Pelvic exenteration

Radiotherapy consists of external beam irradiation of the uninvolved pelvic lymphatics and uninvolved parametrial tissue with a dose of up to 45 Gy and intracavitary brachytherapy with three to six fractions of 4-8 Gy each dehvered to point A or the uterus [62], corresponding to a total dose equivalent of 70-80 Gy delivered to point A. The dose delivered by external beam radiotherapy is adjusted to the local tumor extent and metastatic nodal involvement (boost). A larger field of external irradiation is chosen in patients with para-aortic lymph node metastases. No brachytherapy is done in most patients with infiltration of the bladder or rectum because of the risk of fistula development. Alternatively, cervical cancer with invasion of adj acent pelvic organs can be treated by surgical pelvic exenteration. The most common therapies according to stage are summarized in Table 7.3. 

Local tumor recurrence with infiltration of the bladder or rectum but without extension to the pelvic sidewall can be treated by pelvic exenteration with curative intention. With strict patient selection, the 5-year-survival rate is 82% [63]. Various other surgical options are available for removal of recurrent tumor. In patients not having undergone radiotherapy or chemotherapy before, these therapeutic options are available for treating central pelvic recurrence. Repeat radiotherapy achieves successful local control with improvement of symptoms in cases of recurrent tumor outside the primary radiation field. Palliative chemotherapy is the final option available to all patients in whom curative surgery or radio(chemo)therapy is no longer possible. 

Pelvic exenteration is the curative method of choice in patients with central pelvic tumor recurrence and comprises colpectomy and hysterectomy with removal of the bladder (anterior exenteration) or of the bladder and rectosigmoid (complete exenteration). In addition,the intervention maybe performed as supralevator exenteration with partial resection of the levator plate or as translevator exenteration with vulvectomy and radical resection of the levator muscle, urogenital diaphragm, and vulvoperineal... 

Curtin, 1. P. and Hoskins, W. J. Pelvic exenteration for gynecologic cancers. Surg Oncol Clin North Am 994 3 267-276. 

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