Vaginal reconstruction

Vaginal reconstruction can be an uncomplicated and straightforward procedure when attention to detail is maintained. The Abbe-McIndoe procedure of lining the neovaginal canal with split thickness skin grafts has become standard. The use of the inflatable Heyer-Schulte vaginal stent has enabled comfort for the patient and ease for the surgeon in maintaining skin graft approximation. For large vaginal and perineal defects, myocutaneous flaps, such as the gracilis island, have been extremely useful for correction of radiation tissue to the perineum or for the reconstruction of large ablative defects. Minimal morbidity and scarring ensues since the donor site can be closed primarily. With all vaginal reconstruction, a compliant patient is a necessity. The patient must wear a vaginal obturator for a minimum of three to six months postoperatively and is encouraged to use intercourse as an excellent obturator. In general, vaginal reconstruction can be an extremely gratifying procedure for both the functional and emotional well-being of patients.     

Vaginal reconstruction in gynecologic oncology

The improved prognosis for patients with gynecologic malignancies has resulted in an increased concern for their sexual function. Vaginal reconstruction plays an integral role in this rehabilitation. The care of these patients at the University of Michigan is reviewed and their treatment is described. Fifty-one patients were treated with split-thickness skin graft vaginoplasty. Seven repeat vaginoplasties were required, for a total of 58 procedures. Fifty patients were assessed postoperatively, and 47 (94%) ultimately had a satisfactory outcome. Three of the 50 patients had an unsatisfactory final outcome; two had recurrent malignancy and the third patient did not comply with the proposed dilator regimen. Four patients developed fistulas. The split-thickness skin graft provides an acceptable outcome when used for vaginal reconstruction in the patient with a gynecologic malignancy.     

Vaginal reconstruction following supra-levator total pelvic exenteration

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.     

Vaginal reconstruction following irradiation complication for cervical cancer

With improved results from treatment of advanced gynecologic malignancies, sexual rehabilitation is given more consideration. A simple technique is described for vaginal reconstruction in a patient with a permanent colostomy and nonfunctioning vagina following pelvic irradiation. The rectovaginal lumina were combined through transection of the rectovaginal walls and anal sphincter, and satisfactory sexual rehabilitation was achieved.     

Vaginal brachytherapy alone: an alternative to adjuvant whole pelvis radiation for early stage endometrial cancer

OBJECTIVE: Postoperative management of early stage adenocarcinoma of the endometrium remains controversial. The use of pelvic radiation therapy as shown by the Gynecologic Oncology Group (GOG)-99 trial improves the event free interval at the cost of increased toxicity. We reviewed and compared our results treating early stage endometrial adenocarcinoma using hypofractionated high dose rate (HDR) vaginal brachytherapy (VB) alone with the results of the GOG-99. METHODS: From 1992 to 2002, 243 endometrial cancer patients were treated with TAH/BSO and selective lymph node dissection followed by adjuvant radiotherapy (RT). Of these, 50 FIGO stage I-II (occult) adenocarcinoma (no clear cell or serous papillary) of the endometrium were managed with HDR hypofractionated VB as monotherapy using Iridium-192 to a dose of 30 Gy in 6 fractions twice weekly prescribed to a depth of 5 mm and median length of 4 cm. The characteristics, toxicity rates, and outcomes of our patients were compared with the results of the GOG-99. The median follow up of our patients and the GOG-99 were 3.2 years and 5.8 years, respectively. RESULTS: Patient characteristics including age, stage, and grade were similar in our study and the GOG-99. The local recurrence rate in our study, the pelvic RT arm of the GOG-99, and the no RT arm of the GOG-99 were 4% (n = 2), 2% (n = 3), and 9% (n = 18), respectively. In our study, one patient failed in the vagina alone and a second patient failed in the vagina and pelvis. In the GOG-99, the vagina as a component of locoregional failure was also the most common failure site in the no RT arm 77.8% (n = 14) and in the RT arm 100% (n = 3). The 2-year cumulative recurrence rate in our study was 2%, which compares favorably with the GOG-99 pelvic RT arm (3%) and observation arm (12%). Four-year survival rates of the no RT arm of the GOG-99, the RT arm of the GOG-99, and our study with HDR VB were 86%, 92%, and 97%, respectively. Chronic grade 2 toxicity rates were reduced by the use of VB compared to pelvic RT, especially GI toxicity 0% vs. 34% (P value < 0.001), and GI obstruction 0% vs. 7% (P value = 0.08). CONCLUSION: Stage I-II (occult) endometrial adenocarcinoma treated with postoperative HDR vaginal brachytherapy has similar overall survival, locoregional failure rates, and cumulative recurrence rates to standard fractionation external beam pelvic RT with the benefit of much lower toxicity rates and shorter overall treatment time.     

