Recurrent invasive adenocarcinoma after hysterectomy for cervical adenocarcinoma in situ

BACKGROUND: Unlike its squamous counterpart, therapy for cervical adenocarcinoma in situ with positive endocervical cone margin remains controversial. CASE: A 52-year-old gravida 2, para 1,0,1,1, presented with vaginal bleeding. Gynecologic history was significant for cervical cold knife conization with a positive endocervical margin and endocervical curettage with atypical endocervical cells. Repeat cone biopsy was considered unsafe given the large initial cone specimen. An extrafascial hysterectomy was performed 5 weeks later and pathology confirmed a disease-free cervix. Pap smear performed 1 year later was interpreted as recurrent adenocarcinoma but later downgraded to inflammation. Inspection and random biopsies of the vaginal cuff revealed only inflammation. Two subsequent Pap smears also returned inflammation. Seventeen months after the hysterectomy physical examination revealed a 2 x 3-cm smooth mass at the vaginal cuff. Biopsy revealed invasive adenocarcinoma. The patient underwent an upper vaginectomy followed by postoperative pelvic radiation. CONCLUSION: This case suggests that despite extrafascial hysterectomy for presumed adenocarcinoma in situ of the cervix, a residual focus could remain and present later as invasive adenocarcinoma.     

Patterns of failure of bulky-barrel carcinomas of the cervix.

OBJECTIVE(S): This retrospective study was conducted to analyze the hypothesis that radiation therapy followed by extrafascial hysterectomy would improve survival in patients with bulky-barrel cervical carcinomas. STUDY DESIGN: Forty-three patients with bulky-barrel carcinomas of the cervix were treated over a 14-year period. The majority of these were treated with approximately 4000 cGY external beam, followed by brachytherapy, followed by extrafascial hysterectomy. RESULTS: Forty-seven percent of all patients are dead of disease; 2.3% are alive with disease. Of the total patients, 35% had diseased paraaortic nodes, and 80% of these are dead of disease. Of the patients dead of disease, 80% had distant metastases. Delayed complications included: vesicovaginal fistulas (n = 3), surgery for bowel obstruction (n = 3), rectovaginal fistula (n = 1), and vaginal vault necrosis (n = 3). CONCLUSION: These data do not support an improvement in survival of patients with bulky-barrel-shaped lesions treated with irradiation plus adjunctive hysterectomy.     

The barrel-shaped cervical carcinoma.

Twelve patients had barrel-shaped cervical carcinoma among 493 new patients with primary invasive cervical carcinoma, at the Downstate Medical Center, New York from January, 1964 to December, 1972. The incidence of barrel-shaped lesions among invasive carcinoma of the cervix was 2.43%. All 12 patients were treated with external radiation to the whole pelvis followed by two radium applications. In six patients an extrafascial hysterectomy was performed 6 to 12 weeks after radiation. Six patients died and six survived (50%). Six patients survived for over 2 years after therapy with no evidence of recurrence. Of these, four are alive and well for over 5 years. All six patients died within 20 months after therapy. The barrel-shaped cervical carcinoma fared poorly (six deaths among 12 patients or 50%) when compared with the over-all Stage I and Stage II cervical carcinoma (87 deaths among 339 patients or 25.5%).     

Radical hysterectomy preceded by pelvic irradiation.

A total of 124 patients, who had prior pelvic irradiation, had radical hysterectomy performed at the University of Minnesota Hospitals from 1939 to 1977. The patients fall into two groups: those who had pelvic radiation and radical hysterectomy as primary therapy and those who had radical hysterectomy for postradiation persistent or recurrent cancer of the cervix. A major objective of this report is to describe the incidence, management, and long-term follow-up of patients with complications. Pelvic irradiation followed by radical hysterectomy as primary therapy for cancer of the cervix cannot be justified because of the high risk of urinary tract complications, some of which eventually result in demise of the patient. Radical hysterectomy for postradiation persistent or recurrent cancer is an acceptable procedure for early disease. It would appear from this experience that many patients with small cervical or vaginal postradiation neoplasms can be successfully managed with more conservative procedures such as simple hysterectomy and partial vaginectomy. The value of pelvic lymphadenectomy was not demonstrated. Exenterative procedures are becoming more frequently indicated for eradication of malignancies, with a reduction of long-term urinary tract complications.     

