Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects

[Reconstruction of Oncological Defects in the Pelvic-perineal Region: Report on the Consensus Workshop at the 44th Annual Meeting of the DAM 2023 in Bern, CH]

The surgical-oncological treatment of pelvic and perineal malignancies is associated with a high complication rate and morbidity for patients. Modern multimodal treatment modalities, such as neoadjuvant radio-chemotherapy for anal or rectal cancer, increase the long-term survival rate while reducing the risk of local recurrence. Simultaneously, the increasing surgical radicality and higher oncological safety with wide resection margins is inevitably associated with larger and, due to radiation, more complex tissue defects in the perineal and sacral parts of the pelvic floor. Therefore, the plastic-surgical reconstruction of complex pelvic-perineal defects following oncological resection remains challenging. The reconstructive armamentarium, and thus the treatment of such defects, is broad and ranges from local, regional and muscle-based flaps to microvascular and perforator-based procedures. While the use of flaps is associated with a significant, well-documented reduction in postoperative complications compared to primary closure, there is still a lack of reliable data directly comparing the postoperative results of different reconstructive approaches. Additionaly, the current data shows that the quality of life of these patients is rarely recorded in a standardised manner. In a consensus workshop at the 44th annual meeting of the German-speaking Association for Microsurgery on the topic of "Reconstruction of oncological defects in the pelvic-perineal area", the current literature was discussed and recommendations for the reconstruction of complex defects in this area were developed. The aim of this workshop was to identify knowledge gaps and establish an expert consensus to ensure and continuously improve the quality of reconstruction in this challenging area. In addition, the importance of the "patient-reported outcome measures" in pelvic reconstruction was highlighted, and the commitment to its widespread use in the era of value-based healthcare was affirmed.

Perineal bowel evisceration after extralevator abdominoperineal excision and vertical rectus abdominis myocutaneous flap closure

INTRODUCTION

Perineal bowel evisceration is a rare complication after extralevator abdominoperineal excision (ELAPE). This surgical technique is used to resect low rectal and anal cancer, with a lower likelihood of positive surgical margins, but resulting in a larger perineal defect. A vertical rectus abdominis myocutaneous (VRAM) flap allows filling of the empty pelvic space and closure of the defect in the pelvic floor.

CASE PRESENTATION

A 77-year-old woman, with a hysterectomy in her medical history, underwent an ELAPE followed by reconstruction of the perineal defect with a VRAM flap after neoadjuvant radiotherapy for a moderately differentiated invasive adenocarcinoma of the distal rectum. The postoperative course was complicated with a herniation of the perineal wound and evisceration of a bowel loop.

CONCLUSION

Closure of the perineal defect after ELAPE remains a challenge, especially in cases where several risk factors for delayed wound healing, flap failure and perineal herniation are present.

Bowel seromuscular flaps used to repair pelvic defects in patients undergoing reoperative surgery

BACKGROUND

Pedicled seromuscular bowel flaps may serve as an alternative for pelvic floor reconstruction when conventional omental and muscular flaps are not an option in patients undergoing reoperative abdominopelvic surgery. The aim of this study was to evaluate a unique series of bowel seromuscular flaps used to obliterate intrapelvic defects.

METHODS

We conducted a retrospective study on all patients in a single tertiary care institutional database who had undergone pelvic reconstruction with a seromuscular bowel flap from January 2006 to December 2018. The primary outcomes measured were the 30-day morbidity and mortality rates.

RESULTS

Twelve patients (6 men 6 women, median age 56.5 years [range 33-77 years]) underwent reoperative abdominopelvic surgery requiring the use of a native small or large seromuscular bowel flap to obliterate pelvic defects. The indications for surgery included chronic infections, fistulizing Crohn's disease, and cancer. In all cases, no residual omentum was available and rectus abdominis muscle flaps were not feasible due to prior operative scars. Thirty-day morbidity occurred in 5 patients (42%), and included urine leak from ureteral injury, anastomotic leak, acute kidney injury, and superficial surgical site infection. No flaps became ischemic or required removal in the postoperative setting. No mortality was recorded.

CONCLUSIONS

Bowel seromuscular flaps are a feasible and safe alternative for covering pelvic defects in patients who are undergoing reoperative surgery without the option to use traditional omental and muscular flaps.

Low Concentrated Fractionalized Nanofibers as Suitable Fillers for Optimization of Structural–Functional Parameters of Dead Space Gel Implants after Rectal Extirpation

Dead space after rectal resection in colorectal surgery is an area with a high risk of complications. In this study, our goal was to develop a novel 3D implant based on composite hydrogels enriched with fractionalized nanofibers. We employed, as a novel approach in abdominal surgery, the application of agarose gels functionalized with fractionalized nanofibers on pieces dozens of microns large with a well-preserved nano-substructure. This retained excellent cell accommodation and proliferation, while nanofiber structures in separated islets allowed cells a free migration throughout the gel. We found these low-concentrated fractionalized nanofibers to be a good tool for structural and biomechanical optimization of the 3D hydrogel implants. In addition, this nano-structuralized system can serve as a convenient drug delivery system for a controlled release of encapsulated bioactive substances from the nanofiber core. Thus, we present novel 3D nanofiber-based gels for controlled release, with a possibility to modify both their biomechanical properties and drug release intended for 3D lesions healing after a rectal extirpation, hysterectomy, or pelvic exenteration.

Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice

Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.

[Bilateral pedicled gracilis muscle flap and bilateral gluteus muscle flap for multiple-stage reconstruction of vagina, pelvis and perineal region]

Plastic reconstructions of oncological anorectal defects often prove to be very difficult and lead to prolonged hospitalisation due to severe bacterial contamination, neoadjuvant radiotherapy and chemotherapy and difficult anatomical conditions. There is no common standard for plastic reconstruction in such cases. We present a patient diagnosed with distal rectal cancer with infiltration of the anus and vagina, who underwent radical tumour resection of the rectum and anus as well as partial resection of the vagina. A severe necrotising infection occurred post-surgery, which resulted in an extensive defect of the pelvis and perineal region. This article provides a retrospective clinical evaluation and photographic documentation of the reconstruction of the vagina, pelvis and perineal region with a bilateral gracilis and gluteus muscle flap.

Abdominal, perineal, and genital soft tissue reconstruction with pedicled anterolateral thigh perforator flaps

Background

Pedicled perforator flaps have become a contemporary alternative to muscle flaps for soft tissue reconstruction as they have reduced donor site morbidity, avoid the need for microsurgical transfer, and are versatile and reliable. The anterolateral thigh (ALT) flap was first introduced as a free flap and has since gained popularity as a pedicled flap. Here we review our experience using pedicled ALT flaps for regional soft tissue reconstruction.

Methods

We retrospectively reviewed all patients who underwent loco-regional soft tissue reconstruction using pedicled ALT flaps between March 2014 and October 2018, with the goal of identifying potential applications of pedicled ALT flaps. The following aspects of each case were reviewed: patient demographics, defect location and size, comorbidities such as previous radiotherapy, flap details, clinical follow-up, and postoperative complications.

Results

Our analysis demonstrates the versatility of pedicled ALT flaps in a variety of indications to successfully cover large abdominal, perineal, and genital soft tissue defects. Depending on the patient’s needs to achieve more bulk or stability in the reconstruction, the ALT flap was individually tailored with underlying muscle or fascia. The average follow-up was 7 months (range: 3–13 months).

Conclusions

Pedicled ALT flaps are a valuable reconstructive option for soft tissue defects located within the pedicle’s range, from the lower abdomen to the perianal region. These flaps are usually raised from a non-irradiated donor site and are sufficient for covering extensive soft tissue defects. Three-dimensional reconstruction of the defect using pedicled ALT flaps allows for anatomical function and minor donor sites.

Level of evidence: Level IV, therapeutic study.

[Reconstruction of oncological defects of the perianal region]

In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.

Complex Soft Tissue Defects in Operative Urology: Pedicled Perforator Flaps of the Anterior Lateral Thigh for Tissue Reconstruction of the Lower Trunk

BACKGROUND

Complex soft tissue defects involving the lower abdomen, perineum, and groin (LAPG) represent reconstructive challenges following urologic surgery. Consequently, these often require an interdisciplinary approach involving plastic surgery. While pedicled flaps from the lower abdomen are a reliable option, previous placement of colostomies and urinary urostomies renders these flap types unavailable. Here, the pedicled anterolateral thigh perforator (ALT) flap represents a reliable pedicled alternative which can harvest from the thigh.

MATERIALS AND METHODS

A retrospective data analysis of pedicled perforator flaps harvested from the thigh to reconstruct soft tissue defects was conducted. Seven patients treated in the urology department with soft tissue defects following tumor resection, infection, and dehiscence were included.

RESULTS

In all patients, the ALT flap was utilized successfully to reconstruct soft tissue defects up to 450 cm2 in size. All flaps survived. In 1 case, prolonged wound healing was observed. All defects were adequately addressed with no recurrence of dehiscence or fistula formation.

CONCLUSIONS

Pedicled perforator flaps represent a valid option for the soft tissue reconstruction of the lower abdomen and perineum when a pedicled rectus abdominis flap is no longer available. This flap is, therefore, a good option in an interdisciplinary approach to soft tissue reconstruction, especially following urologic surgery, which is predominantly performed in the LAPG region.

