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Anterior Pelvic Exenteration

This information will hlep prepare you for anterior pelvic exenteration surgery.

Pelvic exenteration surgery is a treatment for cancer that is in the gynecologic and urologic systems.  The urinary system includes your kidneys, ureters, bladder, and urethra (see Figure 1). Your bladder and urethra will be removed. This means you will need a new place for urine to leave your body. Your kidneys and ureters will be reconnected to a new urinary collection system called a urinary diversion. There are two types of diversions. Each opens onto the abdomen. This opening is also called a stoma. With one, the urine drains into a bag that you place around the stoma. This is called an ileal conduit. With the other, you will place a drainage tube in the stoma several times a day to drain the urine. This is called a urinary pouch. Your doctor will discuss these with you. Your nurse will give you a booklet describing the diversion you will have.

The gynecology system includes your ovaries, fallopian tubes, uterus, and vagina. Your ovaries, fallopian tubes, and uterus will be removed  (see Figure 2). All or part of your vagina may also be removed. Your doctor will discuss this with you if it is necessary. In some cases, the vagina can be reconstructed. Ask your doctor if this is an option for you. A plastic surgeon will do it after the rest of the operation is done. A new vaginal canal is created from muscles and skin in other areas of your body. Your nurse will tell you about the care of your new vagina. If you do not want reconstruction, the area can be closed or covered with a flap of skin.

If your vagina is left, you should be able to have intercourse. If you can have reconstruction, you should be able to resume having intercourse when the area heals. If you cannot have reconstruction, remember that sex can include other forms of intimacy. Ask if your clitoris will be removed. Ask how much feeling you will retain in the vaginal area. Your doctor and nurse will tell you what to expect. For example, sensations may not be the same as they were before your surgery. You might like a referral to our Sexual Health Program. A therapist can assist you regarding these concerns.

Preparing for Your Surgery

You will likely see many doctors and nurses before your surgery. Each specialist will describe his or her role in your care and answer your questions. You may see surgeons from other services who will work with your surgeon to complete the operation. You may see a psychologist who works with women having this surgery. You may also see the wound, ostomy, and continence nurse, also known as a CWOCN. The CWOCN will talk to you about the stoma you will have. It might help you to write down questions as you think of them. Take your list with you when you have appointments. You might also ask to speak with someone who has had the operation. Your social worker might be able to arrange that.

Your intestines, also called bowels, must be clean before surgery. The cleaning lowers the level of bacteria in your intestine. You will also be given antibiotics to take by mouth. The bowel cleaning and antibiotics help to prevent infections after surgery. You will get a fact card on your bowel preparation. The nurse will review it with you and answer any questions you have.

After Your Surgery

When you wake up, you will be in the Post-Anesthesia Care Unit (PACU). You will have many tubes, drains, pouches, and bandages on your abdomen (see Figure 3). They may include:

  • A Jackson-Pratt drain or “JP” to drain fluid from around an incision or wound. The drain is taken out when the incision stops draining.
  • A catheter or drainage tube to drain urine from your urinary diversion.
  • A second drainage tube at the site of the incision. This serves as a safety catheter. It is placed in case the urinary diversion catheter
    gets blocked or comes out. It is clamped shut and usually has a “Do Not Touch” sign.
  • If you have an ileal conduit, you will have pouch around your stoma to collect the urine. The CWOCN along with the nursing staff will teach you how to care for the stoma as you recover.

Please don't be alarmed when you first see them. Your abdomen will become more swollen over the next few days and then the swelling will go down. Most of the drains and tubes will be removed over the next days to weeks. In about 3 to 6weeks, most women will have either one stoma for a urinary pouch or a pouch for the ileal conduit (see Figure 4).

You will also have:

  • Bandages and drains on your upper inside thighs if you had reconstruction of your vagina.
  • An intravenous (IV) to give you fluids.
  • A PCA (patient controlled analgesia) to give you pain medication.
  • Compression boots on your calves to help blood circulate. These will stay on whenever you are in bed until you are discharged.

You will need to cough, deep breathe, and use the incentive spirometer every hour while you are awake. You will be taught how to do these before your operation.
Practice before your operation. That will make it easier for you to do them. The nurses will ask you to begin doing them when you arrive in the PACU.

Most women stay overnight in the PACU. You will be transferred to an inpatient room the next day. You will have pain at your incision site and your abdomen. Your pain will be managed with the PCA. A PCA is a pump that you control yourself; it gives you pain medicine through your IV. Your nurse will show you how to use it.

You will not be able to eat or drink for a few days after the surgery. Your doctor will first allow you to drink clear liquids such as tea, broth, and Jell-O®. Your diet will slowly be advanced to solid food.

You will get out of bed soon after you arrive in your inpatient room and will begin walking in the hall. Someone from the nursing staff will help you until you are able to walk on your own. You will be taught how to get out of bed in a way that lessens the pain to your incision. You may feel very tired and may not want to walk. However, walking will help you recover from the operation. If you take pain medicine before getting out of bed, your incision will hurt less. If you had vaginal reconstruction, you will not be able to sit for six to eight weeks. You can lie on your back or side or you can stand.

You can expect bleeding from almost any of the incisions or around the drains. You may also have some discharge and tenderness for a few days. Your nurse will show and tell you what is normal and expected as he or she cares for you. You will also begin to learn how to care for the stoma and incision lines. Most patients are in the hospital for seven to ten days.

