Skip to main content

Pelvic Tumor Resection

Pelvic tumor resection — resection of a primary or recurrent retroperitoneal or pelvic-sidewall tumor, ovarian cancer cytoreduction, and pelvic exenteration — places the ureter and bladder at risk through a mechanism distinct from hysterectomy: the tumor itself, rather than a predictable anatomic landmark, often defines the dissection plane, and prior surgery, radiation or bulky disease routinely obliterate the planes the surgeon would otherwise rely on.[1][2] This page covers non-urologic tumor resections in the pelvis and retroperitoneum (sarcoma, ovarian cancer cytoreduction, and recurrent or extended pelvic resection including exenteration) where genitourinary injury or reconstruction is a recognized part of the operation. Resection for primary rectal cancer (low anterior resection, abdominoperineal resection, total mesorectal excision) is addressed separately; see Intraoperative Urologic Consultation and Ureteral Trauma for the colorectal-surgery risk data already on this site.

See also: Hysterectomy and Radical Hysterectomy and Pelvic Lymphadenectomy for gynecologic operations, Ureteral Trauma and Bladder Trauma for organ-specific repair, The Presacral Space for posterior pelvic exenteration anatomy, and Reoperative Bowel Harvest and Flaps in GU Reconstruction for the bowel-segment and soft-tissue reconstruction that often accompanies these resections.

General Principles​

Across retroperitoneal and pelvic tumor resection, the shared preventive principle is the same regardless of tumor type: identify both ureters in normal, unoperated anatomy before entering the tumor field or a previously operated or irradiated field, then trace them distally using fixed landmarks — the common iliac bifurcation, the course medial to the internal iliac artery, and the posterolateral entry into the bladder — rather than relying on tissue planes the tumor or prior treatment has distorted.[1][2][3] Because the pelvic ureter receives its blood supply from a longitudinal network of small vessels entering through its adventitia rather than from a single named pedicle, dissection lateral to the ureter is minimized and the adventitia is preserved wherever possible, particularly near the bladder, to reduce the risk of delayed ischemic stricture or fistula.[3]

A margin decision distinct from benign or gynecologic surgery arises in oncologic pelvic resection: for selected benign or low-grade tumors, leaving a small amount of tumor at a ureteral or bladder margin may be considered when a negative-margin resection would require reconstruction unavailable to the operating team, whereas sarcoma surgery more often requires en bloc resection of the involved urinary tract with planned reconstruction to achieve an adequate margin.[1] This judgment is a multidisciplinary oncologic and reconstructive decision, not a fixed rule, and should not be read as license for a routine positive margin.

Ovarian Cancer Cytoreduction​

Mechanism of Injury​

Complete gross resection in advanced ovarian cancer often requires bladder-peritoneal stripping; bladder mucosal invasion is uncommon, but injury can occur when tumor involves the bladder serosa or muscularis, when anatomy is distorted by bulky disease, or from thermal energy used during the dissection. Prior hysterectomy or cesarean delivery compounds the difficulty of this dissection.[2] Pelvic ureters are frequently adherent to fixed ovarian masses or tumor-involved peritoneum, so ureterolysis is a routine part of cytoreductive surgery; identifying and isolating both ureters is emphasized, with particular difficulty described after bulky disease, prior radiation, or prior pelvic or retroperitoneal surgery.[2]

Stenting and Fluorescence Adjuncts​

Conventional ureteral stents, stents combined with intraureteral indocyanine green (ICG), or lighted stents have been described as adjuncts for ureteral identification in selected difficult cases. No randomized trial supports this practice in ovarian cytoreduction specifically; the cited supporting literature is a small colorectal series using intraureteral ICG,[4] a colorectal lighted-stent series,[5] and a single-center experience with routine stenting before cytoreduction with hyperthermic intraperitoneal chemotherapy for gynecologic peritoneal carcinomatosis.[6] These should be read as feasibility and identification aids described by the chapter authors, not as a demonstrated reduction in injury rate for this operation.

