• cervical cancer

This educational video shows a step by step approach for anterior infra levator exenteration with colpectomy along with intraoperative radiation for recurrent/persistent cervical cancer in a patient with one kidney. The patient underwent urinary diversion and neovaginal reconstruction.

A 31-year-old woman with a past medical history of systemic lupus erythematosus and congenital absence of the left kidney was diagnosed with a 4 cm IIA squamous cervical carcinoma in the context of immunosuppressive therapy. Beyond the proximal vaginal involvement, the workup failed to show any extracervical disease.

Standard concomitant chemoradiotherapy resulted in a questionable partial response. Four months after chemoradiation, pelvic magnetic resonance imaging showed a 4.5 cm persistent cervical mass along with mild right hydronephrosis and vaginal involvement. Positron emission tomography-computed tomography (PET-CT) confirmed the metabolic activity of the cervical tumor without demonstrating distant metastases.

In this video the following procedures are shown, highlighting tips for the most complex steps: (Video 1)

• Anterior exenteration with colpectomy (en bloc resection of the uterus (type D radical hysterectomy), bladder, and vagina).

• Intraoperative radiation with electron therapy over the right pelvic side wall (infiltration of the right parametria).

• Neovaginal reconstruction from a rectus abdominis musculocutaneous flap.

• Urinary diversion was accomplished with an ileal urinary conduit (Bricker procedure) using the only available (right) renal unit.

The final pathological report was a 3 cm epidermoid cervical tumor with involvement of the superior vagina and right parametria. After an uneventful postoperative period, the patient was discharged on day 10. Ten months after surgery, the patient has no sign of recurrence.

Pelvic exenteration after radiation is a challenging surgical procedure that may prolong survival in selected patients with local and persistent disease.1 Intraoperative radiation allows an extra amount of radiation to be administered in the context of a previous radiated field. Intraoperative radiotherapy after total resection of the recurrence can improve local control rates.2