Survival of women with surgical stage II endometrial cancer.

OBJECTIVE: The aim of this study was to report survival and determine prognostic factors and results of therapy in women with surgical stage II endometrial cancer. METHODS: Forty-eight consecutive women with surgical stage II endometrial cancer treated at the University of Vermont between March 1984 and March 1998 were reviewed. Patients' characteristics, surgical procedure, postoperative treatment and its complications, and tumor recurrence and its treatment were recorded. In addition, a formal review of their pathological material for confirmation of the diagnosis was performed. RESULTS: The median duration of follow-up was 6.2 years. Three patients (6.3%) had tumor recurrence and two (4.2%) died of their disease. The estimated 5-year overall survival and disease-free survivals were 92.1% (SE = 5.5%, 95% confidence interval: 81.3, 100%) and 89.9% (SE = 5.8%, 95% confidence interval: 78.5%, 100%), respectively. None of the patients treated by total abdominal hysterectomy followed by both whole pelvic and vaginal cuff radiation therapy (the main line of treatment for patients in whom cervical involvement was diagnosed following hysterectomy, n = 20) or by radical hysterectomy (the main line of treatment for patients in whom cervical involvement was known before hysterectomy, n = 11) had tumor recurrence. Three of 17 (17.6%) patients treated with total abdominal hysterectomy followed by either whole pelvic (n = 13) or vaginal cuff (n = 4) radiation therapy had tumor recurrence. The difference between those two groups was statistically significant (0/31 versus 3/17, P = 0.02). There was no difference in survival among women with stage IIA and IIB or women who underwent radical abdominal hysterectomy and those who underwent total abdominal hysterectomy with postoperative pelvic and vaginal cuff radiation. Morbidity secondary to therapy was mild. Age, depth of myometrial invasion, tumor histology, and grade were not significantly related to recurrence. CONCLUSIONS: Survival of women with surgical stage II endometrial cancer is excellent especially among those treated with total abdominal hysterectomy followed by both pelvic and vaginal cuff radiotherapy or by radical abdominal hysterectomy.     

Pelvic sidewall adenocarcinoma after definitive therapy for cervical adenocarcinoma in situ

BACKGROUND: Traditionally, hysterectomy is considered definitive therapy for cervical adenocarcinoma in situ (AIS) in women beyond childbearing. CASE: A 45-year-old gravida 2, para 2 patient presented with cervical dysplasia and on pathology review of the large loop excision procedure cervical adenocarcinoma in situ was diagnosed. She underwent extrafascial hysterectomy and bilateral salpingo-oophorectomy. Final pathology revealed adenocarcinoma in situ with negative margins. Twenty-eight months later, she presented with right lower extremity deep venous thrombosis. A computed tomography (CT) scan of the abdomen and pelvis showed a pelvic sidewall mass. A CT-guided biopsy of the mass was consistent with invasive adenocarcinoma of the endocervical type. She underwent combination therapy with weekly cisplatin and extended field radiation therapy. CONCLUSION: This case depicts another example of the unpredictable nature of cervical AIS. Despite undergoing definitive surgery, a residual focus of disease may remain leading to invasive adenocarcinoma. Close follow-up is required of all patients diagnosed with AIS because the disease is poorly understood.     

