Journal of Cancer and Clinical Oncology

Vol. 3(2), pp. 030-035, June, 2019. © www.premierpublishers.org. ISSN: 5907-4449

Research Article
A Retrospective Analysis of Complications of Pelvic Exenteration
- A Single Institution Experience of 6 Years
*1Subbiah Shanmugam, 2Murali Kannan, 3Arul Murugan
1,2,3Centre for Oncology, Government Royapettah Hospital & Kilpauk Medical College, Chennai, India

To analyse complications in patients who underwent pelvic exenteration procedures performed

in our, between January 2013 – December 2018. A retrospective analysis of the baseline
characteristics, surgical outcomes, complication rates of 51 patients who had undergone pelvic
exenteration procedures between January 2013 and December 2018 was made. The results
analysed using chi-square test. Of the 51 patients, 38 were operated for primary malignancy and
13 underwent exenteration for recurrences. Seventeen patients were operated by laparoscopy
whereas the rest underwent open procedures. The diagnosis for which exenteration had been
done included cancers of cervix (37), urinary bladder (5), rectum (4), urethra (1), vagina (3), and
ovary (1). Bleeding was the most common complication encountered. Hypokalaemia, surgical site
infections, urine leak and sepsis were seen in early post-operative period. The morbidity rate
(major) was 33.3% and the mortality rate was 5.8% in our centre. The late outcome was
inadequately evaluated as most patients lost follow-up. Pelvic exenteration is the only surgical
option available for advanced pelvic malignancies and the morbidity pattern differs based on
diagnosis, extent of resection and the type of diversion procedure. In a high-volume centre, the
morbidity and mortality rates are acceptable compared with international standards.

Keywords: Complications, Hypokalaemia, Pelvic exenteration, Sepsis, Wet colostomy

