Palliative pelvic exenteration using iliofemoral bypass with synthetic grafts for advanced cervical carcinoma

Abstract

Objective: Recurrent cervical cancer can cause severe morbidity. Despite the severe morbidity after surgery, pelvic exenteration is still used today for mainly curative intent. This intention is neither based on randomized controlled trials (RCTs) nor high quality non-RCTs with adequate patient numbers comparing medical management with surgery. The same is true for exenteration for palliative intent, so the patient selection for either curative or palliative intent must be considered on a patient-by-patient basis.

Materials and methods: A 35-year-old patient who had undergone primary chemo-radiotherapy for advanced cervical cancer presented with intractable pain on the swollen left leg and pelvis 8 months later. Left lower extremity Doppler ultrasound revealed echogenic thrombus in the external iliac, femoral, and popliteal veins, consistent with acute deep vein thrombus. She underwent total exenteration, end colostomy, ileal urinary conduit, pelvic lymphadenectomy, paraortic lymph node sampling, and ilio-femoral arterial and venous bypass.

Results: The procedure relieved her pain, the leg diameter dramatically decreased from 75 cm to 44 cm, and circulation of the leg was reestablished. The procedure deferred leg amputation for about five months.

Conclusion: To the best of our knowledge, this is the first report of a palliative pelvic exenteration for cervical cancer with combined iliofemoral arterial and venous bypasses. These procedures, with high morbidity and mortality, are also more controversial when undertaken for just palliation of symptoms. They must be considered in the basis of each patient, and the benefits and risks must be discussed thoroughly in a realistic perspective with the patient.

Keywords: Cervical cancer; iliofemoral bypass; palliation; pelvic exenteration.

Figure 1

The image of the patient just before the procedure. Swollen left lower extremity is clearly seen

Figure 2

Before the reconstruction phase; operative field after total pelvic exenteration and left external iliac vessels ligated RU: Right ureter, IV: Internal iliac vein, EV: External iliac vein, IA: Internal iliac artery, EA: External iliac artery, LU: Left ureter, SN: Sacral nerve roots

Figure 3

Operative field after iliofemoral arterial bypass and femoro-iliac venous bypass with polytetrafluoroethylene grafts EA: External iliac artery, EV: External iliac vein, SN: Sacral nerve roots, RAM: Rectus abdominis muscle before flap reconstruction