Surgical mortality from exenterative procedures has steadily decreased to less than 10%. Common causes of postoperative death are sepsis, pulmonary thromboembolism, and hemorrhage.
Fistulas of the gastrointestinal and genitourinary tract are serious surgical complications, with a 30% to 40% mortality rate despite attempts at surgical repair. The risk for fistula formation is decreased if nonirradiated segments of bowel are used for formation of the urinary conduit (191). The 5-year survival rate is 33% to 60% for patients undergoing anterior exenteration and 20% to 46% for those undergoing total exenteration (187–197). Survival rates are worse for patients with recurrent disease (larger than 3 cm), invasion into the bladder, positive pelvic lymph nodes, and recurrence diagnosed within 1 year after radiotherapy (190). The 5-year survival rate of patients with positive pelvic lymph nodes is less than 5%; thus, the performance of an extensive lymphadenectomy in the irradiated field is not warranted. Discontinuation of the procedure is advisable if any nodes are positive for metastatic cancer. Patients who have any disease in the peritoneal cavity have no chance of survival.
Locally recurrent cervical cancer in a previously irradiated field is associated with a dismal prognosis. Exenterative therapy traditionally was reserved for the highly select patient with centrally recurrent disease, a selection criteria that excludes most patients with recurrence. A technique called the laterally extended endopelvic resection (LEER) procedure was described, which offers a surgical treatment option for patients with recurrent disease involving the pelvic sidewall. The LEER procedure involves extending the lateral resection plane of the traditional pelvic exenteration to include resection of the internal iliac vessels; the endopelvic portion of the obturator internus muscle; and the coccygeus, iliococcygeus, and pubococcygeus muscles. Extension of the surgical plane allows for resection of lateral tumors with a negative margin. Experience with it is limited to one center, which reports as high as a 62% recurrence-free survival, but as high as 70% moderate to severe morbidity (198).
Recurrent cervical cancer is not considered curable with chemotherapy. The delivery of chemotherapy to recurrent tumor in a prior radiated field may be compromised because of altered blood supply caused by radiation. Topotecan and cisplatin had response rates of 15% to 20%, with a median duration of 6 to 9 months (199). Many other agents showed activity against cervical cancer and may be used in attempt to help control symptoms. Several clinical trials with various drugs (e.g., paclitaxel, topotecan, cisplatin, and carboplatin) showed response rates of up to 45%. Most responses are partial; complete responses are unusual and limited to patients with chest metastases in whom the dose of drug delivered to the disease is stronger than that delivered to the fibrotic postirradiated pelvis (200,201). Doublet therapy with cisplatin and paclitaxel is considered standard therapy based on GOG 204, which analyzed four cisplatin-containing doublets for the best efficacy; although no major differences existed in overall survival for the four doublets, the cisplatin and paclitaxel doublet trended toward the best results (153). Other studies showed comparable survival and less toxicity with carboplatin and paclitaxel (154).