Recognition​

Inspection before closure and bladder distension with saline, dye, or sterile milk can expose an occult partial-thickness bladder defect. Urine or bladder mucosa in the field, air in the catheter drainage bag, and persistent hematuria are described clues; transient blood during ureterolysis or bladder manipulation is common and not itself diagnostic of injury.[2] Cystoscopy has been described as less useful after composite pelvic resection, because the ureters are often dissected nearly to their bladder insertions by the oncologic procedure itself; it is reserved for suspected occult injury that cannot be visualized directly from the abdominal field.[2] The evidence cited for cystoscopy's yield in this setting is drawn from benign gynecologic surgery, not from ovarian cytoreduction directly, so it should be read as an extrapolation rather than operation-specific evidence.[7]

Delayed or unrecognized injury after cytoreduction may present nonspecifically — vague illness, ileus, fever, nausea and vomiting, or flank pain — and intraperitoneal urine can raise the serum creatinine. Described workup includes CT urogram or cystogram to localize a suspected leak, renal ultrasound for urinoma, hydronephrosis or free fluid, and creatinine testing of any aspirated or drained fluid.[2] Organ-specific repair follows the pathways on Ureteral Trauma and Bladder Trauma.

Retroperitoneal Sarcoma​

Retroperitoneal sarcoma resection presents a different problem from epithelial tumor surgery: the tumor can directly abut, displace, or invade the ureter over a long segment, and the goal is a single en bloc resection achieving a negative margin, with reconstruction planned rather than improvised.[1] Ureteral reconstruction after sarcoma resection has been described using the full range of standard techniques — primary repair, ureteroureterostomy, psoas hitch, Boari flap, and interposition grafts, including a vascularized appendix interposition graft for a long ureteral defect — selected by defect length and location rather than by the tumor itself.[8] The reconstructive decision framework for ureteral substitution is covered in full on Ureteral Trauma; this page does not duplicate that technique detail.

Recurrent and Extended Pelvic Resection (Including Exenteration)​

Setting and Composite Urinary-Complication Rate​

Resection of a recurrent pelvic-sidewall tumor, or an extended pelvic resection that approaches pelvic exenteration, occurs in a field that has typically already been operated on, and often irradiated. In the cited literature on lateral pelvic compartment excision during exenteration and on extended pelvic resection for gynecologic malignancy, a composite of urinary-related complications — grouped together as urinary retention, ureteral fistula, stricture, hydronephrosis and bladder injury — has been reported in up to 25% of patients.[9][10] This is a broad composite across heterogeneous, extended operative populations, not a rate for ureteral injury alone or a rate applicable to routine pelvic surgery, and it should not be read as such.

Operative Anatomy and Prevention​

The ureter is identified in its normal proximal anatomy before entering the previously operated field, then followed distally across the common iliac bifurcation, medial to the internal iliac artery along the sidewall, and toward its posterolateral entry into the bladder, often with a vessel loop used to guide atraumatic mobilization.[3] Dissection lateral to the ureter is limited and the periureteral adventitia preserved, particularly near the bladder, to protect the ureter's segmental blood supply and reduce the risk of ischemic stricture or fistula.[3] Preoperative ureteral stenting can aid early identification in a bulky-tumor or previously irradiated field; evidence on whether prophylactic stenting reduces injury is conflicting and is drawn from laparoscopic gynecologic and colorectal surgery rather than from a comparative recurrent-sidewall cohort.[11][12][13] See Intraoperative Urologic Consultation — Prophylactic Ureteral Stenting for the broader evidence across surgical specialties.

Recognition​

Seeing a stent through a ureteral defect, or clear fluid in the field, raises suspicion for injury; cystoscopy, ureteral efflux assessment, catheter passage or retrograde pyelography are options when injury remains suspected intraoperatively.[3] Delayed presentations include urinoma, clear drain or vaginal leakage, prolonged ileus, flank pain, infection, hydronephrosis, or an unexplained rise in BUN or creatinine; CT urogram is the preferred localization study.[3] General workup and repair follow Intraoperative Urologic Consultation and the organ-specific trauma pages.

Urinary Reconstruction After Pelvic Exenteration​

When exenteration includes cystectomy, urinary reconstruction is a planned part of the operation rather than an injury to be repaired. The ileal conduit (Bricker) is the most commonly used diversion in gynecologic pelvic exenteration, followed by the self-catheterizable continent pouch and the orthotopic ileal neobladder; continent and non-continent diversions carry similar overall long-term complication rates, including lower urinary tract infection and pyelonephritis (5–50%), ureteral stricture (3–27%), and urolithiasis (5–25%), while each diversion type carries a distinct technique-specific morbidity — urinary incontinence in roughly half of orthotopic neobladders, stoma-related complications in about a quarter of ileal conduits, and difficulty with self-catheterization in about a fifth of continent pouches.[14] A double-barrel wet colostomy (combined fecal and urinary diversion through a single stoma) has been described as an alternative to a separate ileal conduit in selected exenteration patients, intended to reduce the number of bowel anastomoses and stomas.[15] In a single-institution series of pelvic exenteration for colorectal and gynecologic malignancy, postoperative hydronephrosis developed in 59% of patients and was strongly associated with disease recurrence, underscoring that a new or worsening upper-tract finding after exenteration should prompt evaluation for both a technical and an oncologic cause.[16] The full decision framework for diversion selection, including bowel-segment choice, is covered on Urinary Diversion and Reoperative Bowel Harvest; this page does not duplicate that detail.

