What Women Should Know About Pelvic Exenteration

One of the most radical and rarely conducted surgeries in medicine is known as pelvic exenteration. This surgery is typically a last-resort cancer treatment, and candidates must be carefully selected and counseled.

Here is an overview of the safety and implications of the procedure and its effects on your sex life and overall quality of life.

What are the side effects of pelvic exenteration?

Pelvic exenteration is a measure of last resort used to treat aggressive forms of cancer. Certain organs, including the vagina, cervix, ovaries, uterus, bladder, anus and even part of the intestines may have to be removed to stop the cancer cells from spreading.

Since it's a serious intrusion into the function and balance of your body, various side effects during the procedure and afterward are possible. These include, but are not limited to, the following:

• Pain from wounds
• Infections
• Bowel joint problems
• Necessity for blood transfusion
• Emergency procedures and operations

"There are only about 150 performed per year in the U.S. Indications for pelvic exenteration usually include the treatment of very locally advanced and/or recurrent pelvic cancers," said Clare Bertucio, M.D., a radiation oncologist with Peninsula Radiation Oncology Center in Soldotna, Alaska. "In general, this surgery is only considered when all other methods of treatment have either failed or have been deemed to be noneffective. The goal can be pain relief, life extension or even, potentially, cure in patients with recurrent or persistent disease despite aggressive therapy.

"Because of the nature of this procedure and the rarity with which it is performed, patients should consider seeking care in a center where a surgeon trained and experienced in these types of procedures practices," Bertucio added.

How long is the surgery and recovery?

The length of the surgery depends on the patient's health condition, any potential complications during the surgery and how much intervention has to be done.

"On average, [procedures last] approximately six to 12 hours; very complex ones can go on for longer," said Jamie Murphy, B.Chir., Ph.D., a consultant surgeon with Imperial College Healthcare NHS Trust and a clinical professor of surgery at Cleveland Clinic London, Case Western Reserve University. "My longest has been 36 hours. Approximately five days in ICU and in hospital for three to four weeks on average. More complex ones obviously result in longer hospital stays. Recovery takes three to six months, depending upon complexity."

After the procedure, patients spend approximately five days in intensive care under constant medical supervision so doctors can ensure the wounds have been closed successfully with no signs of infection and are starting to heal.

The whole procedure is very straining on the body, so any adverse side effects, such as lung or heart complications, are most likely to arise.

"Big operations like this can also be associated with heart or lung problems, blood clots in legs or lungs, uncommon medical problems such as stroke, and a small risk of death during or after the operation," Murphy added.

After that intense initial period, patients usually stay three to four weeks in the hospital. They may enroll in an outpatient program to receive regular checkups and medical assistance, as the road to full recovery usually lasts at least six months. The total length depends on the complexity of the procedure, how successful the surgery was, the general health of the person and the quality of the medical care they experienced.

"Exenteration is a cover-all term. It can be something relatively simple, such as removal of the bladder, vagina or prostate, or it can also include removal of the sacrum, blood vessels to the legs and nerves to the legs," Murphy explained. "The three latter groups have much greater complications, operation and recovery times. [This] specifically applies to rectal cancer. Exenterations can also be performed for bladder, prostate and gynecology cancers, and while the complication and recovery rates will be the same for all cancers, the survival data will be different."

"Pelvic exenteration may be appropriate in patients who have received prior definitive radiation, but any pelvic surgery following definitive pelvic radiation can be more complicated," Bertucio added. "With such an extensive and relatively rare procedure, each case must be individually considered and in-depth discussions need to be undertaken between all involved teams and the patient."

Does pelvic exenteration improve survival rates?

Survival rates vary depending on the type of cancer. For rectal cancer, statistics suggest full tumor removal leads to a 45 percent chance of full recovery.

The recovery rate also varies from person to person, depending on the type of cancer, how aggressively it spread before the procedure, and whether the removal of the tumor made other interventions more effective in treating the condition.

How does pelvic exenteration affect your sex life?

Pelvic exenteration can affect a person's ability to experience an orgasm, reduce sexual gratification and lead to discomfort or even pain after the procedure. The potential side effects you experience depend on how the procedure went.

For example, some women experience full vaginal loss, while others may retain the front wall or have the opportunity for reconstruction through the use of tissues, such as skin flaps, abdominal muscles and so on.

The individual symptoms depend on your gender. Women may experience discomfort during penetration, reduced sensitivity to pleasure in certain areas and other changes. Men may experience issues with ejaculation and erection.

"Depending on the extent of the surgery, or any cancer therapy/treatment, sexual function will likely be significantly impacted," Bertucio said. "It is always paramount to discuss these potential changes and impacts with a woman, and her partner, if willing, prior to treatment. Pelvic therapists and sexual counselors, as well as treating physicians, will add a tremendous amount to these discussions. I strongly advise including them as early as possible in the process. Unfortunately, pelvic exenteration is a life-changing procedure, so early, frequent and robust support for the patient and her family is an absolute requirement preoperatively."

What should a person do before undergoing pelvic exenteration?

Pelvic exenteration is a life-changing operation with long-term implications to a person's overall health, sex life and self-esteem. Personalized therapy before and after the procedure and during recovery is advised so they can understand the changes they will be going through, learn to adapt to the new circumstances and employ coping strategies for the challenges they are likely to face in their journey against cancer.

"It is not only important but imperative that patients receive in-depth counseling prior to considering a pelvic exenteration," Bertucio noted. "Secondary to the radical nature of this procedure, a patient's life will be altered and greatly impacted. She definitely needs to understand the full repercussions of this type of surgery. And a full and frank discussion to help start understanding not only the long-term physical changes which may be involved but also to start identifying some of the potential psychological impacts of these changes is a must.

"I would say that this rare surgery may offer hope, pain relief, life extension or even cure in some patients, but the associated morbidity and lasting life changes must be carefully weighed and discussed with each individual patient in terms of risk versus benefit," she added. "Full disclosure and open dialogue with all team members and support specialties should be undertaken with the patient prior to surgery."