Pelvic Exenteration Surgery in Ankara, Turkey

Pelvic exenteration is a radical surgical method used in the treatment of advanced-stage pelvic cancers. During this procedure, it may be necessary to remove multiple organs such as the bladder, rectum, and uterus. The goal is to prolong survival by completely removing the tumor.

Pelvic exenteration surgery generally includes patients with locally advanced cancers that do not respond to radiotherapy or chemotherapy. It is especially preferred in rectal, cervical, or bladder cancers when the spread is limited to surrounding organs.

Quality of life after pelvic exenteration depends on the reconstruction procedures performed and the patient’s overall health status. Urinary and bowel pathways can be reconstructed, and sexual function may be affected. Physical and psychological support after surgery is important.

Risks of pelvic exenteration surgery include complications such as infection, bleeding, and organ failure. Therefore, the operation should be planned with experienced colorectal surgeons and a multidisciplinary team. The preparation process must be managed meticulously.

You can contact Prof. Dr. Ebru Soy, one of the doctors performing Pelvic Exenteration Surgery in Ankara, to get information about Pelvic Exenteration Surgery prices, the process, and the hospital where Pelvic Exenteration Surgery is performed.

What Is Pelvic Exenteration?

Pelvic exenteration is a comprehensive and radical surgical method used in advanced-stage or recurrent gynecologic cancers. In this procedure, all or part of pelvic organs such as the uterus, bladder, rectum, and sometimes the vagina are removed. Depending on the spread of the disease, the surgery may be performed as anterior, posterior, or total pelvic exenteration. This highly complex and lengthy operation requires careful patient selection and a multidisciplinary approach.

How has the role of pelvic exenteration in medicine changed in the historical process?

The perception of this surgery in the medical world has undergone an incredible transformation over the past thirty years. In the past, namely in the 1990s or the early 2000s, the approach to this procedure was much more cautious. In those periods, surgeons viewed this operation as a “last resort” that was technically very challenging, carried a very high risk of complications, and did not always yield satisfying outcomes. In fact, many centers hesitated to perform it. Those years were pioneering years in which it was questioned whether this could be done technically.

However, today the picture has completely changed. With increased refinement in surgical techniques, improved intensive care capabilities, and most importantly the establishment of a culture of different specialties working together, pelvic exenteration has become a “standard treatment” for selected patients rather than a feared last resort. Especially in advanced-stage rectal cancers or recurrent cases, it is the strongest bridge that keeps the patient connected to life. With advances in systemic therapies, namely chemotherapy and targeted drugs, since distant organ spread can be controlled better, we as surgeons can focus much more boldly and safely on clearing the disease in this region.

What are the pelvic exenteration criteria when deciding on this difficult surgery?

Deciding on such a major operation is never an instant decision made by a single doctor in a clinic room. This process is a serious analysis in which the patient’s condition, the tumor’s biology, and the hospital’s capabilities are weighed on a very sensitive scale. When making this decision, we consider the patient not only as a cancer case but as an individual with physiological reserve and expectations.

At this point, our most important goal is to achieve “curative” treatment, meaning complete cure. In surgical oncology, we have a sacred rule: R0 resection. This term means removing the tumor completely together with surrounding healthy tissue, leaving no visible or microscopic disease behind. If we proceed with this operation, our aim is not to leave the tumor behind. Scientific data clearly tell us this: In this surgery, the most important factor determining the patient’s chance of survival is whether the surgeon can leave a clear margin behind. That is why preoperative planning is not a simple procedure but a vital strategy meeting.

However, sometimes even if complete cure is not possible, we may pursue this path to improve the patient’s quality of life. We call this a “palliative” approach. Cancer can sometimes reach a point where the patient’s suffering becomes unbearable. In such cases, even if complete clearance (R0) cannot be achieved, surgery may be considered to relieve the patient.

Conditions that suggest palliative surgery are as follows:

• Severe pain
• Persistent fistulas
• Uncontrollable bleeding
• Tumor necrosis
• Foul odor
• Infectious episodes

In such situations, it is necessary to balance very well the risks of surgery with the comfort the patient will gain. If we cannot provide complete relief from cancer, the surgical trauma we inflict must be worth the patient spending their remaining life with a better quality.

