
[[Category:Surgical procedures]]

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
Unrated
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

  1. ↑ Jaffe, Richard (2015). Anesthesiologist's Manual of Surgical Procedures. Philadelphia, PA: Wolters Kluwer. pp. 781–786. ISBN 978-1-4511-7660-5.
  2. ↑ Grimes, W. R.; Dunton, Charles J.; Stratton, Michael (2026), "Pelvic Exenteration", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33085416, retrieved 2026-03-11
  3. ↑ "UpToDate". www.uptodate.com. Retrieved 2026-03-11.
  4. ↑ 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.

Top contributors: Chelsea Rogers, Nirav Kamdar, Mitchel DeVita and Chris Rishel

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