INTRODUCTION

Pelvic exenteration is performed for advanced cancers of (2014) and varies based on the primary diagnosis. This
cervix, urinary bladder, vagina, rectum and post chemo aim of this study is to analyse the morbidity and mortality
radiation residue or recurrences that are localised to associated with pelvic exenteration procedures in our
pelvis. Distant metastasis is considered as a centre.
contraindication for the procedure. It involves radical
enbloc removal of pelvic organs including recto sigmoid
and urinary bladder and uterus and tubes. Pelvic
exenteration surgery may be anterior (uterus and urinary
bladder), posterior (uterus and rectum) or total (rectum,
uterus and urinary bladder) and patients require diversion
of urine or faeces or both depending on the type of
exenteration (ileal conduit/colostomy and wet colostomy –
common stoma for both urine and faeces). This can be
performed with a curative intent and sometimes for
palliation. The postoperative morbidity patterns change *Corresponding Author: Subbiah Shanmugam;
based on the type of exenteration and the diversion Professor and Head, Centre for Oncology, Government
procedures being performed. It is well known that, pelvic Royapettah Hospital & Kilpauk Medical College, Chennai,
exenteration is a highly morbid procedure, with metabolic, India. Email: subbiahshanmugam67@gmail.com, Tel:
gastrointestinal and urinary complications affecting most 9360206030;
patients. In spite of all these, the 5 year survival after pelvic Co-Authors Email: 2drmjmuralikannan@gmail.com;
exenteration procedures is 30-60% as per Westin et al 3
drarulramalingam@gmail.com
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years
Shanmugam et al. 031
MATERIALS AND METHODS
All the patients who underwent pelvic exenteration in our
centre for oncology, between January 2013 and December
2018 were included in the study. Their case records were
analysed from the cancer department registry. The
patients were analysed for their baseline characteristics,
surgical outcomes, complication rates. The complications
were graded using clavien dindo grading and the
complications were also compared between various types
of urinary diversion procedures. The morbidity and
mortality patterns were analysed and was compared with
various studies. Early complications are defined as those
that occur within 30 days of surgery. Major morbidity
included urine leak and sepsis. Others include
hypokalemia and surgical site infections. Sepsis was
defined in our study as per Sepsis – 3 consensuses.
(documented infection and organ dysfunction).
Data regarding Urine leak was retrieved from the case
records. All the patients were routinely subjected to
ultrasound of abdomen in the postoperative period which
demonstrated intraabdominal collection which was
aspirated and proven to be urine by biochemical analysis.
Urine leak was also confirmed by CT scan in selected
patients.
All the procedures were done by experienced surgical
oncologists under standard epidural and general
anaesthesia. Institutional ethical committee approval was
obtained for this study. Chi square test (p value) was used
for the analysis of the results.
RESULTS
The patient characteristics and surgical outcomes are
tabulated in Table I and Table 2 respectively. All the
patients who underwent pelvic exenteration in our centre
between January 2013 and December 2018 were included
in the study. Among the 51 who underwent pelvic
exenteration, 23 patients (45.09%) were treatment naïve
whereas 14 patients (27.45%) were post chemoradiation
residue and the rest 27.45% had recurrences. The
average age of the patients who underwent pelvic
exenteration is 52.1 years. Most patients (72.54%) had a
performance scale of ECOG 1. 72.5% patients had
carcinoma cervix as the primary site whereas the rest
included vagina, bladder, rectum, urethra, ovary. 25
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years
patients (49.01%) had a history of previous
chemoradiation for the same diagnosis.
The estimated average blood transfusion during surgery
is 393.2 ml with a range of 0 to 4 units of blood transfusion.
The average duration of surgery is 200 minutes with a
range of 165 to 300 minutes. Seventeen patients were
operated by laparoscopy whereas the rest underwent
open procedures. The average postoperative stay was 24
days for the patients with a range of 16 to 49 days. The
complications (figure 1) that were frequently encountered
included metabolic (hypokalemia), surgical site infections
(superficial and deep), urine leak and sepsis.
Hypokalaemia was seen in 42 (82.3%) patients. However,
the degree of hypokalaemia varied (mild, moderate,
severe). Patients were given oral or intravenous potassium
supplementations accordingly. Surgical site infections
were seen in 19 patients (37.2%) and urine leak in 13
patients (25.4%). Surgical site infections were seen 15
patients (60%) who had received prior chemo radiation.
Out of the 15 patients who went into sepsis, 11 had urine
leak (73.3%). 15 patients had sepsis with blood cultures
showing E.coli and Proteus organisms sensitive to
amikacin in 5 patients and sensitive to piperazillin-
tazobactum in 6 patients. Three patients died in the
postoperative period due to sepsis and shock. Majority of
the patients, had clavien dindo grade 2 complications while
few had complications with grades 3, 4, 5. None of the
complications were graded 1. (Table 3)
Of the 51 patients, 20 (39.2%) underwent anterior pelvic
exenteration with ileal conduit as diversion procedure, 4
(7.8%) underwent posterior pelvic exenteration and the
rest underwent total pelvic exenteration with ileal conduit
(5 patients) or wet colostomy (23 patients) as diversion
procedure. As most of the patients had lost follow-up, only
13 of them were reviewed for long term morbidity. 7 of
them had complaints of pedal edema and elevated renal
parameters suggestive of chronic kidney disease. 3
patients had recurrent episodes of infections and were
treated conservatively.
On a comparison of the complications between the urinary
diversion procedures, (Table 4) there were no statistical
difference between ileal conduit – colostomy and Wet
colostomy. The overall major morbidity of the procedure
was 33.3% while mortality was 5.8% which has been
compared with various other studies in table 5.
 J. Cancer Clin. Oncol. 032

Figure 1: Complications following pelvic exenteration

Table I: Baseline characteristics of the 51 patients who underwent exenteration

Patient characteristics No. of patients (%)
1. Presentation of disease
a. First diagnosis 23 (45.09)
b. Chemo radiation Residue 14(27.45)
c. Recurrence 14(27.45)
2. Age ( mean) in years (range) 52.1 (35 – 70)
3. ECOG performance status
a. 0 8(15.6)
b. 1 37(72.54)
c. 2 6(11.7)
4. Primary tumour origin
a. Cervix 37 (72.5)
b. Vagina 3(5.88)
c. Bladder 5(9.8)
d. Rectum 4(7.84)
e. Urethra 1(1.96)
f. ovary 1(1.96)
5. Previous treatment
a. None 26(50.98)
b. Chemo Radiation 25(49.01)

