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Loverro M, Aloisi A, Tortorella L, Aletti GD, Kumar A. Trends and current aspects of reconstructive surgery for gynecological cancers. Int J Gynecol Cancer 2024; 34:426-435. [PMID: 38438169 DOI: 10.1136/ijgc-2023-004620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the surrounding bony pelvis and pelvic musculature. As opposed to advanced ovarian cancer, where cytoreduction is the goal, in these scenarios, an oncologic approach to achieve negative margins is critical for benefit. Surgeries aimed at achieving a R0 resection in gynecologic oncology can have a significant impact on pelvic anatomy, and require reconstruction. Overall, it appears that these types of radical surgery are less frequently performed; however, when required, multidisciplinary teams at high-volume centers can potentially improve short-term morbidity. There are few data to examine the long-term, quality-of-life outcomes after reconstruction following oncologic resection in advanced and recurrent gynecologic cancers. In this review we outline considerations and approaches for reconstruction after surgery for gynecologic cancers. We also discuss areas of innovation, including minimally invasive surgery and the use of 3D surgical anatomy models for improved surgical planning.In the era of 'less is more', pelvic exenteration in gynecologic oncology is still indicated when there are no other curative-intent alternatives in persistent or recurrent gynecological malignancies confined to the pelvis or with otherwise unmanageable symptoms from fistula or radiation necrosis. Pelvic exenteration is one of the most destructive procedures performed on an elective basis, which inevitably carries a significant psychologic, sexual, physical, and emotional burden for the patient and caregivers. Such complex ultraradical surgery, which requires removal of the vagina, vulva, urinary tract, and/or gastrointestinal tract, subsequently needs creative and complex reconstructive procedures. The additional removal of sidewall or perineal structures, like pelvic floor muscles/vulva, or portions of the musculoskeletal pelvis, and the inclusion of intra-operative radiation further complicates reconstruction. This review paper will focus on the reconstruction aspects following pelvic exenteration, including options for urinary tract restoration, reconstruction of the vulva and vagina, as well as how to fill large empty spaces in the pelvis. While the predominant gastrointestinal outcome after exenteration in gynecologic oncology is an end colostomy, we also present some novel new options for gastrointestinal tract reconstruction at the end.
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Affiliation(s)
- Matteo Loverro
- Department of Gynecology and Obstetrics, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Alessia Aloisi
- European Institute of Oncology IRCCS Library, Milan, Italy
| | - Lucia Tortorella
- Department of Women, Child and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Damiano Aletti
- Department of Gynecology, European Institute of Oncology, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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Fahy MR. A review of functional and surgical outcomes of gynaecological reconstruction in the context of pelvic exenteration. Surg Oncol 2024; 52:101996. [PMID: 38096764 DOI: 10.1016/j.suronc.2023.101996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/02/2023] [Accepted: 09/17/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship of patients undergoing exenterative surgery remain. This is especially important in the context of vulvovaginal resection, where patients are often younger and surgery can have a profoundly negative impact on quality of life, body image and overall wellbeing. Reconstructive procedures are an important means of mitigating these adverse effects but outcomes are poorly described. AIM To define the outcomes associated with gynaecological reconstructive procedures following pelvic exenterative surgery and to compare them with the outcomes of those patients who did not undergo reconstruction. METHODS An international, multicentre retrospective investigation comparing the outcomes of reconstruction with no reconstruction. The protocol was prospectively registered (NCT05074069). RESULTS 334 patients were included. 77 patients had a neovagina reconstructed, 139 patients underwent flap reconstruction and 118 were not reconstructed. Patients who underwent reconstruction had a longer operative time and hospital stay with an increased risk of minor perineal complications. Reconstruction did not confer an increased risk of surgical reintervention, and overall complication rates were equivalent. Procedure-specific major morbidity was 5.2 % and 11.5 % for neovaginal and flap reconstruction, respectively. 66 % of patients undergoing neovaginal reconstruction experienced no long term morbidity. 7 % developed neovaginal stenosis and 12 % suffered disease recurrence. CONCLUSION Neovaginal reconstruction is safe in carefully selected patients and offers specific advantages over alternative techniques, with few patients requiring reoperation. Primary closure does not increase perineal morbidity.
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Arcieri M, Restaino S, Rosati A, Granese R, Martinelli C, Caretto AA, Cianci S, Driul L, Gentileschi S, Scambia G, Vizzielli G, Ercoli A. Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107278. [PMID: 38134482 DOI: 10.1016/j.ejso.2023.107278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.
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Affiliation(s)
- M Arcieri
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy; Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy.
| | - S Restaino
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy
| | - A Rosati
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - R Granese
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy
| | - C Martinelli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - A A Caretto
- Department of Plastic Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - S Cianci
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - L Driul
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - S Gentileschi
- Plastic Surgery, Lymphedema Center Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G Scambia
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Woman, Child and Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - G Vizzielli
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - A Ercoli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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Pappou E, Ben-Yaakov A, Jiménez-Rodríguez RM, Garcia-Aguilar J. Simultaneous posterior vaginal and perineal reconstruction using gluteal fasciocutaneous flaps following pelvic exenteration with sacrectomy. Br J Surg 2024; 111:znad395. [PMID: 37988590 PMCID: PMC10938539 DOI: 10.1093/bjs/znad395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Emmanouil Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Almog Ben-Yaakov
- Department of Surgical Oncology, Chaim Sheba Medical Center, Tel Aviv, Israel
| | - Rosa M Jiménez-Rodríguez
- Department of General and Digestive Surgery, University Hospital Virgen del Rocio, Seville, Spain
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Managing Pelvic Organ Prolapse After Urinary Diversion or Neobladder. CURRENT BLADDER DYSFUNCTION REPORTS 2023. [DOI: 10.1007/s11884-023-00685-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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The reconstructive strategy for pelvic oncological surgery with various types of MS-VRAM flaps. J Plast Reconstr Aesthet Surg 2022; 75:2090-2097. [PMID: 35300926 DOI: 10.1016/j.bjps.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/21/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Muscle-sparing vertical rectus abdominis myocutaneous (MS-VRAM) flaps are widely used in pelvic reconstruction. Aiming at optimal reconstructive outcomes, flap design and modification should be individualized to restore various kinds of defects. OBJECTIVE Summarize an empirical strategy about MS-VRAM selection for different pelvic and perineal reconstructions. METHODS Thirty patients who underwent total pelvic exenteration and pelvic reconstruction surgery from 2009 to 2017 were enrolled. The patients were divided into four groups according to the type of MS-VRAM-based flap used in the procedure: the modified long vertical flap (n = 10), the wrapping flap (n = 6), the de-epithelialized flap (n = 6), and the cork flap (n = 8). The follow-up period was 1 year after the surgery. Flap size, drainage volume, postoperative satisfaction, and complications were recorded, and postoperative photographs were collected. RESULTS All of the patients achieved satisfying effect under the targeted reconstruction strategy. Of the four groups, the accurate cork flap finally acquires higher satisfaction, the shortest hospital stay, and the least total drainage volume. Meanwhile, the incidence of complications was not increased compared with the other groups. CONCLUSIONS A new reconstructive strategy for pelvic reconstruction was established. Functional or non-functional reconstruction was accomplished by using various MS-VRAM flaps. Among them, the cork flap is the most economical flap to reconstruct pelvic floor defects with minimal tissue requirement and donor trauma.