Another important criterion is institutional competence. This operation is not a procedure that can be performed in every hospital. Pelvic exenteration requires general surgery, urology, plastic surgery, interventional radiology, and advanced intensive care support. Therefore, receiving treatment in a well-equipped center with extensive case experience is an indispensable requirement in order to manage complications.

Is age a barrier in patient selection, and who is suitable for pelvic exenteration?

The question we hear most often from our patients and their relatives is, “Doctor, can my age handle this surgery?” Here, a very clear distinction must be made: chronological age and biological age are not the same. An individual who is 75 years old, walks every day, and has no comorbidities may be much more “young” and suitable from a surgical perspective than a 55-year-old who has serious heart and lung problems and smokes. Therefore, chronological age alone is not a barrier to this surgery.

What is truly decisive for us is the patient’s “performance status” and “physiological reserve.” In other words, how well the body can withstand this major surgical trauma and the subsequent recovery process. We use international scales to measure this. Ideal candidates are patients who can handle their daily tasks independently and are active or only minimally restricted. For patients who are bedridden or unable to perform personal care, the risks of this surgery may unfortunately be far greater than the benefits.

In the preoperative evaluation, we pay attention to the following points:

• Heart functions
• Lung capacity
• Kidney values
• Nutritional status
• Presence of obesity
• Diabetes control
• Muscle mass

Nutritional status is especially critical. Chronic weight loss and malnutrition, which we see in cancer patients, are the greatest enemies that impair postoperative wound healing. Therefore, we put our patients on a strict nutrition program before surgery.

Another important issue is psychological preparation. This is not only a physical operation; it can create permanent changes in the patient’s life. Living with a bag (stoma), changes in sexual functions, or a long recovery period require strong psychology. The patient’s mental readiness for this process, adherence to treatment, and acceptance of outcomes are at least as important as heart health. The patient should know what they will face and embark on this path together with us with full belief.

Why are preoperative imaging and pelvic exenteration planning critical?

Before lying on the operating table, the surgeon must have, so to speak, a “perfect battle map” in hand. Since pelvic exenteration is usually performed in areas that have previously received radiation therapy or chemotherapy, tissues may be adherent to each other. Advanced imaging methods are our eyes and ears to find the way through this complexity.

The most important part of this planning is Pelvic MRI (Magnetic Resonance Imaging). MRI is excellent at distinguishing soft tissues from each other. It shows us, millimeter by millimeter, where the tumor ends, how close it is to the pelvic walls, which vessel it touches, or which muscle it involves. These details are vital to avoid surprises during surgery.

In addition, we обязательно perform a whole-body scan called PET/CT. Our goal here is to understand whether there is an “invisible part of the iceberg.” In other words, is the cancer confined to the pelvic region, or has it spread to distant organs such as the lungs or liver? If there is metastasis in a distant region, we generally refrain from performing such a large and risky operation with curative intent.

The information provided by imaging methods is as follows:

• Tumor size
• Organ involvement
• Vascular proximity
• Bone spread
• Distant metastasis
• Lymph nodes

With this map, we plan in advance where to make the incision, which organs must be sacrificed, and which vessels can be preserved. These images also guide us for bleeding control. Unexpected bleeding impairs the surgeon’s view and reduces the success of clearing cancerous tissue (R0). Knowing the location of vessels beforehand minimizes this risk.

What are the types and scope of pelvic exenteration surgery?

Pelvic exenteration is not a single-type surgery. Depending on the location and extent of the disease, the strategy the surgeon will apply changes. We general surgeons classify this surgery anatomically according to the involved regions (compartments). The basic principle is to remove at least two organ systems in order to remove cancerous tissue with a safe margin.

The main types of surgery are as follows:

• Anterior exenteration
• Posterior exenteration
• Total exenteration
• Extended exenteration

Anterior Exenteration is generally performed in gynecologic or urologic cancers when the tumor does not involve the rectum (the end of the large intestine). The bladder and, in women, the uterus/vagina are removed, but the intestinal system is preserved. In these patients, a new urinary pathway must be created.

Posterior Exenteration is more commonly applied in rectal cancers. The bladder is clean and preserved, but the rectum, anus, and in women the posterior wall of the uterus are removed. In this case, the patient will need a permanent colostomy (fecal bag).