Table 2: Surgical outcomes of various exenteration procedures

Overall APE PPE TPE/ic TPE/wc P

(n=51) (%) (n=20) (%) (n=4) (%) (n=6) (%) (n=21) (%) value**
Mean operating time (min) 200.1 202.3 188 198.1 190 -
Mean Transfusion units 1.2 1.3 1.2 1.2 1.1 -
Mean hospital stay (post-surgery) 24 21 25 26 23 -
Metabolic complication (Hypokalaemia) 42(82.3) 20(100) 4(100) 6(100) 10(47.6) -
Surgical site infections 19(37.25) 9(45) - 4(66.6) 6(28.5) 0.58
Urine leak 13(25.4) 5(25) - 4(66.6) 4(19.04) 0.49
Sepsis 15(29.4) 6(30) 2(50) 2(33.3) 5(23.8) 0.61
Mortality 3(5.88) 2(10) - - 1(4.76) 0.38
** Chi-square test
APE – anterior pelvic exenteration; PPE – posterior pelvic exenteration; TPE – total pelvic exenteration; ic – ileal conduit;
wc – wet colostomy

A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years

Shanmugam et al. 033

Table 3: Clavien dindo grading of the complications (Dindo et al. 2004)

Grade of Hypokalemia (%) Surgical site infections(%) Urine leak (%) Sepsis (%)
complication (n=42) (n=19) (n=13) (n=15)
I - - - -
II 42 (100) 15(78.9) 10 (76.9) 9(60)
III - 2 (10.5) 1(7.69) 3(20)
IV - 1(5.2) 1(7.69) 2(13.3)
V - 1(5.2) 1(7.69) 1(6.66)

Table 4: Comparison of complications between ileal It has been done traditionally as a curative procedure for
conduit/colostomy and Wet colostomy locally advanced and recurrent pelvic malignancies
Complications PE +IC/c PE + WC P- including that of cervix, vagina, urinary bladder, and
(n=26) (%) (n=21) (%) value* rectum. The contraindication doesn’t just stop with distant
Hypokalemia 26(100) 10(19.6) 0.11 metastasis, but, Bhangu A et al. (2013) elaborated poor
Urine leak 8(15.6) 3(5.88) 0.29 performance status, bilateral sciatic nerve involvement
Sepsis 8(15.6) 5(9.80) 0.68 and circumferential bone involvement also. Relative
Mortality 2(3.92) 1(1.96) 0.70 contraindications like vessel encasement and pelvic side
*Chi-square test wall involvement are to be managed with laterally
PE – pelvic exenteration; ic – ileal conduit; wc – wet extended endopelvic resections as described by Höckel M
colostomy; c-colostomy (2008). Patient’s performance status, physiological age,
diversion procedures, radiation exposure and the primary
Table 5: Morbidity and Mortality of Pelvic Exenteration in disease are the major factors that determine the morbidity.
various studies The most common indication for pelvic exenteration was
Series [2] Year No. of Morbidity Mortality carcinoma cervix post chemoradiation residue and
patients (%) (%) recurrence.
Benn et al 2011 54 44 -
Maggioni et al. 2009 106 - 0 Pelvic Exenteration remains the only curative procedure
for patients with recurrent cervical cancer after nonsurgical
Marnitz et al. 2006 55 38 6
treatment (Radiation with or without Chemotherapy) (Tixier
Goldberg et al. 2006 103 25 1
et al. 2010). Another condition where Pelvic Exenteration
Sharma et al. 2005 48 45 4
is appropriate is primary ovarian cancer in which resection
Berek et al. 2005 75 45 4 of the bladder and/or rectum is necessary to achieve free
Poletto et al. 2004 96 15.6 19.8 margins or optimal cytoreduction. Also, uterine cancer
Lke et al 2003 45 77.8 14.3 (Khoury-Collado et al. 2012) sometimes presents as a
Wiig et al 2002 47 38.29 13 locally recurrent neoplasia in which some irradiation of the
Our series 2019 51 33.3* 5.8 pelvis has already been performed as part of the primary
*major morbidity only treatment and for which a radical surgical approach is
necessary to pursue a curative treatment. Most of the
complications after Pelvic Exenteration are related to the
DISCUSSION pre-irradiated tissue condition. Pelvic Exenteration’s
postoperative mortality is described as less than 5%, but
This analysis brings out that the major morbidity and with a high morbidity rate (around 50%). Cases with
mortality following pelvic exenteration are 33% and 5.5.% involvement of the pelvic bone have classically been
respectively. Described for the first time by Brunschwig in considered as inoperable, although (Milne et al. 2013;
1948 (Botoncea et al. 2017), Pelvic exenteration Dobrowsky and Schmid 1985; Milne et al. 2014; Solomon
procedures were palliative in advanced gynaecological et al. 2014) reported 37 cases in which it was required.
malignancies. Later, it was considered to be curative in They achieved a 40% Overall Survival at 5 years
certain circumstances with a reasonable survival benefit. compared with an OS of 4% for chemo-radiotherapy.
Major advances happened when separate stoma for faecal
and urinary diversion were made. Laparoscopic assisted In our analysis of 51 patients, the most common cancer for
procedures improved postoperative wound morbidity. which it was done was that of cervix (72.5%) and post
Despite these developments, pelvic exenteration remains chemoradiation (49.01%) patients. Some of the
a high morbid procedure with significant complication both complications that were studied included hypokalemia,
intraoperatively and postoperatively. The mortality rates surgical site infections, urine leak and sepsis. The
are however around 5%. percentage of patients who had hypokalemia was 82.3%
overall. The surgical site infections were more common in
Pelvic exenteration refers to radical excision of the pelvic the Total pelvic exenteration with ileal conduit (66.6%) and
organs including internal reproductive organs, urinary mortality of 10% was seen in anterior pelvic exenteration
bladder, recto-sigmoid as described in Pawlik et al (2006). patients as a result of sepsis.

