Vaginal reconstruction with a greater omentum–pedicled graft combined with a vicryl mesh after anterior pelvic exenteration. Surgical approach with long-term follow-up

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.

Novel modification of the vertical rectus abdominis myocutaneous flap for neovagina creation

OBJECTIVE

We describe a modification of the traditional vertical rectus abdominis myocutaneous flap for neovagina creation and our experience to date.

METHODS

Our modified vertical rectus abdominis myocutaneous flap uses a smaller flap size with a full-thickness skin graft posteriorly to decrease the size of the abdominal wall defect. We have used the modified vertical rectus abdominis myocutaneous flap in 18 patients between March 1998 and March 2004 to create a neovagina after exenterative surgery.

RESULTS

The mean age of the patients was 54 years, and the mean body mass index was 27 (range 18-44). Twelve patients underwent a total pelvic, 5 anterior, and 1 posterior exenteration. Among the 13 patients requiring a colostomy, the vertical rectus abdominis myocutaneous flap was taken from the contralateral side. In these patients, the urostomy was brought out on the vertical rectus abdominis myocutaneous flap donor side. There has been only 1 partial flap loss, which eventually resulted in a fully epithelialized neovagina. Eight patients at last follow-up were sexually active. Two other patients have died from recurrent disease, and 2 are alive with recurrence. The other 6 patients have no evidence of recurrent disease and, although not sexually active at the time of this report, have a viable and adequate neovagina. All patients had a successful primary closure of the abdominal wound in a vertical fashion. Three patients had superficial abdominal wound breakdown, which healed by secondary intention.

CONCLUSION

The modified vertical rectus abdominis myocutaneous flap allows for creation of an adequate neovagina with a smaller abdominal wall defect.

[Conservative surgery and restoration after pelvic exenteration]

Pelvic exenteration can be proposed to non-metastatic patients with advanced or recurrent pelvic cancer and remains frequently the only potentially curative option in combination with others therapies. Colorectal function preservation and reconstructive procedures are useful to decrease functional and psychologic impact and postoperative morbidity. Technical procedures including urinary diversion, colorectal function preservation, vaginal reconstruction and pelvic filling are described and commented. Specific morbidity is analysed.

Vaginal reconstruction using a vertical rectus abdominis myocutaneous flap in a child: a case report

Rhabdomyosarcoma is the most common soft tissue sarcoma in infants and children younger than 15 years old. Multimodal treatment using chemotherapy, radiation, and surgery have increased survival. Because of the potential for long-term survival, the importance of organ preservation and vaginal and pelvic reconstruction has been recognized. The authors report a case in which special circumstances led to vaginal reconstruction concomitantly with exenteration surgery. The authors present the first reported use of a vertical rectus abdominis myocutaneous flap in a child and describe the technique and its potential advantages.

[Is it possible to improve the quality of life of patients who have undergone pelvic evisceration?]

Locally spread cancer makes up considerable percent (20-30%) in statistical structure of rectal tumors. In cases of cancer spread into the area of urine bladder triangle the operation of choice is pelvic evisceration. From 1977 to 1997 in the State research Centre of the Ministry of Health for Coloproctology pelvic evisceration in cancer spread to back wall of urine bladder in the area of triangle was carried out in 22 patients (20 male and 2 female). Mean age was 43.4 (29-56) years, 16 patients have undergone typical infralevator pelvic evisceration. There were no intraoperative lethality. Postoperative lethality made up 6.3%, complications--68.8%, 5-years survival rate--25%. Presence of two fecal fistulas on the anterior abdominal wall has decreased considerably the quality of life of the patients. Since 1993 the conception of preservation and restoration of natural passage of urine and bowel contents was adopted. In 4 cases infralevator pelvic evisceration with various types of ileocystoplasty and pull-through of colon into small pelvis with creation of smooth muscle cuff in perineal colostomy was carried out. In 2 patients evisceration was of supralevator-character cystoplasty of local tissues and performance of coloanal anastomosis were carried out. The application of reconstructive-restorative ways in coloproctology and urology considerably contributed to the improvement of the quality of life of the patients after pelvic evisceration.

Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration

BACKGROUND

Although the technique for gracilis myocutaneous vaginal reconstruction was first described in the mid-1970s and has been used in conjunction with pelvic exenteration since that time, there is little available information regarding sexual adjustment after such a procedure. The purpose of this study was to assess the sexual adjustment of women who underwent pelvic exenteration and gracilis myocutaneous vaginal reconstruction at the study institution.

METHODS

In a prospective study design, 95 patients were identified who underwent pelvic exenteration and gracilis myocutaneous vaginal reconstruction at the study institution from 1977 through 1989 and a convenience sample was selected of 44 patients who completed a modified version of the Sexual Adjustment Questionnaire (SAQ) when they returned to the gynecologic oncology outpatient clinic for routine follow-up care. A vaginal assessment was also performed by the attending physician.