The prognostic significance of radiation dose and residual tumor in the treatment of barrel-shaped endophytic cervical carcinoma

OBJECTIVE: The aim of this study was to evaluate the impact of total radiation dose on residual tumor and the prognostic significance of persistent disease in women with bulky, barrel-shaped cervical carcinoma who received definitive radiation followed by adjuvant hysterectomy. METHODS: The medical records of 57 patients with bulky endophytic cervical carcinoma treated at the University of Washington between 1976 and 1997 were reviewed. All patients received external beam pelvic radiotherapy supplemented by intracavitary brachytherapy, followed by extrafascial hysterectomy 6 to 8 weeks later. RESULTS: The mean pretreatment tumor diameter was 5.9 cm, with a range of 4-9 cm. Total radiation dose to point A ranged from 5040 to 9700 cGy, and the mean for the group was 7966 cGy. Residual disease was present in 35 (61%) of the hysterectomy specimens. The frequency of cervical tumor sterilization correlated significantly with the mean radiation dose to point A (P = 0.016). Patients without histologic residual disease had a significantly improved outcome, with 95% of patients remaining clinically free of disease at last follow-up, versus 31% of those with residual disease (P < 0.001). As expected, the pelvic control rate was excellent (100%) in patients with complete tumor eradication compared to the group with residual tumor (44%). Those with no residual disease enjoyed a significantly improved survival compared to those with residual tumor (P < 0.001). Furthermore, a statistically significant higher survival was realized in patients harboring only microscopic residual compared to those with either macroscopically evident tumor residuum and/or positive surgical margins (P = 0.036). CONCLUSIONS: Higher radiation doses are associated with an improved likelihood of tumor eradication in the treatment of bulky, endophytic cervical cancer and complete tumor sterilization at adjuvant hysterectomy is predictive of significantly enhanced survival and pelvic control. The high rate of histologic tumor persistence in our series emphasizes the need for more efficacious therapies in patients with bulky endophytic cervical cancer and argues for escalation of radiation dose even when adjuvant hysterectomy is planned.     

Laparoscopic radical trachelectomy or parametrectomy and pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma: report of six cases

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.     

Total laparoscopic radical parametrectomy, partial colpectomy, and pelvic lymphadenectomy in patients with occult cervical cancer

Objective

To assess total laparoscopic radical parametrectomy (TLRP) with pelvic lymphadenectomy and partial colpectomy as a safe and feasible treatment option for patients with occult cervical cancer.

Methods

Twelve patients with occult invasive cervical cancer underwent TLRP after prior extrafascial hysterectomy.

Results

No intraoperative complications occurred. Two patients experienced postoperative complications: an iliac lymphocyst with pyelectasis, and a vaginal evisceration that occurred during sexual intercourse. Nine patients required no further treatment. One patient with residual disease received brachytherapy as adjuvant treatment. Two patients with positive nodes not detected at preoperative work-up received adjuvant concomitant radiochemotherapy.

Conclusion

TLRP with pelvic lymphadenectomy is a safe and feasible treatment in patients with occult invasive cervical cancer discovered after extrafascial hysterectomy.     

Total abdominal hysterectomy after radiation therapy for cervical cancer: use of omental graft for fistula prevention

Abdominal hysterectomy after treatment of cervical cancer by radiation therapy is associated with a significant rate of postoperative vesicovaginal fistulas. In this series, five patients with invasive cancer of the cervix treated by radiation therapy developed new cervical or uterine neoplasms 1 to 27 years after treatment. All underwent abdominal hysterectomy without postoperative fistula formation. Success is attributed to cautious surgical technique and to the use of the omental pedicle graft to bring new vascularity to the vaginal apex and bladder base. The technique of forming an omental pedicle graft is described.     

Endometrial carcinoma. Clinical and pathological correlations with survival and surgical treatment

From 1978 to 1985 a total of 151 patients were treated for endometrial carcinoma. Of these, 25 patients underwent extrafascial abdominal hysterectomy and pelvic lymphadenectomy, 25 were treated according to Wertheim procedure and pelvic lymphadenectomy and 32 underwent intrafascial abdominal hysterectomy; 62 women underwent vaginal surgery, 7 of whom according to Shauta. A correlation between the degree of myometrial invasion, histological grading, hystological type and stage of the tumor showed no statistically significant difference. The 5-year actuarial survival rate was found to be 76.5%. A comparison between survival and age of patients showed a significant difference in the survival (p less than .01) of the group less than 55 years as compared to the older age group. As far as the surgical treatment instituted is concerned, no statistical difference in survival was found between patients operated vaginally and those operated abdominally (p greater than .05). The site of recurrences were then analyzed in 22 patients, 50% were local recurrences, and the remaining distant metastases. Of these only one patient was cured and is still free of disease 5 years after recurrence. The criteria used to select patients for vaginal surgery are also indicated.     