The dead space after extirpation of rectum. Current management and searching for new materials for filling

Pelvic surgeries such as extirpation of the rectum or pelvic exenteration lead to a creation of a dead space, which can be cause of complication, such as bowel obstruction, perineal hernia, abscess or hematoma. A growing incidence of complication is expected in connection with the increasing use of laparoscopic and robotic approaches or ELAPE method. Since the bone structures do not allow compression, the only way to deal with the dead space is to fill it in. Present methods provide the filling with omental or myofascial flaps. The length and the mobility of the omental flap can be the limitation. Myofascial flaps are technically more demanding and bring the complications of a donor place. Synthetic or biological meshes do not deal with dead space problematic. Modern technologies using nanomaterials offer the possibility to produce a material with specific properties for example shape, inner structure, surface, or time of degradation. The modified material could also satisfy the requirements for filling the dead space after surgeries.

Interdisciplinary Surgical Approaches in Vaginal and Perineal Reconstruction of Advanced Rectal and Anal Female Cancer Patients

Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy-and in case of a relapse a second irradiation-rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (tpVRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.

Complex microsurgical perineal reconstruction after resection of a giant verrucous carcinoma associated with anal fistulas in Crohn's disease-a unique case report

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory disorder which leads to anorectal fistulas. In rare cases, patients develop anal squamous cell carcinoma (ASCC) within these lesions. There is limited literature regarding ASCC in patients with CD. Here, we report on a unique case of advanced verrucous carcinoma (VC), a rare variant of squamous cell carcinoma, developing on the grounds of extensive chronic anorectal fistulas in CD.

METHODS AND RESULTS

A 54-year-old male patient with a 20-year history of CD presented with a large inflammatory tumor at the perineal region with multiple discharging perianal fistulas. Histopathological analysis of the perineal mass revealed a VC. Subsequent surgery with radical tumor resection and terminal colostomy resulted in a large perineal cavity and a partially exposed sacrum. The defect extended to a total of 35 × 25 × 25 cm. Reconstruction was achieved through a two-step approach. A first surgical step established an arteriovenous (AV) loop in the upper thigh. Subsequently, a free latissimus dorsi (LD) myocutaneous flap was harvested and anastomosed with the AV loop, allowing for satisfactory closure of the defect and reconstruction of the perianal and perineal region.

CONCLUSION

Radical surgical excision with negative margins is the therapy of choice for VC. This case report demonstrates a curative treatment option with special emphasis on the reconstructive possibilities of a unique case of extended perianal and perineal VC associated with chronic anorectal fistulas in CD.

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer

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.

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects

AIM

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects.

METHODS

We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal.

RESULTS

Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes.

CONCLUSIONS

The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Incisions and reconstruction approaches for large sarcomas

Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer

AIM

In advanced pelvic cancer it may be necessary to perform a total pelvic exenteration. In such cases urinary tract reconstruction is usually achieved with the creation of an ileal conduit with a urinary stoma on the right side of the patient's abdomen and an end colostomy separately on the left. The potential morbidity from a second stoma may be avoided by the use of a double-barrelled wet colostomy (DBWC), as a single stoma. Another advantage is the possibility of using a vertical rectus abdominis muscle flap for perineal reconstruction.

METHOD

All patients undergoing formation of a DBWC were included.

RESULT

A DBWC was formed in 10 patients. One patient underwent formation of a double-barrelled wet ileostomy.

CONCLUSIONS

In this technical note we present our early experience in 11 cases and a video of DBWC formation in a male patient.

Surgery for chronic mesh infection occurred 10 years after sacrectomy - Mesh resection and mesentric leaf repair: A case report

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An 83-years old woman underwent sacrectomy combined with mesh reconstruction for chordoma suffered chronic mesh infection and bowel penetration 10 years after surgery.

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This is the first report of mesh infection after sacrectomy and its surgical strategy.

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We performed subtotal mesh resection and Mesenteric leaf repair for pelvic reconstruction.

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Mesentric leaf repair might be a useful procedure for pelvic reconstruction when the use of a mesh has to be avoided.

Introduction

Sacrectomy to treat malignant tumors is often results in large pelvic defects to require reconstruction, using a prosthetic mesh. Importance is to avoid its direct contact of mesh with intestine to prevent adhesion between them.

Presentation of case

An 83-year old woman who was diagnosed with a mesh infection caused by a small bowel penetration 10 years after sacrectomy combined with mesh reconstruction for chordoma. In the first operation, because of incomplete re-peritonealization due to a large defect in the retroperitoneum, a mesh unavoidably was compelled to contact with the small intestine. We subtotally removed the mesh and performed mesentric leaf repair of the pelvic defect.

The postoperative course was complicated by infection of the pelvis. She was discharged 59 days after surgery with a little purulent discharge from perineal wound, which was persisted for two years after operation.

Discussion/Conclusion

We used the mesenteric leaf to repair the pelvic defect at the operation. This procedure might be the best alternative, when the use of mesh has to be avoided like present case. To our knowledge, this is the first report of mesh infection after sacrectomy, so we report herein.