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Schellerer VS, Bartholomé L, Langheinrich MC, Grützmann R, Horch RE, Merkel S, Weber K. Donor Site Morbidity of Patients Receiving Vertical Rectus Abdominis Myocutaneous Flap for Perineal, Vaginal or Inguinal Reconstruction. World J Surg 2020; 45:132-140. [PMID: 32995931 PMCID: PMC7752873 DOI: 10.1007/s00268-020-05788-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/20/2022]
Abstract
Background Management of donor site closure after harvesting a vertical rectus abdominis myocutaneous (VRAM) flap is discussed heterogeneously in the literature. We aim to analyze the postoperative complications of the donor site depending on the closure technique. Methods During a 12-year period (2003–2015), 192 patients in our department received transpelvic VRAM flap reconstruction. Prospectively collected data were analyzed retrospectively. Results 182 patients received a VRAM flap reconstruction for malignant, 10 patients for benign disease. The median age of patients was 62 years. 117 patients (61%) received a reconstruction of donor site by Vypro® mesh, 46 patients (24%) by Vicryl® mesh, 23 patients (12%) by direct closure and 6 patients (3%) by combination of different meshes. 32 patients (17%) developed in total 34 postoperative complications at the donor site. 22 complications (11%) were treated conservatively, 12 (6%) surgically. 17 patients (9%) developed incisional hernia during follow-up, with highest incidence in the Vicryl® group (n = 8; 17%) and lowest in the Vypro® group (n = 7; 6%). Postoperative parastomal hernias were found in 30 patients (16%) including three patients with simultaneous hernia around an urostomy and a colostomy. The highest incidence of parastomal hernia was found in patients receiving primary closure of the donor site (n = 6; 26%), the lowest incidence in the Vypro® group (n = 16; 14%). Conclusion The use of Vypro® mesh for donor site closure appears to be associated with a low postoperative incidence of complications and can therefore be recommended as a preferred technique.
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Affiliation(s)
- Vera S Schellerer
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Lenka Bartholomé
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Melanie C Langheinrich
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
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Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2733. [PMID: 32440406 PMCID: PMC7209827 DOI: 10.1097/gox.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
Background: Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration. Methods: Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate. Results: A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m2 (IQR: 24.2–26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient. Conclusions: The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.
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Laporte GA, Zanini LAG, Zanvettor PH, Oliveira AF, Bernado E, Lissa F, Coelho MJP, Ribeiro R, Araujo RLC, Barrozo AJJ, da Costa AF, de Barros Júnior AP, Lopes A, Santos APM, Azevedo BRB, Sarmento BJQ, Marins CAM, Loureiro CMB, Galhardo CAV, Gatelli CN, Quadros CA, Pinto CV, Uchôa DNAO, Martins DRS, Doria-Filho E, Ribeiro EKMA, Pinto ERF, Dos Santos EAS, Gozi FAM, Nascimento FC, Fernandes FG, Gomes FKL, Nascimento GJS, Cucolicchio GO, Ritt GF, de Oliveira GG, Ayala GP, Guimarães GC, Ianaze GC, Gobetti GA, Medeiros GM, Güth GZ, Neto HFC, Figueiredo HF, Simões JC, Ferrari JC, Furtado JPR, Vieira LJ, Pereira LF, de Almeida LCF, Tayeh MRA, Figueiredo PHM, Pereira RSAV, Macedo RO, Sacramento RMM, Cardoso RM, Zanatto RM, Martinho RAM, Araújo RG, Pinheiro RN, Reis RJ, Goiânia SBS, Costa SRP, Foiato TF, Silva TC, Carneiro VCG, Oliveira VR, Casteleins WA. Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer. J Surg Oncol 2019; 121:718-729. [PMID: 31777095 DOI: 10.1002/jso.25759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.
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Affiliation(s)
| | | | | | | | - Enio Bernado
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - Fernando Lissa
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | - Reitan Ribeiro
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Andre Lopes
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | - Cláudio V Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Eric R F Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | | | - Gunther P Ayala
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Gustavo Z Güth
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - João C Simões
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - José C Ferrari
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - Lucas F Pereira
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Ramon O Macedo
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | - Rosilene J Reis
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | - Tyrone C Silva
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
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Brar H, May T, Tau N, Langer D, MacCrostie P, Han K, Metser U. Detection of extra-regional tumour recurrence with 18F-FDG-PET/CT in patients with recurrent gynaecological malignancies being considered for radical salvage surgery. Clin Radiol 2017; 72:302-306. [DOI: 10.1016/j.crad.2016.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
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12
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Contralateral Component Separation Technique for Abdominal Wall Closure in Patients Undergoing Vertical Rectus Abdominis Myocutaneous Flap Transposition for Pelvic Exenteration Reconstruction. Ann Plast Surg 2016; 77:90-2. [DOI: 10.1097/sap.0000000000000327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Lakhman Y, Nougaret S, Miccò M, Scelzo C, Vargas HA, Sosa RE, Sutton EJ, Chi DS, Hricak H, Sala E. Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Patients Treated with Pelvic Exenteration for Gynecologic Malignancies. Radiographics 2016; 35:1295-313. [PMID: 26172364 DOI: 10.1148/rg.2015140313] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pelvic exenteration (PE) is a radical surgical procedure used for the past 6 decades to treat locally advanced malignant diseases confined to the pelvis, particularly persistent or recurrent gynecologic cancers in the irradiated pelvis. The traditional surgical technique known as total PE consists of resection of all pelvic viscera followed by reconstruction. Depending on the tumor extent, the procedure can be tailored to remove only anterior or posterior structures, including the bladder (anterior exenteration) or rectum (posterior exenteration). Conversely, more extended pelvic resection can be performed if the pelvic sidewall is invaded by cancer. Preoperative imaging evaluation with magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is central to establishing tumor resectability and therefore patient eligibility for the procedure. These imaging modalities complement each other in diagnosis of tumor recurrence and differentiation of persistent disease from posttreatment changes. MR imaging can accurately demonstrate local tumor extent and show adjacent organ invasion. FDG PET/CT is useful in excluding nodal and distant metastases. In addition, FDG PET/CT metrics may serve as predictive biomarkers for overall and disease-free survival. This pictorial review describes different types of exenterative surgical procedures and illustrates the central role of imaging in accurate patient selection, treatment planning, and postsurgical surveillance.