Total Exenteration is performed when the disease involves both the anterior and posterior regions. The bladder, rectum, and reproductive organs are completely removed. New pathways must be created for both urine and stool.

There is also Extended Exenteration, which is the most radical. The cancer is not confined to the organs; it has adhered to bones (the coccyx or the anterior pelvis) or to the main vessels and nerves on the lateral wall. To obtain a clear margin, these bone or vascular structures may also need to be removed en bloc.

This is where the concept of “patient-specific surgery” comes into play. Our goal is not to take pieces from the patient but to clear the cancer. If we can obtain a clear margin (R0), we do not remove organs unnecessarily. However, if bone resection is required for clearance, we do not avoid it either. Because incomplete surgery is worse than no surgery at all.

Should pelvic exenteration be performed with open surgery or minimally invasive methods?

With the development of technology, these surgeries, which used to be performed only with large incisions from top to bottom (open surgery), can now also be performed with laparoscopic or robotic methods. The ultimate goal of both methods is the same: to remove the cancer in one piece without fragmenting it.

Open surgery is a classic and reliable method in which the surgeon has the advantage of tactile feedback. It is still indispensable especially in very large tumors or in cases where intra-abdominal adhesions are very dense. However, in open surgery, blood loss may be greater and the recovery process may be more painful due to the large wound area.

On the other hand, Minimally Invasive Surgery (Robotic and Laparoscopic) offers tremendous advantages, especially when working in the pelvis, which is a narrow, deep, and dark well. The three-dimensional and magnified view in robotic surgery, instruments that can move at angles the human hand cannot rotate to, enable the surgeon to work with millimeter precision.

Advantages of minimally invasive surgery are as follows:

• Less bleeding
• Clear visualization
• Faster recovery
• Less pain
• Shorter hospital stay
• Cosmetic result

Scientific studies show that cancer clearance success (R0) in surgeries performed with minimally invasive methods is the same as in open surgery, while patients are discharged from the hospital sooner. Less bleeding means a cleaner surgical field and a smaller margin of error. In addition, since the patient’s bodily integrity is less disrupted, postoperative recovery is faster and the patient can return to normal life earlier. However, which method to choose should again be determined by the surgeon according to the characteristics of the patient and the tumor.

Where do stoma creation and pelvic cavity filling fit into the pelvic exenteration process after surgery?

After the cancer removal part of the surgery is completed, a second phase begins that is at least as vital: reconstruction. At this stage, there are two enormous problems we must solve. The first is creating new pathways to take over the function of the removed organs (bladder and rectum); the second is how to close the large empty space formed inside the pelvis.

Stoma planning is critical for the patient’s postoperative comfort. In a patient who undergoes total exenteration, both urine and stool output are diverted to the abdominal wall. For urine, an “ileal conduit” is usually created by using a segment of the small intestine. For stool, the end of the large intestine is brought out to the skin. Sometimes these two outputs can be collected in a single bag. The stoma site must be marked by specialist nurses before surgery while the patient is standing, sitting, and lying down. A stoma opened in the wrong location leaks, burns the skin, and can make the patient lose heart.

The second major problem is the pelvic cavity. When organs are removed, a large hollow remains below in the perineal region. If we simply suture and leave this space as it is, fluid accumulates inside, forms an abscess, and leads to very serious infections. In addition, the intestines can fall into this cavity and adhere.

This is where we work shoulder to shoulder with Plastic Surgery. The method we call the “VRAM Flap” is the gold standard. The rectus muscle in the anterior abdominal wall (the so-called “six-pack” muscle in athletes) is prepared like a living island with its vessels and rotated downward into that cavity.

Benefits of the VRAM flap are as follows:

• Fills the cavity
• Prevents infection
• Improves blood supply
• Accelerates healing
• Prevents hernia

This living tissue filling helps the area fight infection by increasing blood flow. Studies show that the risk of abscess formation in wounds closed with a flap is almost zero. If the patient’s abdominal structure is not suitable for this, biological meshes or muscles taken from the leg can also be used.

What are recovery, complications, and quality of life like after pelvic exenteration?

To speak frankly, the period after pelvic exenteration is not a “bed of roses.” This is one of the greatest surgical traumas a patient can experience, and the recovery process requires patience. However, the light at the end of the tunnel—the possibility of being cured of cancer—makes it worth enduring this difficulty.

