Pelvic exenteration

In gynaecological cancer, exenteration is mainly considered for cervical, vaginal, vulval or womb cancer that has recurred in the pelvis after radiotherapy, or for a locally advanced cancer that has invaded the bladder or rectum without spreading further. The NHS describes extensive surgery of this kind as reserved for recurrent cervical cancer when other treatments have not worked.

It is a decision made with care, because it is a major operation with permanent consequences. The aim is to remove all the cancer in the pelvis with a clear margin, which offers the possibility of long-term control. It is not suitable if scans show cancer outside the pelvis or if the person is not well enough to tolerate surgery.

Macmillan describes three versions according to which structures are removed. An anterior exenteration takes the front pelvic organs, including the bladder. A posterior exenteration takes the back organs, including the rectum. A total exenteration takes both groups. In women the womb, cervix, ovaries and part or all of the vagina are removed along with the organs named.

Which type you need is decided before surgery by scans and examination, though the surgeon may adjust it if the findings differ at operation. If the cancer is found to have spread beyond the pelvis, the operation may be stopped.

A multidisciplinary team assesses whether the operation is right for you, considering the extent of cancer, general health, ability to tolerate major surgery and realistic expectations of recovery. Macmillan lists blood tests, CT, PET-CT and MRI scans, examination under anaesthetic, cystoscopy, bowel endoscopy and biopsies as the tests that confirm the cancer is confined to the pelvis.

Prehabilitation, which can include exercise, nutrition, stopping smoking and cutting back on alcohol, is encouraged to improve fitness before surgery. Stoma nurses and psychological support are introduced early so that you have time to prepare.

A team of colorectal, urological and gynaecological surgeons often works together, with plastic surgeons if reconstruction is needed. Surgery may be open, through a long abdominal incision, or keyhole with four or five small cuts, as Macmillan explains. The surgeon begins by looking for spread and may take biopsies before removing organs.

Depending on what is removed, the bowel is brought out as a colostomy and the urine is diverted through a urostomy, so waste is collected in bags on the tummy wall. Reconstruction can rebuild the pelvic floor or vagina using tissue from elsewhere. Stoma nurses teach care of the stoma before and after the operation.

Macmillan describes the first days in intensive or high dependency care, then several more days to weeks on a ward. Pain is controlled through an epidural or a patient-controlled pump, and drips, drains and tubes are used for nutrition and fluid removal. Early walking, breathing exercises and anti-clot injections reduce complications; Macmillan describes four weeks of self-injected blood thinners after discharge.

Recovery from the operation can take from several weeks to a year, depending on its extent. People gradually resume work, driving and exercise. Late problems can include wound healing difficulty, infection, bowel or urinary complications and changes to sex life, so rehabilitation includes physiotherapy, sexual health advice and counselling.

Body image, intimacy and identity can change in ways that are hard to predict, and counselling and peer support have been found helpful. Many people find it useful to meet others who have had the same operation, and specialist nurses can often arrange this.

Follow-up includes scans and clinic checks. Ask your team about district nurse support at home, stoma supplies, and signs that should prompt a call to the hospital, such as fever, a wound that opens, a swollen leg or stoma changes.