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Affiliation(s)
- Yulia Lakhman
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Stephanie Nougaret
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Maura Miccò
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Chiara Scelzo
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Hebert A Vargas
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Ramon E Sosa
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Elizabeth J Sutton
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Dennis S Chi
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Hedvig Hricak
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
| | - Evis Sala
- From the Department of Radiology (Y.L., S.N., H.A.V., R.E.S., E.J.S., H.H., E.S.) and Department of Surgery, Gynecology Service (D.S.C.), Memorial Sloan Kettering Cancer Center, 300 E 66th St, Room 703, New York, NY 10065; Department of Bioimaging and Radiological Science, Catholic University A. Gemelli Hospital, Rome, Italy (M.M.); and Department of Surgery, Gynecology and Obstetrics Section, Tor Vergata University, Rome, Italy (C.S.)
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Morbidity after pelvic exenteration for gynecological malignancies: a retrospective multicentric study of 230 patients. Int J Gynecol Cancer 2014; 24:156-64. [PMID: 24362721 DOI: 10.1097/igc.0000000000000011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Our study purpose was to evaluate morbidity and postoperative mortality in patients who underwent pelvic exenteration (PE) for primary or recurrent gynecological malignancies. METHODS We identified 230 patients who underwent PE, referred to the gynecological oncology units of 4 institutions: Charitè University in Berlin, Friedrich-Schiller University in Jena, S. Orsola-Malpighi University in Bologna, and Catholic University in Rome and in Campobasso. RESULTS The median age was 55 years. The tumor site was the cervix in 177 patients, the endometrium in 28 patients, the vulva in 16 patients, and the vagina in 9 patients. Sixty-eight anterior, 31 posterior, and 131 total PEs were performed in 116 women together with hysterectomy. A total of 82.6% of the patients required blood transfusion. The mean operative time was 446 (95-970) minutes, and the median hospitalization was 24 (7-210) days. We noted a major complication rate of 21.3% (n = 49). We registered 7 perioperative deaths (3%) calculated within 30 days. The operation was performed within clear margins in 166 patients (72.2%). The overall mortality rate depending on tumor site at the end of the study was 75% for vulvar cancer, 57.6% for cervical cancer, 55.6% for vaginal cancer, and 53.6% for endometrial cancer. CONCLUSIONS Although an important effort for surgeons and for patients, PE remains a therapeutic option with an acceptable complication rate and postoperative mortality. A strict selection of patients is mandatory to reach adequate surgical and oncologic outcomes.
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15
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Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology. Gynecol Oncol 2014; 134:172-80. [DOI: 10.1016/j.ygyno.2014.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 04/26/2014] [Accepted: 04/30/2014] [Indexed: 11/23/2022]
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16
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Comparison of TRAM versus DIEP Flap in Total Vaginal Reconstruction after Pelvic Exenteration. Plast Reconstr Surg 2013; 132:1020e-1027e. [DOI: 10.1097/prs.0b013e3182a97ea2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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[Rectal cancer: situation where a referral center is needed]. Bull Cancer 2011; 98:1455-68. [PMID: 22172939 DOI: 10.1684/bdc.2011.1501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
One of the objectives of the French strategic plan for cancer 2009-2013 is to structure the need for referral surgery, particularly for low rectal carcinoma. However, low rectal cancer is not the only situation in the field of rectal surgery where expert unit are needed for the referral of appropriate patients. We developed the multidisciplinary strategies for low rectal cancer, advanced rectal cancer, recurrent rectal cancer and peritoneal carcinomatosis. Optimal management of these difficult situations can give a chance of long term survival while a non-optimal management could jeopardise the future of patients by changing a potentially curable disease into an incurable one.
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18
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Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes. Gynecol Oncol 2011; 125:252-5. [PMID: 22166844 DOI: 10.1016/j.ygyno.2011.12.427] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/02/2011] [Accepted: 12/03/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine the early and late flap related morbidity and associated risk factors in patients with modified vertical rectus abdominis myocutaneous (VRAM) flap neovaginal reconstruction at the time of pelvic exenteration for gynecologic malignancy. METHODS From January 1993 to January 2011, all patients were identified who underwent anterior, posterior, or total pelvic exenteration with VRAM flap neovaginal reconstruction. Patient records were systematically reviewed and demographic, clinicopathologic, operative details, flap related complications, and risk factors for wound healing were recorded and statistical analysis performed. RESULTS 46 patients were identified who underwent exenteration with VRAM flap vaginal reconstruction. A risk factor for poor healing including obesity, diabetes, smoking, prior radiation, previous abdominal surgery, or poor nutritional status was present in 38 (82.6%) patients, and 24 (52.2%) had two or more risk factors. Flap complications occurred in 9 (19.6%) patients, one with complete flap necrosis that required re-operation, two with superficial flap necrosis, and three with superficial flap separation. Three patients (6.5%) suffered from vaginal stenosis, one of which was complete. Anterior abdominal wound separation occurred in 22 (47.8%) patients and pelvic abscess occurred in 14 (30.4%) patients. No individual risk factor was significantly associated with VRAM flap related morbidity; however obesity, prior radiation, and prior abdominal incision were present in nearly all the patients with flap complications. CONCLUSIONS This series confirms that modified VRAM flaps can be used successfully at the time of exenteration, even in an increasingly high risk patient population with an acceptable risk for flap complications.