Some of the tubes and drains may be removed before you are discharged from the hospital. If you have a stapled incision, the staples are usually taken out before you leave the hospital. Some women will have them removed at the first follow-up visit. If you go home with the drains, your nurses will teach you how to care for them.

Going Home

When you are discharged from the hospital, you will be given supplies you need to care for yourself for the first month. You will then order your supplies from an outside source. Your discharge nurse case manager will arrange to have a visiting nurse see you at home. You may still have drains in when you go home. Ask your nurse or doctor when they will be removed. This nurse will help you while you are learning to care for your incision and urinary diversion. The changes will not be visible under most of your clothes.

As time goes on, you will get stronger. You will be more confident in caring for your incision and urinary diversion. Your appetite and energy will improve. Before too long, you will be able to resume most of your normal activities.

Support

This is a major operation which will change your body, and it will probably take time for you to adjust to these changes. You may feel frightened, angry, or worried. You may have questions or fears about how this surgery will impact your sexuality. These feelings are normal and occur in most patients.

Each person adjusts in her own way. For some, coming to terms with a changed body image will happen over several months. For others, it may take longer. Please know that we have many resources to help you. Your doctors and nurses will answer your questions. We also have social workers, psychologists, psychiatrists, and CWOCNs who have helped many women through this adjustment. You might like to see someone from our Sexual Health Program who deals with issues like these. We also have clergy available for spiritual support. We may be able to arrange for you to meet with another woman who has had this surgery, and who can talk with you and answer questions.

Just as your body will heal and you will be able to resume your normal activities, you will also learn to adapt to changes that at first seemed overwhelming. Every new situation requires time to adjust. Loss of a body part, external or internal, often triggers a time of grieving. Remember that we have many resources to guide you to recovery.

MSKCC Support Services

If you would like more support or information about intimacy after cancer, please speak with your nurse or doctor. You can also contact the Female Sexual Medicine & Women's Health Program for more information and an appointment.

MSKCC Female Sexual Medicine & Women's Health Program
(646) 888-5076 
Rockefeller Outpatient Pavilion: 160 East 53rd Street
Evelyn H. Lauder Breast Center and MSKCC Imaging Center: 300 East 66th Street 
 

If you are having persistent pain or incontinence call your nurse or doctor. He or she can give you a referral to physical therapy for an evaluation.

Sillerman Center for Rehabilitation
515 Madison Avenue, 4th Floor
(Entrance on 53rd Street, between Park and Madison Avenues)
New York, NY 10022
(646) 888-1900
 

To make an appointment with a psychiatrist or psychologist, call the Counseling Center at (646) 888-0100.

To speak with a social worker, call (212) 639-7020.

To see a CWOCN, ask your doctor or nurse to contact that nurse and arrange a visit.

Support Group 

The Bladder Cancer: Challenges and Solutions support group meets the second Thursday of each month. To register, call (646)888-4740.

Resources

Women's Cancer Network: Gynecological Cancer Foundation (GCF)
(312) 644-6610
www.wcn.org
 
United Ostomy Associations of America, Inc (UOAA)
(800) 826-0826
United Ostomy Associations of America is a volunteer based health organization. They work to give support to people who have had or will have intestinal or urinary diversions
 
Wound, Ostomy, Continence Nurses Society
(888) 224-WOCN (9626)
This is a professional nursing society. Members are specialists in the care of patients with wounds, ostomies, and continence problems
 

Glossary

Abdomen: The part of the body below the ribs and above the pelvis

Antibiotics: Medicine used to treat infections

Bladder: A sac in the pelvis that holds urine

Catheter: A small tube that can be used to drain fluid from an area such as the bladder

Compression: Boots that wrap around the lower legs and gently squeeze and relax to aid circulation boots

CWOCN: A nurse who manages wounds, ostomies, and continence problems

Discharge: The release of fluid from a wound or opening

Fallopian tubes: Slender tubes between the ovaries and the uterus through which eggs travel to the uterus

Gynecologic: The system that includes the female reproductive organs

Ileal conduit: The implantation of the ureters into a part of the small intestine called the ileum

Ileum: The last section of the small intestine

Incentive: A device that measures the amount of air breathed into the lungs
spirometer

Intravenous (IV): Through a blood vein

Jackson Pratt: A type of drain used after surgery to let fluid escape drain

Kidneys: The organs where liquid waste from the body is turned into urine

Ostomy: A new opening such as a colostomy or ileostomy

Ovaries: The female organ that produces ova (eggs) and the hormones estrogen and progesterone

PACU: Post-anesthesia care unit; a recovery room

Patient-controlled: A method that lets a patient control the amount of pain medicine that goes into the body
analgesia

Pelvic exenteration: An operation that removes organs in the pelvis

Pelvis: The part of the body that is surrounded on three sides by the hip bones and spine

Post-Anesthesia: Recovery room
Care Unit

Stoma: An opening from within the body to the outside

Ureters: Tubes that carry urine from each kidney to the bladder

Urethra: The tube that carries urine from the bladder to the outside of the body

Urinary diversion: The creation of a new pathway for urine to leave the body

Urinary system: The system that includes the kidneys, ureters, bladder and urethra

Visiting nurse: A nurse who travels to patients' homes