and Walsh described “resection of the great veins of the lateral pelvic wall” to gain clearance for advanced gynecological tumors in the late 1940s [60]. However, extension of pelvic cancer into the pelvic sidewall was traditionally been considered contraindication to resection. Due to the technical difficulty of safely attaining an R0 resection margin. Efforts at vascular reconstruction were hampered by the procedure being frequently preformed in a grossly contaminated and often previously heavily irradiated field [61]. Due to these poor early outcomes, few undertook such radical resections until very recently [62].
Contemporary studies have reported en‐bloc resection of the pelvic sidewall for both locally advance and recurrent rectal cancer involving the lateral pelvic neurovasculature with good outcomes [63]. Similarly, extended lateral wall resection is possible in advanced gynecological tumors [64]. Some units are providing “higher and wider” resections for tumors involving the common and external iliac vessels [65, 66] and extending to the sciatic nerve and ischial bone [2, 57, 67]. Reported R0 resection rates range from 38 to 58%, with no perioperative mortality, and 96–100% long‐term graft patency [65, 66].
Perineal Reconstruction
In the original series, after the exenteration was performed, the pelvis was generally packed and allowed to heal by secondary intention. Later, surgeons closed the perineum in two layers, to prevent the small intestine prolapsing into the pelvic cavity [1]. In recent decades, various techniques for filling the “dead‐space” have been examined. The omental pedicle flap was reported as an adjunct in keeping the small bowel and urinary conduit from prolapsing into the pelvic cavity, with the hope of reducing fistula rates [68, 69]. In addition, the use of mesh reconstruction of the pelvic inlet, colonic advancement, and locoregional myocutaneous flaps have been advocated with varying degrees of success (Figure 1.5) [70–72]. The use of flaps in particular was an important development that simultaneously allowed closure of perineal wounds not amenable to primary closure and transfer of viable tissue into the pelvis to decrease septic and perineal complications [73, 74]. Moreover, myocutaneous flaps may be used to construct a neovagina [75, 76].
Figure 1.4 Diagrams from the first description by Wanebo and Marcove of abdomino‐prone sacral resection showing the extent of resection required for recurrence of rectal cancer in the posterior compartment (A), lines of transection of the sacrum from the posterior approach (B), the operative defect after sacral resection (C), and rotational skin flaps for wound closure (D). Copyright © 1981 J.B. Lippincott Company.
Source: Reproduced with permission from Wolters Kluwer [49].
Future Directions
The ability to perform radical and extended pelvic cancer surgery is the only potentially curative treatment for patients with locally advanced or recurrent pelvic tumors.
Better diagnostics and chemotherapeutics are likely to be “key” in personalizing patient care, improving survival, or converting unresectable disease to resectable. In addition, there is growing research on quality‐of‐life outcome data following extended radical surgery. This is increasingly becoming as important an outcome measure as survival. The PelvEx Collaborative, offers an unique opportunity to prospectively assess exenterative outcomes, refine treatment options and further improve the management of advanced pelvic malignacies.
Figure 1.5 Gracilis myocutaneous flap for reconstruction of the perineum after PE as described by McCraw et al. in 1976. Copyright © 1976 Plastic & Reconstructive Surgery.
Source: Reproduced with permission from Wolters Kluwer [70].
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