In patients who undergo a successful R0 resection, long-term survival rates are quite high. Saving the patient from the grip of cancer is the greatest reward. However, it is also necessary to know the obstacles we may face along the way, namely complications. In modern medicine, the risk of death is very low, but the rate of “morbidity,” meaning unwanted side effects, is high.

Common problems are as follows:

• Wound dehiscence
• Urinary leakage
• Bowel leakage
• Pelvic abscess
• Leg swelling
• Stoma problems
• Loss of sexual function

The most common problem we see is delayed wound healing or wound opening, especially in tissues that have received radiation therapy. This may require prolonged dressing processes. However, these processes can be managed with advanced wound care products and nutritional support.

And what about quality of life? Our patients understandably worry, “What will it be like to live with a bag?”, “Will my body change a lot?” Yes, there will be an adaptation period. However, scientific studies reveal a striking fact: The quality of life of patients who have this surgery and recover is much higher than that of patients who do not have surgery and are forced to live with an advanced tumor that is painful, bleeding, and foul-smelling.

The first months after surgery can be physically and psychologically challenging. However, by the end of the 12th month, most patients adapt to their new routine, return to their social life, and most importantly continue their lives with the peace of mind that comes with “having been cured of cancer.” For us as doctors, the greatest happiness is to see our patient at the clinic door after that difficult recovery process, smiling and having reconnected with life.

Frequently Asked Questions

In which types of cancer is pelvic exenteration surgery performed?

Pelvic exenteration is performed in advanced-stage rectal, bladder, cervical, and vaginal cancers when the tumor has spread to organs within the pelvis. The goal is to remove all tumor-bearing tissues and bring the disease under control.

In which situations is pelvic exenteration surgery not preferred?

It is not preferred in the presence of distant organ metastasis, in patients in whom the surgery is not thought to meaningfully prolong survival, or in individuals whose general health condition is too weak to tolerate major surgery. A risk–benefit analysis should be performed carefully.

What are the types of pelvic exenteration surgery?

Depending on the scope of the surgery, there are three different types: anterior, posterior, and total pelvic exenteration. Which organs will be removed is determined according to the location and extent of the tumor and is planned specifically for each patient.

How are urinary and bowel functions affected after pelvic exenteration?

If the bladder or bowel has been removed, alternative pathways are created for urine and stool. Usually, a urostomy or colostomy is created and the patient may use these systems permanently.

What is the recovery process like after pelvic exenteration?

The recovery process is long. Hospital stay may take 1–2 weeks; in the first months, infection monitoring, stoma care, and nutritional support may be required. Full recovery usually takes a few months and requires multidisciplinary follow-up.

How is quality of life affected after pelvic exenteration surgery?

This radical surgery can lead to significant physical and emotional changes. Living with a stoma, loss of sexual function, and changes in body image are common. Psychological support and rehabilitation are of great importance in this process.

What is the risk of tumor recurrence after pelvic exenteration?

If the tumor has been completely removed (R0 resection), the local control rate is high. However, in advanced-stage cancers, the risk of recurrence persists. Close follow-up is required with regular oncologic monitoring and early detection of recurrence.

What preparations are done before pelvic exenteration surgery?

The patient undergoes detailed imaging, laboratory tests, and specialist consultations. Information is provided about the scope of the surgery, possible outcomes, and lifestyle changes. Physical and psychological preparation is important.

How common are complications after pelvic exenteration?

The risk of complications is high in this major surgical procedure. Infection, wound healing problems, bleeding, and fistula formation can be common. In experienced centers, these risks can be reduced to lower levels.

Can re-surgery be required after pelvic exenteration?

Re-surgery may be required if complications develop or if the tumor has not been completely removed. In addition, corrective procedures may be performed for reconstruction issues or stoma complications.

How Long Does Pelvic Exenteration Surgery Take?

Pelvic exenteration is a highly complex and extensive procedure; it generally takes between 6 and 12 hours. This duration may vary depending on the number of organs to be removed, the extent of the cancer, and the patient’s overall health condition.

Which Doctor or Department Should Be Consulted for Pelvic Exenteration?

For this extensive operation, it is necessary to apply to a tertiary (advanced-level) healthcare center managed by a multidisciplinary team including surgeons specialized in general surgery, gynecologic oncology, urology, and colorectal surgery.