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19
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Benn T, Brooks RA, Zhang Q, Powell MA, Thaker PH, Mutch DG, Zighelboim I. Pelvic exenteration in gynecologic oncology: a single institution study over 20 years. Gynecol Oncol 2011; 122:14-8. [PMID: 21444105 DOI: 10.1016/j.ygyno.2011.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 03/02/2011] [Accepted: 03/03/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The profile of women with gynecologic malignancies treated with pelvic exenteration has changed since the initial description of this procedure. We sought to evaluate our experience with pelvic exenteration over the last 20 years. METHODS Patients who underwent anterior, posterior, or total pelvic exenteration for vulvar, vaginal, and cervical cancer at Barnes-Jewish Hospital between January 1, 1990 and August 1, 2009 were identified through hospital databases. Patient characteristics, the indications for the procedure, procedural modifications, and patient outcomes were retrospectively assessed. Categorical variables were analyzed with chi-square method, and survival data was analyzed using the Kaplan-Meier method and log rank test. RESULTS Fifty-four patients were identified who had pelvic exenteration for cervical, vaginal, or vulvar cancer. Recurrent cervical cancer was the most common procedural indication. One year overall survival from pelvic exenteration for the entire cohort was 64%, with 44% of patients still living at 2 years and 34% at 50 months. Younger age was associated with improved overall survival after exenteration (p = 0.01). Negative margin status was associated with a longer disease-free survival (p=0.014). Nodal status at the time of exenteration was not associated with time to recurrence or progression, site of recurrence, type of post-operative treatment, early or late complications, or survival. CONCLUSIONS Despite advances in imaging and increased radical techniques, outcomes and complications after total pelvic exenteration in this cohort are similar to those described historically. Pelvic exenteration results in sustained survival in select patients, especially those that are young with recurrent disease and pathologically negative margins.
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Affiliation(s)
- T Benn
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University School of Medicine, USA.
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20
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Griffin N, Rabouhans J, Grant LA, Ng RLH, Ross D, Roblin P, George ML. Pelvi-perineal flap reconstruction: normal imaging appearances and post-operative complications on cross-sectional imaging. Insights Imaging 2011; 2:215-223. [PMID: 22347949 PMCID: PMC3259312 DOI: 10.1007/s13244-011-0070-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Revised: 12/03/2010] [Accepted: 01/14/2011] [Indexed: 11/04/2022] Open
Abstract
Radical pelvic surgery is often required in patients with advanced, persistent or recurrent gynaecological and anorectal malignancies. In the last decade, pedicled flap reconstructions have been increasingly used for pelvic floor and neovaginal reconstruction, introducing well-vascularised non-irradiated tissue into the wound cavity and hence reducing wound complications. The aim of this pictorial review is to describe the normal post-operative cross-sectional imaging appearances of the most commonly used pelvi-perineal flap reconstructions and to illustrate the complications that may arise at the flap donor and recipient sites.
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21
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Bridoux V, Kianifard B, Michot F, Resch B, Sibert L, Tuech JJ. Transposed right colon segment for vaginal reconstruction after pelvic exenteration. Eur J Surg Oncol 2010; 36:1080-4. [DOI: 10.1016/j.ejso.2010.08.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 07/21/2010] [Accepted: 08/19/2010] [Indexed: 10/19/2022] Open
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Shukla H, Tewari M. An evolution of clinical application of inferior pedicle based rectus abdominis myocutaneous flap for repair of perineal defects after radical surgery for cancer. J Surg Oncol 2010; 102:287-94. [DOI: 10.1002/jso.21605] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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May the rectus abdominis myocutaneous flap be the best option for the reconstruction of complicated large defects of pelvic exenteration for vulvar malignancies after pelvic radiation? Open Med (Wars) 2010. [DOI: 10.2478/s11536-008-0080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractReconstruction of the large defects that develop after pelvic exenteration with local flaps may result in higher morbidity because of poor perineal wound healing after pelvic radiation. A well vascularised reconstructive flap originating from distant non-irradiated areas is needed. We report two cases of pelvic exenteration and rectus abdominis myocutaneous flap procedure in patients with recurrent vulvar malignancies that had undergone external beam pelvic radiation and subsequently developed pelvic fibrosis, necrosis and fistulas. Both flaps were totally viable postoperatively; the abdominal wound healed without any complication, no perineal wound complications developed with a follow-up of nine months. In conclusions, rectus abdominis myocutaneous flap reconstruction seems to be an ideal option for the large defects resulting from exenteration operations in patients with previous perineal radiation.
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Castillo PA, Aguilar VC, Wexner S, Davila GW. Uterine retroversion for vaginoperineal reconstruction following resection of distal rectal tumors. Dis Colon Rectum 2010; 53:350-4. [PMID: 20173485 DOI: 10.1007/dcr.0b013e3181c52d1d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Vaginal and perineal reconstruction following wide resection of locally invasive rectal cancer can be challenging. Various techniques have been reported, all of which contribute the additional morbidity inherent in tissue procurement. We present a technique applicable to nonhysterectomized patients who undergo posterior vaginal wall reconstruction with retroversion of the in situ uterus. METHODS Four nonhysterectomized patients with recurrent rectal carcinoma and abdominoperineal resection with en bloc resection of the posterior vagina leaving a large defect necessitating reconstruction of the vagina, perineum, or both, have undergone posterior vaginal wall and perineal reconstruction with uterine retroversion into the posterior pelvis and fixation to the perineum. RESULTS Satisfactory vaginoperineal reconstruction was achieved in all our patients at 3 months. In addition, patients are able to resume sexual activity after tissue re-epithelialization. CONCLUSION Uterine retroversion is a viable option for vaginal and perineal reconstruction.