See Also​

References​

1. Zervos E, Vohra NA. Complications of Resection of Retroperitoneal Tumors in the Female Pelvis. In: Hoffman M, Hull TL, Bochner BH, eds. Major Complications of Female Pelvic Surgery: A Multidisciplinary Approach. Springer; 2025:275-288.

2. Long B, Cliby WA. Composite Pelvic Resection for Ovarian Cancer. In: Hoffman M, Hull TL, Bochner BH, eds. Major Complications of Female Pelvic Surgery: A Multidisciplinary Approach. Springer; 2025:379-381.

3. McDonald JD, Gonzalez RJ. Resection of Recurrent Pelvic Sidewall Tumor. In: Hoffman M, Hull TL, Bochner BH, eds. Major Complications of Female Pelvic Surgery: A Multidisciplinary Approach. Springer; 2025:442-443.

4. White LA, Joseph JP, Yang DY, et al. Intraureteral indocyanine green augments ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Colorectal Dis. 2021;23(3):718-723. doi:10.1111/codi.15407

5. Boyan WP Jr, Lavy D, Dinallo A, et al. Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience. Ann Transl Med. 2017;5(3):44. doi:10.21037/atm.2017.02.01

6. Abu-Zaid A, Abou Al-Shaar H, Azzam A, et al. Routine ureteric stenting before cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in managing peritoneal carcinomatosis from gynecologic malignancies: a single-center experience. Ir J Med Sci. 2017;186(2):269-273. doi:10.1007/s11845-016-1452-4

7. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015;126(6):1161-1169. doi:10.1097/AOG.0000000000001096

8. Sohail M, Loke SN, Sim SK, et al. Right ureteric reconstruction with vascularised interpositional appendix graft in retroperitoneal leiomyosarcoma. Med J Malaysia. 2021;76(3):432-435. PMID 34031348

9. Solomon MJ, Brown KG, Koh CE, Lee P, Austin KK, Masya L. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg. 2015;102(13):1710-1717. doi:10.1002/bjs.9915

10. Daix M, Martinez Gomez C, Angeles MA, et al. Extended pelvic resection for gynecological malignancies: a review of out-of-the-box surgery. Gynecol Oncol. 2022;165(2):393-400. doi:10.1016/j.ygyno.2022.03.002

11. Feng D, Tang Y, Yang Y, Wei X, Han P, Wei W. Does prophylactic ureteral catheter placement offer any advantage for laparoscopic gynecological surgery? A urologist's perspective from a systematic review and meta-analysis. Transl Androl Urol. 2020;9(5):2262-2269. doi:10.21037/tau-20-674

12. Merola J, Arnold B, Luks V, et al. Prophylactic Ureteral Stent Placement vs No Ureteral Stent Placement During Open Colectomy. JAMA Surg. 2018;153(1):87-90. doi:10.1001/jamasurg.2017.3477

13. da Silva G, Boutros M, Wexner SD. Role of prophylactic ureteric stents in colorectal surgery. Asian J Endosc Surg. 2012;5(3):105-110. doi:10.1111/j.1758-5910.2012.00134.x

14. Martínez-Gómez C, Angeles MA, Martinez A, Malavaud B, Ferron G. Urinary diversion after pelvic exenteration for gynecologic malignancies. Int J Gynecol Cancer. 2021;31(1):1-10. doi:10.1136/ijgc-2020-002015

15. Wright JP, Guerrero WM, Lucking JR, et al. The double-barrel wet colostomy: An alternative for urinary diversion after pelvic exenteration. Surgeon. 2023;21(6):375-380. doi:10.1016/j.surge.2023.03.004

16. Lazarovich A, Drori T, Guttman Y, et al. Urological outcomes following pelvic exenteration for non-urological malignancies. Heliyon. 2024;10(8):e29640. doi:10.1016/j.heliyon.2024.e29640