RESULTS

Twenty-one of 40 patients (52.5%) completing the questionnaire reported not resuming sexual activity after surgery; 19 patients reported sexual activity between 1.5 months to 12 years postoperatively. Of the patients who resumed sexual activity, 84% did so within 1 year of surgery. The most common problems noted by patients in adjusting to sexual activity after surgery were self-consciousness about the urostomy or colostomy and being seen in the nude by their partner, vaginal dryness, and vaginal discharge. The mean rank of preexenteration SAQ scores was 66.4, and the mean rank of postexenteration scores was 48.7 (P < 0.0001), demonstrating that sexual adjustment after exenteration was significantly poorer than before the surgery. On the basis of data gathered from a vaginal assessment form, 31 of 44 patients (70.4%) were judged to have a potentially functional neovagina.

CONCLUSIONS

Based on the findings of this questionnaire study, sexual adjustment is often significantly impaired in women after pelvic exenteration and gracilis myocutaneous vaginal reconstruction. Future modifications in surgical technique, more realistic patient counseling and aggressive postoperative support will hopefully minimize such problems.

The transversus and rectus abdominis musculoperitoneal (TRAMP) composite flap for vulvovaginal reconstruction

The transversus and rectus abdominis musculoperitoneal (TRAMP) flap, a novel composite flap supplied by the deep inferior epigastric vessels, was used successfully for partial vulvovaginal reconstruction following anterior and posterior exenteration. The full potential of the TRAMP flap in vulvovaginal reconstruction is being investigated further.

Reconstruction with myocutaneous flaps following resection of locally recurrent rectal cancer

Local or regional recurrence is frequent in patients treated for rectal cancer. Many will die with regional disease in the absence of distant metastases. To achieve cure or palliation, radical surgery resulting in large pelvic defects may be warranted. Myocutaneous flap reconstruction may be used to achieve satisfactory closure. From 1988 to 1993, nine patients (5 female, 4 male) underwent 10 myocutaneous flap reconstructions for large perineal or pelvic defects following surgical extirpation of recurrent rectal cancer at Fox Chase Cancer Center. All nine patients had been previously treated with radiation therapy. Their clinical course was reviewed and quality of life assessed. The mean age at diagnosis of recurrence was 56 years. In six, this was a first, and in three patients a second recurrence. Clinical presentation was most often bleeding, abscess, or perineal pain. Resection was determined by extent of recurrence and included perineal resection, pelvic exenteration, cystectomy, sacrectomy, or coccygectomy. Extent of disease necessitated intraoperative radiation therapy in one case and placement of brachytherapy catheters in four. Bilateral gracilis flaps were used in four, unilateral in three, gluteus maximus in two, and combined gluteal and gracilis flaps in one patient. Six perineal and four combined perineal and vaginal defects were reconstructed. The mean length of surgery was 9.1 hours, and the length of hospitalization averaged 17.5 days. In nine of 10 cases, patients had prehospital level of function at discharge. Acute surgical flap-related complications included three cases of minor wound infection or separation, two of minimal but persistent drainage, and one of vaginal colonization.(ABSTRACT TRUNCATED AT 250 WORDS)

A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report

The blood supply to the skin of the perineum, medial groin, and upper thigh was studied in fresh female cadavers. The pudendal-thigh flap was designed as a result to reconstruct the vagina. The flaps are raised bilaterally in the groin crease just lateral to the labia majora and then are transposed toward the midline and sutured together to form a skin-lined cul-de-sac which opens at the introitus. The technique has been used successfully in three patients to reconstruct the vagina. The first patient, an adult, was reconstructed after total pelvic exenteration for malignancy, while two children had reconstructions for congenital vaginal anomalies. This technique is superior to currently available methods because it is simple and reliable. No stents or dilators are needed. It is safe technique without complications in our hands. The reconstructed vagina has a natural angle for intercourse and is sensate. The donor scars in the groin are well hidden.

A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.

Pelvic exenteration

Exenteration, or complete excision of the pelvic viscera, is an ultra-radical surgical procedure intended for curative treatment of the patient with advanced pelvic malignancy--primary or recurrent. At the time of introduction of this procedure, enthusiasm for its use was marred by the high incidence of serious surgical morbidity and mortality, which approached the five-year survival rate. With more careful physiological and psychological selection of patients, concentration of this kind of procedure in centres familiar with its use, improved urinary conduit techniques and careful attention to covering the pelvic floor with omentum and/or synthetic materials, the morbidity and mortality rate has been significantly reduced thus making exenteration a more acceptable treatment option to a wider spectrum of patients. More sophisticated haemodynamic monitoring, both intra- and postoperatively, intravenous hyperalimentation, prophylactic antibiotics and low-dose heparin are undoubtedly important adjuncts to the improvements in surgical technique and judgment. Psychosexual 'rehabilitation' in the broadest sense must be an integral part of patient care for those undergoing exenteration and in most instances necessitates involvement of the patient's partner. Exenteration has only a very limited role in palliation and all attempts should be made to avoid this procedure when cure is clearly not a possibility.