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Affiliation(s)
- P A Castillo
- Division of Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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25
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Incorporating pelvic/vaginal reconstruction into radical pelvic surgery. Gynecol Oncol 2009; 115:154-163. [DOI: 10.1016/j.ygyno.2009.05.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 05/26/2009] [Accepted: 05/28/2009] [Indexed: 11/20/2022]
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26
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Reconstruction of Pelvic Exenteration Defects with Anterolateral Thigh–Vastus Lateralis Muscle Flaps. Plast Reconstr Surg 2009; 124:1177-1185. [DOI: 10.1097/prs.0b013e3181b5a40f] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Ang Z, Qun Q, Peirong Y, Fei LZ, Lin Z, Wei LW, Lin ZH, Rong FB. Refined DIEP Flap Technique for Vaginal Reconstruction. Urology 2009; 74:197-201. [DOI: 10.1016/j.urology.2008.11.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Revised: 11/27/2008] [Accepted: 11/30/2008] [Indexed: 11/27/2022]
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28
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Schneider W, Nguyen-Thanh P, Dralle H, Mirastschijski U. Ileal J-pouch vaginoplasty: reconstruction of a physiologic vagina with an ileal J-pouch. Am J Obstet Gynecol 2009; 200:694.e1-4. [PMID: 19376491 DOI: 10.1016/j.ajog.2009.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 02/26/2009] [Accepted: 03/06/2009] [Indexed: 11/25/2022]
Abstract
Vaginal reconstruction has been performed for more than a century. Main complications are vaginal stenosis requiring dilatation, dyspareunia, excessive mucus secretion, and poor aesthetic and functional outcome. Here we report a new operation method modified after Baldwin for intestinal vaginoplasty in a patient with pelvic exenteration after spinal cell carcinoma of the vagina. Because of balanced liquid resorption and mucus secretion with sufficient vessel length in the terminal ileum, this intestinal segment was chosen. A J-pouch of distal ileum was constructed pedicled on the ileocolic artery and accompanying nervous plexus, transferred into the lower pelvis and sutured to the vaginal stump. One year follow-up showed a highly satisfied, sexually active patient, with adequate vaginal size, optimal lubrication and no molesting fecal odor. Terminal ileum J-pouch vaginoplasty is an optimal method for vaginal reconstruction providing a sufficient vaginal lumen and lubrication and thereby restoring patients' sexual life and increasing life quality.
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Di Mauro D, D'Hoore A, Penninckx F, De Wever I, Vergote I, Hierner R. V-Y Bilateral gluteus maximus myocutaneous advancement flap in the reconstruction of large perineal defects after resection of pelvic malignancies. Colorectal Dis 2009; 11:508-12. [PMID: 18637929 DOI: 10.1111/j.1463-1318.2008.01641.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the role of the V-Y bilateral gluteus maximus myocutaneous flap (GLM) in the reconstruction of large perineal defects after wide surgical resections for pelvic malignancies. METHOD Twelve consecutive patients (seven females and five males), of mean age 59 years (36-78), with primary or recurrent pelvic malignancies (rectal, anal and vulvar carcinoma), underwent either abdomino-perineal rectum excision with partial sacrectomy or total pelvic exenteration. The perineal defect was reconstructed by means of a GLM flap. Intra-operative blood loss, operative time, hospital stay, postoperative complications and long-term outcome were retrospectively assessed. RESULTS One patient died postoperatively. All the remaining patients had at least one early and/or late complication. After a mean follow-up of 31.2 months, seven patients were alive. No major functional impairment in daily activities was observed. Five patients experienced a slight discomfort in either walking, sitting or cycling. CONCLUSION Gluteus maximus myocutaneus flap is a useful technique for the repair of perineo-pelvic defects after abdomino-perineal rectum excision with partial sacrectomy.
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Affiliation(s)
- D Di Mauro
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
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30
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Delotte J, Ferron G, Lim YKT, Querleu D. First Laparoscopic Repair of Neovaginal Prolapse Following Ileocecal Reconstruction After Resection of Vaginal Carcinoma. J Laparoendosc Adv Surg Tech A 2009; 19:67-9. [DOI: 10.1089/lap.2008.0098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jerome Delotte
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse, France
| | | | - Denis Querleu
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse, France
- University Toulouse III Paul Sabatier, Toulouse, France
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Jurado M, Bazán A, Alcázar JL, Garcia-Tutor E. Primary Vaginal Reconstruction at the Time of Pelvic Exenteration for Gynecologic Cancer: Morbidity Revisited. Ann Surg Oncol 2009; 16:121. [DOI: 10.1245/s10434-008-0171-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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32
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Laparoscopic radical hysterectomy with vaginectomy and reconstruction of vagina in patients with stage I of primary vaginal carcinoma. Gynecol Oncol 2008; 109:92-6. [DOI: 10.1016/j.ygyno.2007.12.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 12/08/2007] [Accepted: 12/11/2007] [Indexed: 11/19/2022]
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33
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Exenterative Pelvic Surgery in the Treatment of Female Genital Organ Malignancies. POLISH JOURNAL OF SURGERY 2008. [DOI: 10.2478/v10035-008-0098-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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34
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Caceres A, Mourton SM, Bochner BH, Gerst SR, Liu L, Alektiar KM, Kardos SV, Barakat RR, Boland PJ, Chi DS. Extended pelvic resections for recurrent uterine and cervical cancer: out-of-the-box surgery. Int J Gynecol Cancer 2007; 18:1139-44. [PMID: 18053063 DOI: 10.1111/j.1525-1438.2007.01140.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with recurrent uterine and cervical cancer have poor prognoses. The objective of this study was to analyze the outcomes of patients with recurrent uterine and cervical cancer who had undergone attempted curative resection of pelvic bone, sidewall muscle, major blood vessels, and/or nerves. We reviewed the records of all 14 patients with recurrent uterine and cervical cancer who had extended pelvic resections at our institution between June 2000 and November 2006. Primary sites of disease were the uterus (11 patients) and cervix (3 patients). Tumor histology was as follows: adenocarcinoma, seven; squamous cell carcinoma, three; leiomyosarcoma, three; and adenosarcoma, one. Previous treatment included hysterectomy, 11; pelvic radiation, 9; chemotherapy, 9; and total pelvic exenteration, 2. Extended pelvic resections included removal of pelvic sidewall muscle, five; bone, five; common and/or external iliac vessel, five; femoral nerve, two; lumbosacral nerve root, one; and obturator nerve, one. Other procedures included total pelvic exenteration, three; posterior exenteration, two; and anterior exenteration, one. Complete resection with negative margins was obtained in 11 (78%) of 14 patients. Seven patients (50%) received high-dose rate intraoperative radiation therapy. Reconstructive procedures included continent or incontinent urinary diversion, four; femoral-femoral arterial bypass, two; myocutaneous flap, two; and urinary ileal interposition, one. Median total operating time was 628 min (range, 345-935 min) and median estimated blood loss was 900 mL (range, 300-16,000 mL). Seven patients (50%) had one or more major complication(s), including pelvic abscess, three; colonic fistula, two; massive intraoperative hemorrhage, one; postoperative bladder perforation, one; thrombosed femoral-femoral graft, one; and disruption of appendicocutaneous urinary anastomosis, one. At a median follow-up of 26 months (range, 5-84 months), ten patients (71%) are alive and four patients (29%) have died of disease at 8, 13, 33, and 42 months postoperatively.