A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years


The major morbidity and mortality were 33.3% and 5.8%
respectively in our study and was comparable with the
other studies such as Berek et al. and Marnitz et al. which
had a morbidity of 45% and 38% respectively and a
mortality rate of 4% and 6% respectively.
Hypokalemia was managed by oral and intravenous
potassium supplementation. Any patient who had a serum
potassium levels between 3 and 3.5 mmol/L was treated
with oral potassium (40 to 100 mmol of oral potassium per
day) and patients with serum potassium levels less than 3
mmol/L were treated with intravenous potassium(20 to 40
mmol of potassium in 1 litre of normal saline). 20mmol per
day was given as supplementation in view of ongoing
potassium loss.
Sepsis in our study was seen more in pelvic exenteration
patients with ileal conduit and end colostomy. Sepsis was
defined in our study as per Sepsis – 3 consensuses.
(documented infection and organ dysfunction). Sepsis was
managed by intravenous antibiotics.
Urine leak was seen in 25.4% of patients with majority
(66.6%) occurring in ileal conduit patients. Some patients
had a controlled leak which was diagnosed only by and
ultrasound of the abdomen, whereas for some the leak
was evident through the perineal wound. Urine leak was
managed conservatively (pigtail catheters insertion in 1
patient). Mortality was seen in 5.8% of patients overall and
it was attributed to sepsis. The morbidity and mortality of
these patients are due to the advanced nature of the
disease and the extent of surgical resection.
In a similar study conducted by Pandey et al (2004), the
operative morbidity and mortality were 62.5% and 10.42%.
In our study, it was 33.3% and 5.8%. Several other studies
have also been listed in table 5.
Seventeen patients were operated by laparoscopy and in
view of the small number, the comparison of complications
between laparoscopic and open procedures was not done.
However, studies comparing the complications between
laparoscopic and open procedures are ongoing in our
institution.
Pelvic exenteration provided approximately 40% chance of
survival at 4 years (Lago et al. 2019) in a selected group
of patients with cancer of the low and middle female genital
tract in which other therapy cannot be performed. Pelvic
Exenteration can offer locoregional control in patients with
no abdominal spread and where R0 resection is
accomplished (Koch et al. 2012).
CONCLUSIONS
Pelvic exenteration, though a highly morbid procedure can
be performed with a curative intent. In our analysis, though
the morbidity is around 33%, it is still acceptable for it is
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years
J. Cancer Clin. Oncol. 034
the only available surgical option in advanced stage
disease. Sepsis has been the most common cause of
mortality. Laparoscopy may improve outcomes but this
needs larger studies for validation. It is important to stratify
and select patients so as to minimize the degree of
morbidity and mortality associated with this procedure.
Source of Funding: None
Conflict of Interest: None
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A Retrospective Analysis of Complications of Pelvic Exenteration - A Single Institution Experience of 6 Years