Surgical Procedures: Pelvic Exenteration

What is a pelvic exenteration?

A pelvic exenteration is the removal (taking out) of a woman's uterus, cervix, ovaries, fallopian tubes, and vagina (the reproductive organs). There are times when the bladder, urethra and/or bowel, anus, and rectum are removed also. A pelvic exenteration may be used to treat some cases of gynecological cancers, such as recurrent cancers (cancer that comes back) of the uterus, cervix, vulva, or vagina.

There are three types of pelvic exenteration:

• Anterior: Removal of all reproductive organs and bladder.
• Posterior: Removal of all reproductive organs and bowel.
• Total: The bladder, urethra, rectum, anus, colon, and reproductive organs are removed. This requires the placement of two ostomies (holes), one for urine and one for stool.

An ostomy to help stool leave the body is called a colostomy. The part of the colostomy seen on the abdomen (belly) is called the stoma and will be covered by a collection bag.

When the bladder and urethra are removed, a urinary diversion (a way to get urine to the outside of the body) will be made. During this procedure, your kidneys and ureters are connected to the urinary diversion, which will exit through the belly. There are two types of urinary diversions with stomas:

• Ileal conduit: Uses a collection bag around the stoma.
• Urinary pouch: You will need to place a tube (catheter) into the hole to drain the urine.

Some women may choose to have surgery to rebuild or reconstruct a vagina. This surgery can often be done by a plastic surgeon at the end of your pelvic exenteration surgery. This new vagina is called a "neovagina.” The neovagina is made by using skin and/or muscle from other parts of the body. Ways to make a neovagina are:

• Skin Grafting: Skin taken from other parts of the body is used to make the new vagina. When using only skin grafts, vaginal stents are needed to keep elasticity (stretching) of the new vaginal tissues. These stents prevent shrinkage, scarring, or closure. At first, the stent will be worn all the time. You will then just wear it for most of the day for many months. Often, after a few months, women can either use a tube, dilator, or vaginal intercourse to keep the vagina open.
• Muscle flap and skin grafting: Muscle flaps and skin grafts can be used to make a neovagina. Muscle and skin from the lower chest and abdomen are often used. This is called a vertical rectus abdominis muscle flap (VRAM). Other muscle flap areas may be used as well. This procedure allows for better sensation and patency (keeping the vagina open). Although this neovagina will look like the pre-surgery vagina, the sensation and function will be different.

A neovagina is not able to cleanse itself so you will need to douche to prevent vaginal discharge and odor. You will be told how and when to do this. Light bleeding or spotting after having intercourse is normal. Heavy vaginal bleeding is not normal, and you should call your care team if this occurs. Having an orgasm can be challenging.

If you don’t want a reconstructed vagina, it will be closed with skin.

How is it done?

A pelvic exenteration is done using an up-and-down incision (cut) on the belly to access the pelvic organs. Drains will be placed. A catheter will drain urine and collection bags will be placed over the ostomy stomas. Bandages will also be placed on the abdomen (belly) and inner thighs if reconstructive surgery was done. Talk to your provider about your specific surgery and ask them any questions you may have.

What are the risks of having a pelvic exenteration?

As with any surgery, there are risks and possible side effects. These may be:

• Blood loss.
• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery. It helps you to not remember the surgery and it manages pain. Reactions could be wheezing, rash, swelling, and low blood pressure).
• Infection.
• Wound separation (opening of the wound).
• Anastomotic breakdown (breakdown of the areas joining the stomas, colon, and/or ureters).
• Fistula (hole).
• Bowel obstruction (blockage).
• Blood clots.
• Flap and/or stoma necrosis (flap and/or stoma tissue death).
• Lymphedema (swelling).
• Change in sensation (feeling).
• Decrease in quality of life.

What is recovery like?

The hospital stay for a pelvic exenteration is often 7 to 10 days, based on the surgery you have had.

Early walking and deep breathing will be help prevent blood clots and pneumonia. If a vaginal reconstruction was done, you will only be able to stand or lie on your back and side. You will be unable to sit for 6-8 weeks.

Your care team will teach you about the medications you will be taking for blood clot prevention, infection, pain, and constipation, among others.

Your healthcare provider will talk to you about any changes to your activity level while you are at home based on the extent of your surgical procedure. Often, a nurse will visit you at home to teach you how to care for your stoma, drain, and incision.

Your healthcare team will tell you when you can return to normal activity. Until that time, you should:

• Get plenty of rest.
• Walk as tolerated.
• Avoid sitting for 6-8 weeks following vaginal reconstruction.
• Avoid housework and lifting.
• Follow vaginal dilation instructions and do not place anything other than what you are told into the vagina.

What will I need at home?

• Thermometer to check for fever, which can be a sign of infection. Your provider will tell you at what temperature you should call them.
• Loose clothes and underwear.
• Incision care items, which can be given to you by the hospital/provider's office.
• Sanitary pads for vaginal bleeding/discharge.

Symptoms to report to your healthcare team include:

• Fever. Your care team will tell you at what temperature you should call them.
• Any new or worsening pain.
• Nausea/Vomiting.
• Vaginal bleeding or foul-smelling discharge.
• Urinary problems such as burning or inability to pass urine from stoma or pouch.
• Constipation.
• Wound pain, swelling, redness, discharge, opening.

How do I care for my incision?

You will be told how to care for your incision. Incisions should be kept clean and dry. Shower as told by your team.

Be sure to look for signs of infection, like redness, swelling, drainage, or separation (opening) of the incision, and call your healthcare provider if these happen.

If you have staples, they will be removed either in the hospital or at your first follow up visit.

Wear loose-fitting clothes to avoid irritation of the incision.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice that you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.