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Affiliation(s)
- A Caceres
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Soper JT, Secord AA, Havrilesky LJ, Berchuck A, Clarke-Pearson DL. Comparison of gracilis and rectus abdominis myocutaneous flap neovaginal reconstruction performed during radical pelvic surgery: flap-specific morbidity. Int J Gynecol Cancer 2007; 17:298-303. [PMID: 17291272 DOI: 10.1111/j.1525-1438.2007.00784.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To compare flap-specific complications of gracilis myocutaneous (GM) and rectus abdominis myocutaneous (RAM) flap neovaginal reconstructions after radical pelvic surgery. The study was a single-institution retrospective review of patients undergoing concurrent radical pelvic surgery with GM or RAM neovaginal reconstructions performed on a gynecological oncology service, 1978–2003. Flap-specific complications were compared between the techniques. Forty-four GM and 32 RAM neovaginal reconstructions were analyzed: plastic surgeons developed 12 (27%) GM and 4 (13%) RAM flaps, with all other flaps performed by gynecological oncologists. Primary procedures included 54 (71%) total pelvic exenterations, with partial exenterations or radical vulvovaginectomies in 16 (21%) and 6 (8%) patients, respectively. Forty (53%) patients had received radiation and 28 (36%) received chemoradiation before radical surgery. There were no significant differences in patient characteristics, other than more frequent use of continent urinary conduits (P < 0.001) and a trend for more frequent sidewall radiation (P < 0.1) in the RAM group, reflecting use in more recent patients (P < 0.001). Median follow-up is 28 months (range: 2 weeks to 216 months), with 5% acute operative mortality. Flap-specific complications were significantly increased in GM patients (P < 0.03). Overall flap loss was significantly increased in GM patients (P < 0.02). Thirty (59%) of 51 patients surviving for more than 12 months reported coitus, with no significant difference between the groups. Because of lower overall incidence of flap-specific complications and significantly lower incidence of flap loss compared with GM flap, RAM flap has become our technique of choice for neovaginal reconstruction concurrent with radical pelvic surgery.
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Affiliation(s)
- J T Soper
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
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36
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Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol 2006; 7:837-47. [PMID: 17012046 DOI: 10.1016/s1470-2045(06)70903-2] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pelvic exenteration has been used for 60 years to treat cancers of the lower and middle female genital tract in radiated pelves. The mainstay for treatment success in terms of locoregional control and long-term survival is resection of the pelvic tumour with clear margins (R0). New ablative techniques based on developmentally derived surgical anatomy and laterally extended endopelvic resection have raised the number of R0 resections done, even for tumours that extend to the pelvic side wall, which were traditionally judged a contraindication for exenteration. Although mortality has fallen to less than 5%, treatment-related severe morbidity of pelvic exenteration still exceeds 50%, possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. The benefits of exenteration for patients who have advanced primary disease or recurrent tumours after surgery, versus those who have chemoradiotherapy, are not proven by results of controlled trials, but can be assumed from retrospective data. Comparative findings are missing, and arguments are unconvincing to favour pelvic exenteration over less extensive treatments and best supportive care for palliation of cancer symptoms in most patients.
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Affiliation(s)
- Michael Höckel
- Department of Obstetrics and Gynaecology, University of Leipzig, Philipp-Rosenthal-Str 55, 04103 Leipzig, Germany.
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37
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Møller FV, Christensen P, Rasmussen PC, Laurberg S. Ipsilateral ileal conduit placement at vertical rectus abdominis myocutaneous flap donor site in pelvic exenteration. Dis Colon Rectum 2006; 49:1458-61. [PMID: 16897329 DOI: 10.1007/s10350-006-0644-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Placing of ileal conduit at the time of pelvic exenteration in combination with a same-side vertical rectus abdominis myocutaneous flap is controversial. We report our experience with the placement of the ileal conduit at the same side as the donor site of the vertical rectus abdominis myocutaneous flap in 12 patients and describe our technical approach.
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Affiliation(s)
- Flemming V Møller
- Department of Surgery L, University Hospital of Aarhus, Tage-Hansensgade 2, 8000 Aarhus, Denmark.
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Micha JP, Goldstein BH, Rettenmaier MA, Brown JV. Neovagina Reconstruction Utilizing the Bladder and Urethra Following Radical Radiation Therapy. J Gynecol Surg 2006. [DOI: 10.1089/gyn.2006.22.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John P. Micha
- Gynecologic Oncology Associates and Hoag Hospital Cancer Center, Newport Beach, CA
| | - Bram H. Goldstein
- Gynecologic Oncology Associates and Hoag Hospital Cancer Center, Newport Beach, CA
| | - Mark A. Rettenmaier
- Gynecologic Oncology Associates and Hoag Hospital Cancer Center, Newport Beach, CA
| | - John V. Brown
- Gynecologic Oncology Associates and Hoag Hospital Cancer Center, Newport Beach, CA
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Rettenmaier MA, Goldstein BH, Micha JP, Brown JV. Vaginal reconstruction following supra-levator total pelvic exenteration. Gynecol Oncol 2006; 102:397-9. [PMID: 16564075 DOI: 10.1016/j.ygyno.2006.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 02/11/2006] [Accepted: 02/11/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND There are several available techniques for neovaginal reconstruction following exenterative gynecologic surgery. However, all methods are associated with prolonged operative time and increased morbidity. The Apogee and Perigee vaginal vault and prolapse repair systems are innovative and minimally invasive procedures that may prove to be effective in controlling the levator defect and reconstructing the vagina in patients undergoing supra-levator pelvic exenteration. CASE We present a patient who underwent supra-levator total pelvic exenteration for treatment of recurrent squamous cell carcinoma of the cervix. Vaginal reconstruction was performed with the Apogee and Perigee systems utilizing the porcine mesh (InteXen) from American Medical Systems. The patient did well without any postoperative vaginal or small bowel complications. CONCLUSION The Apogee and Perigee systems comprise an innovative technique for vaginal vault reconstruction and prolapse repair. These systems may prove useful in reconstruction of the pelvis following ultra-radical pelvic procedures for recurrent gynecologic malignancies.