Randomized study of preoperative radiation and surgery or irradiation alone in the treatment of stage IB and IIA carcinoma of the uterine cervix: final report

A prospective randomized study in selected patients with Stage IB and IIA carcinoma of the uterine cervix was carried out at Washington University between January 1966 and December 1979. Patients were randomized to be treated with irradiation alone consisting of 1000 cGy whole pelvis, additional 4000 cGy to the parametria with a step wedge midline block, and two intracavitary insertions for 7500 mgh; or irradiation and surgery, consisting of 2000 cGy whole pelvis irradiation, one intracavitary insertion for 5000-6000 mgh followed 2 to 6 weeks later by a radical hysterectomy with pelvic lymphadenectomy. A total of 40 patients with Stage IB and 16 with Stage IIA were randomized to be treated with irradiation alone. A similar group of 48 patients with Stage IB and 14 with IIA were randomized to the preoperative radiation and surgery group. The 5-year, tumor-free actuarial survival for Stage IB patients treated with radiation was 89% and with preoperative radiation and surgery 80%. In Stage IIA, the tumor-free actuarial 5-year survival was 56% for the irradiation alone group and 79% for the patients treated with preoperative radiation and radical hysterectomy. In the patients with Stage IB treated by irradiation alone only one pelvic failure combined with distant metastasis occurred, and 3 patients developed distant metastasis. In the 48 patients treated with combined therapy, there were six pelvic failures (12.5%) all combined with distant metastases and two distant metastases alone. In the 16 patients with Stage IIA treated with radiotherapy alone, there were four pelvic failures (all parametrial), three of them combined with distant metastasis. In the 14 patients treated with irradiation and surgery, two developed a pelvic recurrence, and one distant metastasis. In the preoperative radiation group, the incidence of metastatic pelvic lymph nodes was 6.3% in Stage IB and 7.1% in Stage IIA. Major complications of therapy in the patients treated with radiation alone (10%) consisted of one rectovaginal fistula, two vesicovaginal fistulas, and one rectal stricture. In the preoperative radiation group, three ureteral strictures and two severe proctitis-rectal strictures were noted (8%). The present study shows no significant difference in therapeutic results or morbidity for invasive carcinoma of the uterine cervix Stage IB or IIA treated with irradiation alone or combined with a radical hysterectomy and lymphadenectomy.     

The role of radical parametrectomy in the treatment of occult cervical carcinoma after extrafascial hysterectomy

OBJECTIVES: To assess the morbidity and efficacy of radical parametrectomy (RP) performed following extrafascial hysterectomy in patients with occult cervical carcinoma. METHODS: An IRB approved retrospective chart review identified 23 patients that underwent RP with pelvic and/or para-aortic lymphadenectomy and upper vaginectomy. Data were collected on demographics, tumor stage, grade, histology, indication for hysterectomy, surgical findings, complications, recurrence, and survival. RESULTS: Of the 23 patients, 2 patients had a stage IA(2) lesion while 21 patients had a stage IB(1) lesion. There were 5 patients with a grade 1 tumor, 10 with grade 2, 4 with grade 3, and 4 with unknown grade. Median age was 41 years (range 27-59). The most common indication (48%) for extrafascial hysterectomy was CIS of the cervix. Four patients (17%) had metastasis to pelvic nodes or evidence of tumor at the margin at the time of RP. Three of these 4 patients with a positive specimen received adjuvant radiation and all are alive (mean follow-up 66 months). One patient declined radiation and is alive at 42 months. There were 7 (30%) operative complications: Most notably 4 patients received blood transfusions. Two of 19 patients (11%) with no residual tumor in RP specimen recurred and 1 patient was salvaged with radiation (follow-up 103 months). With a median follow-up of 61 months (range 9-103), overall 5-year survival is 96%. CONCLUSIONS: RP is an acceptable option for patients diagnosed with an occult cervical carcinoma at the time of extrafascial hysterectomy. Careful selection of RP for patients unlikely to have residual tumor will obviate the need for radiation in most instances.     

