Pelvic clearance is the removal of most or all of the pelvic viscera when pelvic tumours are large and locally extensive. It is divided into three types. Anterior pelvic clearance is the removal of the bladder, urethra and male or female sex organs with the formation of a urinary diversion via an ileal conduit. Posterior pelvic clearance involves resection of the rectum and the male or female pelvic sex organs with a bowel anastomosis or formation of an end colostomy. In male patients the bladder is reanastomosed to the membranous urethra. Total pelvic clearance is when the entire contents of the extra-peritoneal pelvic cavity are resected. In these procedures, the vagina is usually partially resected and the remnant oversewn to form a foreshortened vagina. Occasionally the vagina is totally resected. Pelvic lymph node resection is performed in those patients undergoing primary surgery or in those with recurrence who have not already had lymph node dissection.
More extensive pelvic clearance may require resection of the pelvic floor if the tumour is invading any part of it. Historically, tumour involvement of blood vessels or the sacrum rendered the patient ineligible for pelvic clearance. Recent improvements in surgical techniques, and in perioperative support, mean that vascular resection and grafting can be contemplated and sacral resection below S2-3 level is now feasible.
The commonest tumour treated by pelvic clearance is recurrent cervical cancer in the central pelvis. Other gynaecological malignancies which recur here may also be suitable for pelvic clearance. Because ovarian cancer metastasises widely within the abdomen and pelvis, it is not usually considered amenable to exenteration, unless it can be shown that the pelvic tumour mass is an isolated finding.
Locally advanced and recurrent rectal cancers and, less frequently recurrent bladder cancer, can be treated by exenteration. The results of exenteration for advanced prostate cancer are poor and patients with this condition are considered ineligible. Rare pelvic tumours such as sarcoma are also potentially curable by exenteration.
In carefully selected patients the outcome of pelvic clearance is 95% survival in the immediate post-operative period with a 2060% survival at 5 years. When exenteration is performed for gynaecological cancers, 5-year survival is 40-60% but it is approximately 20% less when performed for colorectal cancer. Patients in whom exenteration is performed as a primary treatment have a better 5-year survival compared to those operated on for recurrence, and those with primary tumours which are node negative have a high 5-year survival of 80%. When patients relapse after pelvic clearance nearly all will have local recurrence and approximately half will have systemic metastases.
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