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Affiliation(s)
- Mark A Rettenmaier
- Gynecologic Oncology Associates, Hoag Cancer Center, 351 Hospital Road, Suite 507, Newport Beach, CA 92663, USA.
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Pawlik TM, Skibber JM, Rodriguez-Bigas MA. Pelvic Exenteration for Advanced Pelvic Malignancies. Ann Surg Oncol 2006; 13:612-23. [PMID: 16538402 DOI: 10.1245/aso.2006.03.082] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Accepted: 08/05/2005] [Indexed: 01/24/2023]
Affiliation(s)
- Timothy M Pawlik
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Unit 444, P.O. Box 301402, Houston, Texas, 77230-1402, USA
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O'Connell C, Mirhashemi R, Kassira N, Lambrou N, McDonald WS. Formation of Functional Neovagina With Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap After Total Pelvic Exenteration. Ann Plast Surg 2005; 55:470-3. [PMID: 16258296 DOI: 10.1097/01.sap.0000181361.11851.53] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pelvic exenteration may be the only curative option for women with recurrent pelvic malignancies. After total pelvic exenteration, the resultant perineal defect heals slowly if left to do so by secondary intention. Reconstruction with the vertical rectus abdominis musculocutaneous (VRAM) flap brings a generous bulk of healthy tissue into the defect, speeding recovery by facilitating primary healing. METHODS Six women underwent reconstruction of a neovagina using a vertical rectus abdominis musculocutaneous flap. All 6 had total pelvic exenteration for advanced gynecologic malignancy. Primary diagnosis was cervical carcinoma (n = 3), vulvar carcinoma (n = 1), nonsmall cell vaginal cancer (n = 1), and vaginal melanoma (n = 1). Four patients had received adjuvant radiotherapy preoperatively. RESULTS All flaps remained 100% viable postoperatively. There were no cases of fistula, infection, or bowel obstruction. Two patients died of cardiovascular arrest postoperatively. The 4 other patients report satisfaction with reconstruction. Three had vaginal intercourse with orgasm. CONCLUSION The inferiorly based vertical rectus abdominis musculocutaneous flap is a dependable source of tissue for pelvic reconstruction and is the flap of choice in the Division of Plastic Surgery. In addition to facilitating healing, the VRAM flap (neovagina) improves a woman's psychosocial well-being.
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Affiliation(s)
- Christopher O'Connell
- Division of Plastic and Reconstructive Surgery, University of Miami School of Medicine/Jackson Memorial Hospital, Miami, Florida 33136, USA
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Soper JT, Secord AA, Havrilesky LJ, Berchuck A, Clarke-Pearson DL. Rectus abdominis myocutaneous and myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: comparison of flap-related morbidity. Gynecol Oncol 2005; 97:596-601. [PMID: 15863165 DOI: 10.1016/j.ygyno.2005.01.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Revised: 01/21/2005] [Accepted: 01/25/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare flap-specific complications of rectus abdominis myocutaneous (RAM) and myoperitoneal (RAMP) flap neovagina reconstructions performed concurrently with radical pelvic procedures. MATERIALS AND METHODS Retrospective single institution chart review of all patients with RAM or RAMP flap neovaginal reconstructions performed on a Gynecologic Oncology service, 1988-2003. Analysis for associations with flap-specific morbidity was performed. RESULTS Neovaginal reconstructions comprised 32 RAM and 7 RAMP flaps. Twenty-two (69%) RAM patients underwent total pelvic exenteration compared to 1 (14%) RAMP patient (P < 0.013). Overall, 33 (85%) of the patient population had previously been treated with radiation. Flap-specific complications developed in 12 (32%) RAM versus 4 (57%) of the RAMP patients (P > 0.1). Donor site complications and incisional hernias were increased in RAMP patients (both P < 0.03), with trends for increasing risk of vaginal stricture/stenosis and superficial wound separations (both P < 0.1). Complete vaginal stenosis developed in only 1 (3%) RAM versus 3 (43%) RAMP patients. Furthermore, 3 RAMP patients developed complete stenosis when the vaginal defect was circumferential and involved >65% of the vagina while this did not occur in 22 similar RAM patients (P < 0.0005). Only patients with partial longitudinal defects maintained vaginal patency after RAMP flap. Fifteen (58%) of 26 patients surviving >12 months reported coitus, with no significant difference between the groups. CONCLUSIONS When there is circumferential loss of the upper 2/3 of the vagina. RAMP flaps are not suitable for neovaginal reconstruction after radical pelvic surgery because of an increased risk of vaginal stenosis compared to RAM flaps. Patients with partial longitudinal vaginal defects, however, may have successful neovaginal reconstruction with RAMP flaps.
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Affiliation(s)
- John T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Box 3079, Durham, NC 27710, USA.
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Affiliation(s)
- Marvin J Lopez
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA.
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Lambrou NC, Pearson JM, Averette HE. Pelvic exenteration of gynecologic malignancy: indications, and technical and reconstructive considerations. Surg Oncol Clin N Am 2005; 14:289-300. [PMID: 15817240 DOI: 10.1016/j.soc.2004.11.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nicholas C Lambrou
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami, FL 33136, USA.
