Pelvic exenteration is among the most complex and demanding operations in gynaecological oncology. First described in 1948 by the pioneering surgeon Alexander Brunschwig for women with recurrent cervical cancer, the procedure entails en bloc removal of pelvic organs invaded by malignancy, often including the rectum, bladder, lower colon, vagina and uterus, with reconstruction of urinary and intestinal continuity. Modern practice reserves exenteration for select patients with centrally recurrent gynaecological cancers or locally advanced primary tumours when conventional therapies have failed or are not feasible. The goal is an R0 resection—no tumour left behind—and survival at the price of significant short‑term morbidity.
Exenterations are categorised by the organs removed. Magrina and Stanhope’s classification describes supralevator (type I), infralevator (type II) and infralevator with vulvectomy (type III) operations. Clinicians also distinguish anterior (bladder removal with preservation of the rectum), posterior (rectum removal but preservation of the bladder) and total exenterations. These variations accommodate tumour location, previous radiotherapy and patient factors. Classic indications include a central pelvic recurrence of cervical cancer that is fixed to the bladder or rectum but without distant metastases. The operation may also be offered for recurrent endometrial, vulvar or vaginal cancers, and occasionally as primary treatment for locally advanced malignancy to control bleeding or discharge when palliative measures fail. Absolute contraindications are distant metastasis or unresectable pelvic sidewall or sacral bone involvement. Relative contraindications include ureteric obstruction or severe medical comorbidities; patient motivation and support are crucial because recovery is long and physically demanding.
Five‑year overall survival for pelvic exenteration varies widely. Modern series report survival rates between 20 and 50 per cent, with some high‑volume centres achieving roughly 60 per cent with tolerable morbidity. Disease‑free survival is about 40–50 per cent. These outcomes depend on achieving clear margins and the absence of pelvic or distant lymph‑node metastases, which are adverse prognostic factors. The procedure carries significant morbidity; half of patients experience major complications such as anastomotic leaks or fistulae, and perioperative mortality is around 3–5 per cent. Hospital stay is prolonged and physical recovery often takes 6–12 months. Quality of life deteriorates markedly at one month because of pain, stomas and altered body image, but by 12 months many survivors return to their baseline. Younger patients often worry about sexuality and body image, whereas older patients may struggle to regain independence. These outcomes underline the importance of careful selection and candid counselling.
Successful exenteration demands collaboration. Once imaging confirms an isolated central recurrence without metastases, cases are discussed in gynaecological oncology multidisciplinary meetings. Surgeons, anaesthetists, urologists, colorectal and reconstructive specialists, oncologists, radiologists, stoma nurses, physiotherapists and dieticians contribute to the decision and plan. The team weighs the likelihood of achieving clear margins against the morbidity and the patient’s wishes. Pre‑operative counselling often involves several consultations to ensure that the woman understands the magnitude of the surgery, the risks and the potential need for stomas. Psychological support is essential both before and after the operation.
The surgical team at the Barts gynaecological oncology unit shared a series of 25 patients treated between 2010 and 2017. Most were women in their fifties with recurrent cervical or endometrial cancers. Operations ranged from anterior exenteration with neovaginal reconstruction to total exenterations requiring removal of the vulva and sacrum. Early complications occurred in about 40 per cent of cases, chiefly wound infections and urinary leaks, but there was no 30‑day mortality in their series. Half of their patients remained alive and disease‑free at follow‑up. However, distant recurrences, particularly in the lungs and liver, were not uncommon. These experiences echo the published literature: exenteration is a salvage procedure that can offer durable survival for selected patients but carries a high price in terms of physical and psychological cost.
Pelvic exenteration remains an extraordinary operation undertaken only when all other treatments have failed or when it offers the sole chance of cure. Advancements in imaging, surgical techniques and perioperative care have improved morbidity and survival, yet the operation’s impact on quality of life and the risk of recurrence demand judicious patient selection. A multidisciplinary team, thorough counselling and postoperative rehabilitation are critical. For women facing recurrent or locally advanced pelvic cancers, exenteration can provide the possibility of prolonged survival and freedom from distressing symptoms, but it is never a decision taken lightly.
