Surgical Procedure:
Preparation and Initial Steps
The surgery was conducted as a joint procedure between Gynaecology Oncology, Urology and Colorectal teams. The patient was first cleaned, draped, catheterised, and positioned with her legs in a modified Llyod-Davies position with flow-trons on. A midline xiphi-pubic laparotomy was performed and the abdomen was opened in layers with a handheld diathermy and Lahey dissecting forceps. The ascending colon and the liver were then mobilised to gain access to the right kidney for the nephrectomy. (Figure 1, 2, 3).
Right kidney mobilisation
The right nephrectomy was conducted first as the right kidney had been chronically obstructed by the tumour and appeared atrophic. The ureter was slung, and lower pole, upper pole and lateral attachments were dissected. The renal artery, vein and gonadal vein were then all identified and transected, enabling mobilisation of the right kidney. The ureter was followed to the level of the mass.
Assessment of mass
A 15x15cm pelvic mass was identified in the Pouch of Douglas. The mass was seen to be inseparable from the urinary bladder and recto-sigmoid colon and was in close proximity to the left vesico-ureteric junction. The right ureter was encased in the mass. As the tumour was friable, a fragment detached when mobilisation was attempted.This tissue was sent for frozen section. The frozen section report suggested the tumour was a grade 1 andenocarcinoma, either endometrioid or endometrioid with mucinous component. Pelvic side walls were opened bilaterally, and para-rectal and Latzko spaces developed. Subsequent discussion among the four consultant surgeons present finally led to the conclusion that a total exenteration was required to achieve complete tumour clearance.
Pelvic exenteration
The pelvic exenteration began with the division of the sigmoid colon above the tumour and dissection of the total mesorectal excision (TME) plane to the pelvic floor. A radical cystectomy was performed, and the bladder was mobilised. Subsequent vaginal division and low rectal division then allowed for en-bloc removal of the entire specimen consisting of right kidney, right ureter, urinary bladder, pelvic mass, and recto-sigmoid colon and vaginal cuff. (Figure 4).
Colonic conduit and end colostomy
Following the pelvic exenteration, a colonic conduit and end colostomy were required. First, the splenic flexure was mobilised. The proximal descending colon was then divided, and the distal section used to create the colonic conduit with the left ureter (Bricker procedure). The colonic conduit and proximal segment of the descending colon were matured through the left abdomen and two stomas produced in a vertical orientation.
Closure
Before closure, bulky aorto-caval lymph nodes that had been noticed earlier were removed. The pelvis was washed out and a Jackson-Pratt drain inserted. The abdomen was then closed in layers. The total blood loss was 1500mls.