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Soper JT, Havrilesky LJ, Secord AA, Berchuck A, Clarke-Pearson DL. Rectus abdominis myocutaneous flaps for neovaginal reconstruction after radical pelvic surgery. Int J Gynecol Cancer 2005; 15:542-8. [PMID: 15882183 DOI: 10.1111/j.1525-1438.2005.15322.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The objective of this article is to compare the flap-specific complications associated with vertical (VRAM) and transverse (TRAM) rectus abdominis myocutaneous flap vaginal reconstructions performed during radical pelvic procedures. A retrospective chart review was performed to identify all patients who underwent VRAM and TRAM neovaginal reconstructions performed on the Gynecologic Oncology Service at Duke University Medical Center. Flap-specific complications were compared between the two techniques. From 1988 to 2003, 14 VRAM and 18 TRAM flap neovaginal reconstructions were performed on 32 women during the course of 22 (68%) total pelvic exenterations, 8 (25%) partial exenterations, and 2 (6%) radical vulvovaginectomies. Twenty-eight (88%) patients had been previously treated with radiation therapy or concurrent chemoradiation. Associated procedures included continent urinary conduit in 21 (66%), rectosigmoid reanastomosis in 8 (25%), and intraoperative or postoperative sidewall radiation therapy in 7 (22%) of patients. Overall median survival was 14 months (range: 2-week postoperative death to 65 months), with two (6%) acute postoperative mortalities. Fifteen flap-specific complications occurred in 12 (38%) patients, with no significant differences in flap type. Abdominal wound complications included four (12%) superficial wound separations, while one (3%) patient had a fascial dehiscence associated with complex fistulas that contributed to her death, but no patient developed incisional hernia. One patient each developed > 50% flap loss after TRAM and < 50% flap loss after VRAM flap, respectively. Four (12%) patients developed vaginal stricture or stenosis, two (6%) required percutaneous drainage of pelvic abscess or hematoma, and two (6%) developed rectovaginal fistula. Univariate analysis revealed a trend for increasing flap loss with body mass index > 35 (P = 0.056, Fisher exact two-tailed test), but there were no significant associations with other patient characteristics or flap-specific complications. Thirteen (62%) of 21 patients who survived >12 months reported coitus. Both VRAM and TRAM are reliable techniques for neovaginal reconstructions after radical pelvic surgery and have a similar distribution of flap-specific complications involving the donor and recipient sites.
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Affiliation(s)
- J T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.
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Affiliation(s)
- Emery M Salom
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Miami School of Medicine, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, Miami, Florida, USA.
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Bakx R, van Lanschot JJB, Zoetmulder FAN. Inferiorly based rectus abdominis myocutaneous flaps in surgical oncology: Indications, technique, and experience in 37 patients. J Surg Oncol 2004; 85:93-7. [PMID: 14755512 DOI: 10.1002/jso.20014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Roel Bakx
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Jimenez RE, Shoup M, Cohen AM, Paty PB, Guillem J, Wong WD. Contemporary outcomes of total pelvic exenteration in the treatment of colorectal cancer. Dis Colon Rectum 2003; 46:1619-25. [PMID: 14668586 DOI: 10.1007/bf02660766] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Total pelvic exenteration is performed infrequently in selected patients with locally advanced or recurrent colorectal cancer. We reviewed our contemporary experience with pelvic exenteration for colorectal cancer to identify selection criteria and prognostic factors for long-term survival. METHODS Between 1991 and 2000, 55 patients (males, 29; median age, 62 years) undergoing total pelvic exenteration for colorectal cancer were identified from a prospective database. Clinicopathologic variables were evaluated as prognostic indicators of long-term survival by log-rank test and multivariate Cox regression. RESULTS Indications for surgery were recurrent colorectal cancer in 71 percent and primary colorectal cancer in 29 percent. Of 39 patients with recurrent colorectal cancer, 85 percent had previous radiotherapy, and 64 percent had previous abdominoperineal resection. At the time of pelvic exenteration, 49 percent of patients received intraoperative radiation, and 20 percent required sacrectomy. Complete resection with negative margins was achieved in 73 percent. Perioperative mortality after pelvic exenteration was 5.5 percent, and complications included perineal wound infection (40 percent), pelvic abscess (20 percent), abdominal wound infection (18 percent), and cardiopulmonary events (18 percent). Median disease-specific survival for all patients was 48.9 (range, 3.2-105.6) months. Univariate analysis identified five factors associated with decreased survival: male gender, recurrent colorectal cancer, previous abdominoperineal resection, positive surgical margin, and administration of intraoperative radiation. On multivariate analysis, only previous abdominoperineal resection was an independent predictor of unfavorable outcome (P < 0.04). CONCLUSIONS Total pelvic exenteration can be performed safely in highly selected patients with colorectal cancer and can result in significantly prolonged survival. Less satisfactory outcomes are observed in patients whose indication for pelvic exenteration is recurrent colorectal cancer after abdominoperineal resection.
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Affiliation(s)
- Ramon E Jimenez
- Division of Colorectal Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Ruiz-de-Erenchun R, Murillo J, Bazán A, Jurado M, García-Tutor E. Vaginal Reconstruction Using a Modified Rectus Abdominis Musculocutaneous Flap in Pelvic Cancer Surgery. Ann Plast Surg 2003; 51:455-9. [PMID: 14595179 DOI: 10.1097/01.sap.0000070647.81355.f7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors present a modification of the design for the classic cutaneous pattern of the rectus abdominis musculocutaneous flap for vaginal reconstruction after pelvic cancer surgery. The authors designed a paramedial and supraumbilical dermo-cutaneous flap with paraumbilical randomized vascularization, which was sutured to the classic cutaneous TRAM flap pattern and rotated around a longitudinal axis to form the neo-introitus. The use of this new cutaneous design allows for a perfect cylindrical shape all along the length of the new vagina, thus achieving a more anatomic reconstruction than those currently obtained with the classic cutaneous patterns, and with fewer tendencies to distal retraction, necrosis, and partial stenosis.
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Affiliation(s)
- R Ruiz-de-Erenchun
- Department of Plastic, Reconstructive, and Esthetic Surgery, University Hospital, University of Navarra Pamplona, Spain
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Mirhashemi R, Lambrou N. Reply. Gynecol Oncol 2003. [DOI: 10.1016/s0090-8258(03)00361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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