TOTAL PELVIC EXENTERATION AND LATERALLY EXTENDED ENDOPELVIC RESECTION WITH SCIATIC NEUROPLASTY IN A PATIENT WITH RECURRENT CERVICAL CANCER

WA McCreath, DA Levine, BH Bochner, JH Healey, RR Barakat, DS Chi

   Objective: To describe a surgical approach which facilitates the removal of centrally recurrent pelvic tumors extending to the pelvic sidewall.

   Methods: A case was reviewed and a surgical approach outlined and discussed.

   Results: A 62-year-old woman with Stage IIIB cervical carcinoma was primarily treated with chemoradiation. After a disease-free interval of 3 years, cervical biopsy confirmed recurrent disease. A magnetic resonance imaging scan of the abdomen and pelvis localized a central recurrence with extension to the pelvic sidewall musculature. Laparoscopy confirmed that disease was confined to the pelvis, and paraaortic lymph nodes dissected at that time were negative. She was subsequently taken to the operating room for a total pelvic exenteration (TPE) with a laterally extended endopelvic resection (LEER) to clear the pelvic sidewall disease.

To mobilize the sciatic nerve safely and permit complete removal of the pelvic sidewall tumor, a combined anterior and posterior approach was used. The posterior dissection was performed first through a Kochner-Langenbach incision in the buttock to assess the sciatic notch. The ischial spine was osteotomized, the sacrospinous and sacrotuberous ligaments cut from the sacrum and ischium, and the obturator internus muscle dissected subperiosteally along the inner table of the acetabulum and ischium. This posterior dissection allowed the medial and inferior margins along the sciatic nerve to be easily identified, greatly facilitating the ability to safely perform the TPE and LEER procedures with negative margins around the pelvic sidewall tumor. After the specimen was removed, 1500 Gy of high-dose-rate intraoperative radiation therapy was delivered to the pelvic sidewall.

Postoperative complications included mild coagulopathy and anemia that resolved with blood transfusions. The patient was discharged on the 14th postoperative day. One month later, she presented with a large pelvic abscess, which was drained with a pigtail catheter. She is currently without evidence of disease at 6 months postoperatively.

   Conclusion: In patients who have recurrent gynecologic malignancies extending to the pelvic sidewall, the addition of a posterior approach with a sciatic neuroplasty to the TPE and LEER procedures may aid in the safe removal of the tumor with negative margins.