Total pelvic exenteration: Effective palliation of perineal pain in patients with locally recurrent prostate cancer

Purpose: Locally recurrent prostate cancer can be a debilitating disease. Perineal pain associated with rectal involvement by prostate cancer is difficult to palliate by conventional methods. We describe a group of patients who had intractable perineal pain due to locally recurrent prostate cancer and underwent total pelvic exenteration for palliation. Materials and Methods: We retrospectively reviewed the data for men who underwent total pelvic exenteration with urinary and colonic diversion at our institution between October 1995 and October 2002 for the relief of perineal pain from prostate cancer. Patients were selected for consideration for surgical extirpation on the basis of the presence of biopsy proven recurrent prostate cancer and evidence of rectal invasion on sonography. All patients received radiation therapy and hormonal therapy and had intractable perineal or pelvic pain resistant to narcotics. Results: A total of 14 men underwent total pelvic exenteration for palliation during the 7-year period evaluated. There were no perioperative deaths. There were 7 postoperative events, including pulmonary embolus in 2 patients, and ileus, wound infection, cholecystitis, stomal stenosis and pelvic abscess in 1 patient each. After exenteration all patients had significant relief of pain and 11 (79%) had complete relief of pain symptoms. For these 11 patients the average symptom-free period was 14.1 months (range 3 to 36). Seven patients eventually died of disease, with the median period from exenteration to death being 24 months. Conclusions: Total pelvic exenteration is effective therapy for palliation of perineal pain associated with locally recurrent prostate cancer and can also effectively palliate other local symptoms such as hematuria, ureteral obstruction, voiding dysfunction and rectal incontinence. This procedure can be performed with acceptable morbidity in a highly select group of patients.