Vaginal morphology following hysterectomy

This study was designed to gain more information about morphology of the vagina after hysterectomy. The prospective clinical observations of patients subjected to abdominal or vaginal extrafascial or intrafascial hysterectomy with or without correction of anatomical urinary stress incontinence were included. The length, configuration and axis of the vagina were determined using a vaginal cast technic. Vaginal casts were prepared prior to and 6 months to 4 years after surgery. The gross appearance of the vagina after hysterectomy is affected by understanding normal pelvic anatomy an physiology, careful preoperative evaluation of pelvic defects, proper planning and competent performance of surgery. Proper handling of the endopelvic fascia and its condensations, the cardinal and sacrouterine ligaments, corrects preexisting weakness, provides vaginal suspension and prevents future vaginal disfigurement. Inadequate surgical technics result in magnifying preexisting weakness of pelvic supports. Successful surgery involves correcting the levator complex by reducing and shifting the levator hiatus ventrally. Reconstruction of the perineal body is essential. This study suggests a relationship between successful surgical treatment of urinary stress incontinence and reconstruction of pelvic supportive structures, with restoration of the physiological vaginal axis.     

The prognosis and treatment of stage I adenocarcinoma of the cervix

A review of 125 patients with stage I adenocarcinoma of the cervix is reported. The subtypes included endocervical (60), adenosquamous (38), papillary (15), clear cell (nine), and mucoid (three). The cumulative 5-year survival was 60%, and was significantly related to the following: tumor differentiation--well-differentiated 80%, moderately differentiated 69%, poorly differentiated 41%; lymph node status--nodes positive 28%, nodes negative 82%; the amount of residual disease present in the cervix after radical hysterectomy; and the interval from the previous pelvic examination. Survival was not significantly influenced by histologic subtype, patient age, number of positive lymph nodes, or tumor size beyond 3 cm. Treatment included radical hysterectomy with or without bilateral salpingo-oophorectomy, radiation therapy, radiation therapy with hysterectomy, and hysterectomy followed by radiation therapy. The best cumulative 5-year survival (93%) was found in patients treated by radical hysterectomy without bilateral salpingo-oophorectomy, whereas the poorest survival (18%) was in those treated by standard hysterectomy followed by radiation therapy. Ovarian conservation seems to be an acceptable alternative to bilateral salpingo-oophorectomy in the young patient undergoing radical hysterectomy.     

Analysis of vaginal recurrences in stage I endometrial adenocarcinoma

OBJECTIVE: To determine the risk of vaginal recurrence in Stage 1 endometrial cancer and treatment morbidity associated with different therapeutic approaches MATERIAL AND METHODS: Between 1995 and 2005, 341 patients with clinical Stage I endometrial cancer were treated at Istanbul Medical Faculty. One hundred and forty-four women were included in this study as the follow-ups and records were complete. The patients with no myometrial invasion received no further therapy following hysterectomy. When there was superficial myometrial invasion postoperative vaginal vault radiation was used, and if deep myometrial invasion was present, external pelvic radiation was given. RESULTS: Overall 5-year survival rate for all patients with Stage I disease was 80%. Nine patients (6.25%) developed recurrent disease, three of whom had vaginal recurrences. All three vaginal recurrences were small and diagnosed at routine follow-up exam within 51 months of primary therapy. CONCLUSION: This selective treatment protocol for patients with Stage I endometrial cancer avoided radiation entirely in 38% of the patients while achieving a very low rate of vaginal recurrence and good overall survival.     

