Preoperative Evaluation and Patient Selection It is imperative to search for metastatic disease before undergoing an exenteration. The presence of metastatic disease in this setting is considered a contraindication to exenterative procedures. Physical examination includes careful palpation of the peripheral lymph nodes with FNA cytologic sampling of any nodes that appear suspicious. A random biopsy of nonsuspicious supraclavicular lymph nodes is advocated by some clinicians but is not routinely practiced (145,186). A PET/CT scan of the chest and abdomen and pelvis CT helps in the detection of liver metastases and enlarged nodes. Cytologic study of any abnormality should be undertaken with CT-guided FNA. If a positive cytologic diagnosis is obtained, it will obviate the need for exploratory laparotomy.
Extension of the tumor to the pelvic sidewall is a contraindication to exenteration; however, this may be difficult for even the most experienced examiner to determine because of radiation fibrosis. If any question of resectability arises, exploratory laparotomy and parametrial biopsies should be offered (187–190). The clinical triad of unilateral leg edema, sciatic pain, and ureteral obstruction is nearly always pathognomonic of unresectable disease on the pelvic sidewall. Preoperatively, the patient should be prepared for a major operation. Total parenteral nutrition may be necessary to place the patient in an anabolic state for optimal healing. A bowel preparation, preoperative antibiotic administration, and prophylaxis for deep venous thrombosis with low-dose heparin or pneumatic calf compression should be undertaken (191).
Figure 36.9 Pelvic exenteration specimen.
Surgical mortality increases with age, and the operation should rarely be considered in a patient who is older than 70 years. Other medical illnesses should be taken into account. When life expectancy is limited, exenterative surgery is unwise.
Anterior Exenteration Candidates for anterior exenteration are those in whom the disease is limited to the cervix and anterior portion of the upper vagina. Proctoscopic examination should be performed because a positive finding would mandate a total exenteration. However, a negative proctoscopic examination finding does not exclude disease in the rectal muscularis, and findings at laparotomy still must be considered. The presence of disease in the posterior vaginal mucosa directly over the rectum mandates removal of the underlying rectum.
Posterior Exenteration A posterior exenteration is rarely performed for recurrent cervical cancer. It is indicated, however, for the patient with an isolated posterior vaginal recurrence in which dissection of the ureters through the cardinal ligaments will not be necessary.
Total Exenteration Total exenteration with a large perineal phase is indicated when the disease extends to the lower part of the vagina (Fig. 36.9). Because distal vaginal lymphatics may empty into the nodal basins of the inguinal region, these nodes should be carefully evaluated preoperatively. A supralevator total exenteration with low rectal anastomosis is indicated in the patient whose disease is confined to the upper vagina and cervix (192,193). Samples from margins of the rectal edge should be obtained for frozen-section evaluation because occult metastases to the muscularis may occur.
The development of techniques to establish continent urinary diversion help improve a woman’s physical appearance after exenteration (194–196). When both a rectal anastomosis and a continent diversion are performed, the patient will not have a permanent external appliance. Associated psychological trauma in such cases may be avoided. Every effort should be made to create a neovagina simultaneously with the exenteration (197). This procedure helps in the reconstruction of the pelvic ﬂoor after extirpation of the pelvic viscera. Regardless of whether a neovagina is constructed, it is desirable to mobilize the omentum on the left gastroepiploic artery to create a new pelvic ﬂoor.