Vaginal reconstruction after total pelvic exenteration using a modification of the Williams' procedure.

The complete rehabilitation of women who have been subjected to ultraradical pelvic surgery should include the reconstruction of a functional vagina. The creation of a vaginal pouch as described by Williams for patients with congenital absence of the vagina or vaginal stenosis may be considered in some of these patients. The principle of his operative procedure can be applied to anatomic conditions in which the vagina and vulva have been resected utilizing perineal tissue structures and skin grafts. This is demonstrated in two patients with different postoperative perineal defects.     

Retroperitoneal tumor in the pelvis

Report on a 40 years old patient, who was operated on with suspicion of ovarian tumor or pelvic kidney without function. We discovered a tumor of a size of two fists situated retroperitonally without perceptible starting point. Histologically it could be proved as leiomyoma. Simultaneously there was an aplastic kidney. References to diagnostic and surgical technical problems are given.     

Vaginal reconstruction with two lower abdominal skin flaps in rabbits: histological and macroscopic evaluation

Objective

To evaluate the use of two skin flaps of the lower abdominal wall in the creation of a cylindrical conduit in vaginal reconstruction surgery in rabbits, through macroscopic and histological analysis.

Study design

An experimental study was performed in 16 female New Zealand rabbits, consisting of the use of two rectangular-shaped skin flaps of the lower abdominal wall measuring 1 cm longitudinally and 3 cm transversely anastomosed to each other through continuous suture of the edges of the two flaps to create a tube. Hysterectomy and excision of the vaginal vault were performed, and the skin tube was anastomosed to the remaining vaginal stump with separate points of polyglycolic acid 4.0. Animals were divided into 4 groups according to the euthanasia at 2, 4, 8 and 12 weeks, when after excision of the neovagina, macroscopic and histological evaluation with hematoxylin-eosin and Masson trichrome were performed.

Results

Of 16 operated rabbits, only 1 presented partial abdominal wall dehiscence, not compromising the flap viability. The macroscopic analysis of the vaginal conduit showed that it was kept open throughout the experimental steps, with a good patency and gauge, showing a slight retraction in the skin conduit length of no statistical significance. In the histopathological analysis, a local inflammatory process in the anastomosis was observed, which was larger in the early evaluation but decreased in late evaluations, as well as the local fibrosis process. Integration of the vaginal and skin epithelia was made with no alterations in their primary characteristics.

Conclusion

The use of two skin flaps of the lower abdominal wall as a vaginal conduit presented good integration between skin and vaginal tissue with minimal length retraction, kept the patency during evaluations and did not show strictures, presenting good local healing and a low rate of complications.     

Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques

OBJECTIVES: Vaginal reconstruction following pelvic exenteration is an important aspect of the physical and psychological rehabilitation of women after radical surgery for pelvic malignancies. The choice of techniques is vast, and proper patient and surgical selection is important for obtaining satisfactory functional and aesthetic results. The objective of this retrospective study is to review different techniques for vaginal reconstruction and report the complications and patient satisfaction associated with the different procedures. METHODS: Between January 1988 and April 2001, 104 pelvic exenterations were performed by the division of gynecologic oncology at the University of Miami, School of Medicine. Twenty-five (24%) patients underwent vulvo-vaginal reconstruction at the time of the exenteration. A retrospective chart review of the 25 patients was performed, and 9 patients were available and contacted for an interview. RESULTS: Twenty-four (96%) patients had received prior definitive radiation therapy. Overall, there were 9 complications (6 major and 3 minor) attributed to vaginal reconstruction, accounting for 36% perioperative morbidity. Seven of the nine (78%) patients interviewed reported successful vaginal intercourse at some point after their operation. All 5 surviving patients in the myocutaneous flap group were very satisfied with their sexual function and were sexually active at the time of their interview. CONCLUSIONS: Vaginal reconstruction at the time of pelvic exenteration is an important topic that should be discussed with the patient during the preoperative visit. Although the myocutaneous flaps are associated with longer operative times, they appear to be the preferred type due to decreased postoperative fistulae and better patient satisfaction.