Complete uterine necrosis following chemoradiation for advanced cervical cancer: a case report

BACKGROUND: Radiation therapy is an effective therapy for advanced cervical cancer. Although generally transient, complications of radiation therapy can become severe and require further intervention. Uterine necrosis is uncommon and the management can be complex. CASE: A 46-year-old African American female with stage IB2 squamous cell carcinoma of the cervix was treated with chemoradiation after an aborted radical hysterectomy. Five months after completion, the patient developed severe pelvic pain and persistent vaginal bleeding. Several biopsies confirmed radiation necrosis without evidence of tumor. Due to the severity of symptoms, the patient underwent a total abdominal hysterectomy. CONCLUSION: Uterine necrosis is a rare, late complication after chemoradiation for cervical cancer. Although several treatment options exist for radiation necrosis, surgical intervention may be necessary in severe cases.     

Adenocarcinoma of the uterine cervix.

From January 1, 1947, through December 31, 1971, 219 patients with primary adenocarcinoma of the intact uterine cervix were treated at the M.D. Anderson Hospital and Tumor Institute. Two modes of therapy were primarily used, namely, irradiationtherapy alone and irradiation therapy plus operation. The 5 year survival resultsare 83.7 per cent for patients with Stage i disease, 48.0 per cent for patients with Stage ii disease, 29.2 per cent for patients with Stage iii disease, and 0.0 per cent for patients with Stage iv disease. The group with irradiation plus operation had a better over-all survival rate. In addition, the incidence of central and pelvic recurrent disease was remarkably lower (fourfold difference). The urologic and bowel complications are discussed. This review lends support for our practice of preoperative irradiation followed by simple (constructive) hysterectomy for selected patients eith adenocarcinoma of the uterine cervix.     

Early invasive adenocarcinoma of the uterine cervix: criteria for nonradical surgical treatment

OBJECTIVE: This retrospective study was undertaken to identify selection criteria for nonradical surgery for early invasive adenocarcinoma of the uterine cervix. METHODS: Seventy-nine patients with surgically treated cervical adenocarcinomas (with invasion to 5 mm or less) were examined clinicopathologically. The evaluation of stromal invasion was conducted according to the FIGO (1995) staging system. RESULTS: The mean age was 46 (range: 29-73) years, and the median follow-up was 118 (9-348) months. Definitive treatment modalities included radical hysterectomy in 71 (89.9%) cases, modified radical hysterectomy in 2 (2.5%), and simple extrafascial hysterectomy without pelvic lymphadenectomy in 6 (7.6%). Postoperative adjuvant external radiation therapy was given to 5 (6.3%) patients. The histological subtypes were endocervical in 37 (46.8%) cases, endometrioid in 32 (40.5%), and adenosquamous in 10 (12.7%). Forty-one (51.9%) patients had lesions with up to 3 mm of stromal invasion; of these, 24 (58.5%) had lesions with up to 7 mm of horizontal extension (stage IA1). Thirty-eight (48.1%) patients had lesions with stromal invasion greater than 3 mm and no greater than 5 mm; of these, 4 had lesions with no wider than 7 mm of horizontal extension (stage IA2). Of 73 patients with pelvic lymphadenectomy, one (1.4%) tumor (depth: 5 mm; width: 15 mm) had node metastases. Parametrial involvement was present in one (1.4%) patient (lesion depth: 5 mm; lesion width: 16 mm). None had adnexal metastasis. Eighty-eight percent of the patients with stromal invasion up to 3 mm had well-differentiated adenocarcinoma, compared to 53% of the patients with lesions invading more than 3 mm. Of all of the patients, 5 (6.3%) patients who received curative radical hysterectomies had recurrences and died. Among 5 patients, one patient with central pelvic recurrence had a lesion invading to a depth of 3 mm and width of 7 mm, and the others had lesions with more than 3 mm of invasion and 15 to 36 mm of width. CONCLUSIONS: Patients with early invasive adenocarcinoma to a depth of 3 mm or less stromal invasion, including those who meet the criteria for FIGO stage IA1, may be treated with simple extrafascial hysterectomy without lymphadenectomy and oophorectomy.     

Rectus abdominis myocutaneous flaps for neovaginal reconstruction after radical pelvic surgery

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.