Pelvic, Vaginal, and Perineal Reconstruction in Radical Pelvic Surgery

Reconstruction vaginale par lambeau perforant basé sur le pédicule épigastrique inférieur après pelvectomie antérieure

Muscle sparing technique is one of the latest improvements of rectus abdominis flaps harvesting. It minimizes donor site morbidity by preserving the abdominal wall. The deep inferior epigastric perforator flap (DIEP) provides reliable tissues for vaginal reconstruction with local low morbidity. We describe the surgical technique and flap-related specific complications. This technique is safe and useful in the vaginal reconstruction especially following a radiotherapy.

Composite pelvic exenteration: is it worthwhile?

BACKGROUND

In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis.

METHODS

Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3.

RESULTS

Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively.

CONCLUSIONS

Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.

Vaginal Reconstruction Using a Modified Rectus Abdominis Musculocutaneous Flap in Pelvic Cancer Surgery

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.

Exenterative pelvic surgery

A review of the history, indications, basic technique, end results, and complications of exenterative surgery for pelvic neoplasms is provided. The authors discuss their broad personal experience with the operation. Much of this experience evolved from work at Barnes Hospital and the Ellis Fischel State Cancer Hospital. The techniques are applicable to advanced neoplasms of the cervix uteri, scrotum, urinary bladder, and other, less frequent neoplasms still confined to the pelvis.

Total anorectal and partial vaginal reconstruction with dynamic graciloplasty and colonic vaginoplasty after extended abdominoperineal resection: report of a case

PURPOSE

Quality of life is altered after abdominoperineal resection, because of permanent iliac colostomy. Psychological rehabilitation is even more difficult after extended abdominoperineal resection to the vagina, because of the loss of both continence and sexual functions. We report the first case of total anorectal and vaginal reconstruction using dynamic graciloplasty and colonic vaginoplasty after extended abdominoperineal resection.

METHODS

A 46-year-old female underwent extended abdominoperineal resection with posterior colpectomy for a low rectal adenocarcinoma infiltrating the anal sphincter and vagina. Anorectal reconstruction was performed with coloperineal anastomosis and double dynamic graciloplasty. Vaginal reconstruction was performed using a 10-cm, isolated, rotated sigmoid loop. The procedure was performed in three stages, including abdominoperineal resection with reconstruction, implantation of the stimulator, and closure of the temporary ileostomy.

RESULTS

Resting and electrostimulated pressures of the neosphincter were 40 and 110 cm H2O respectively. Continence was achieved for formed stools two months after closure of the stoma, with spontaneous defecations (30-90 minutes). The patient experienced regular sexual activity six months after closure of the stoma.

CONCLUSION

This new original technique can be proposed in selected young females after extended abdominoperineal resection, to preserve continence, sexual activity, and body image.