Rectus abdominis myocutaneous and myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: comparison of flap-related morbidity

PURPOSE: To compare flap-specific complications of rectus abdominis myocutaneous (RAM) and myoperitoneal (RAMP) flap neovagina reconstructions performed concurrently with radical pelvic procedures. MATERIALS AND METHODS: Retrospective single institution chart review of all patients with RAM or RAMP flap neovaginal reconstructions performed on a Gynecologic Oncology service, 1988-2003. Analysis for associations with flap-specific morbidity was performed. RESULTS: Neovaginal reconstructions comprised 32 RAM and 7 RAMP flaps. Twenty-two (69%) RAM patients underwent total pelvic exenteration compared to 1 (14%) RAMP patient (P < 0.013). Overall, 33 (85%) of the patient population had previously been treated with radiation. Flap-specific complications developed in 12 (32%) RAM versus 4 (57%) of the RAMP patients (P > 0.1). Donor site complications and incisional hernias were increased in RAMP patients (both P < 0.03), with trends for increasing risk of vaginal stricture/stenosis and superficial wound separations (both P < 0.1). Complete vaginal stenosis developed in only 1 (3%) RAM versus 3 (43%) RAMP patients. Furthermore, 3 RAMP patients developed complete stenosis when the vaginal defect was circumferential and involved >65% of the vagina while this did not occur in 22 similar RAM patients (P < 0.0005). Only patients with partial longitudinal defects maintained vaginal patency after RAMP flap. Fifteen (58%) of 26 patients surviving >12 months reported coitus, with no significant difference between the groups. CONCLUSIONS: When there is circumferential loss of the upper 2/3 of the vagina. RAMP flaps are not suitable for neovaginal reconstruction after radical pelvic surgery because of an increased risk of vaginal stenosis compared to RAM flaps. Patients with partial longitudinal vaginal defects, however, may have successful neovaginal reconstruction with RAMP flaps.     

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.     

Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery

The short gracilis myocutaneous flap derives its blood supply from terminal branches of the obturator artery, and the vascular pedicle derived from the medial femoral circumflex artery is sacrificed. Twenty-one short gracilis myocutaneous flaps were used for vulvovaginal reconstructions in 11 patients undergoing radical pelvic surgery: bilateral flaps in nine patients for neovaginal construction after pelvic exenterations, bilateral flaps in one patient for vulvovaginal reconstruction after radical vulvovaginectomy, and a unilateral flap in one patient for vulvovaginal reconstruction after radical vulvectomy with partial vaginectomy. Major complications consisted of bilateral flap necrosis occurring in one patient who had received preoperative irradiation to the vulva and groin combined with chemotherapy. Minor degrees of necrosis (less than 5%) and/or separation of vaginal suture lines occurred in five patients without marked loss of the flaps. Vaginal caliber and depth are excellent in ten patients (91%) after follow-up of 1-22 months. The short gracilis flap is an excellent alternative to the more bulky gracilis flap, which derives its blood supply from perforating branches of the femoral artery. Based on our experience, the short gracilis flap provides adequately vascularized tissue for vulvovaginal reconstruction in patients after radical pelvic surgery, but should not be used in patients who have received extensive groin irradiation.     

Vertical rectus abdominis myocutaneous flap for vaginal reconstruction after radical pelvic surgery for Stage II vaginal carcinoma

Primary carcinomas of the vagina are uncommon, occurring only 2-3% of all gynecological malignancies. In women with early stage of disease, primary surgery, consisting of radical vaginectomy (plus hysterectomy in patients with tumors involving the upper vagina) and systematic dissection of lymphatic drainage of tumor, is a valid option. In these patients, a rectus abdominis myocutaneous (RAM) flap may be favorably used for vaginal reconstruction during radical pelvic surgery. Here we describe a case of Stage II vaginal carcinoma treated with radical pelvic surgery and vertical-RAM (V-RAM) flap reconstruction.     

Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes

Objective

To examine the early and late flap related morbidity and associated risk factors in patients with modified vertical rectus abdominis myocutaneous (VRAM) flap neovaginal reconstruction at the time of pelvic exenteration for gynecologic malignancy.

Methods

From January 1993 to January 2011, all patients were identified who underwent anterior, posterior, or total pelvic exenteration with VRAM flap neovaginal reconstruction. Patient records were systematically reviewed and demographic, clinicopathologic, operative details, flap related complications, and risk factors for wound healing were recorded and statistical analysis performed.

Results

46 patients were identified who underwent exenteration with VRAM flap vaginal reconstruction. A risk factor for poor healing including obesity, diabetes, smoking, prior radiation, previous abdominal surgery, or poor nutritional status was present in 38 (82.6%) patients, and 24 (52.2%) had two or more risk factors. Flap complications occurred in 9 (19.6%) patients, one with complete flap necrosis that required re-operation, two with superficial flap necrosis, and three with superficial flap separation. Three patients (6.5%) suffered from vaginal stenosis, one of which was complete. Anterior abdominal wound separation occurred in 22 (47.8%) patients and pelvic abscess occurred in 14 (30.4%) patients. No individual risk factor was significantly associated with VRAM flap related morbidity; however obesity, prior radiation, and prior abdominal incision were present in nearly all the patients with flap complications.

Conclusions

This series confirms that modified VRAM flaps can be used successfully at the time of exenteration, even in an increasingly high risk patient population with an acceptable risk for flap 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.     

带蒂腹直肌肌瓣用于盆腔廓清术盆底重建的初步探讨

Objective?To explore the feasibility and short-term effectiveness of pelvic floor reconstruction by pedicle rectus abdominis muscular flap after pelvic exenteration. Methods?Eight patients with pelvic floor reconstruction by pedicle rectus abdominis muscular flap after pelvic exenteration between October 2019 and June 2021 were reviewed and analysed retrospectively. Results?The patients were from 39 to 68 years old(median age 57.5), 2 pelvic floor reconstructions with partial pedicle rectus abdominis muscular flap, 6 pelvic floor reconstructions with whole pedicle rectus abdominis muscular flap, the reconstruction time were 60 to 90 minutes. 1 case had ureteral fistula and underwent further surgical repair. 2 cases complained of increased vaginal discharge, they were all improved with anti infection therapy after 1 month and without any further surgical intervention. Abdominal incision infection occurred in 2 cases, and the wound healed after debridement. The patients were followed up 2 to 13 months (median 6.5 months), 1 case died of tumor recurrece 4 months after surgery, and 7 patients survived. There was no late complication, such as bowel obstruction, bowel perforation and fistulas. There was no early and late muscular flap related complications. Conclusion?The pedicled rectus abdominis muscular flap is a safe, effective, simple and rapid method for pelvic floor reconstruction after pelvic exenteration.     

Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity

PURPOSE: The purpose of this study was to analyze our experience with the influence of reconstructive techniques at the time of pelvic exenteration on morbidity. MATERIALS AND METHODS: Between June 1986 and December 1998, 60 pelvic exenterations for gynecologic malignancies were performed in our hospital. Forty-five were selected for this study because they met two criteria: they were performed by the same team (gynecologic oncologist), and they had similar primary tumors. There were 38 cervical, 2 vaginal, and 5 uterine malignancies. Sixteen patients underwent reconstructive surgery: 11 (68.8%) with placement of a myocutaneous flap with left rectus abdominis, 3 (18.8%) with gracilis muscle, and 2 (12.5%) with the Singapore fasciocutaneous flap. Twenty-nine patients had no reconstruction. Records were reviewed and statistical analysis was performed. RESULTS: Attachment of the grafts was complete in 14 of 16 (87.5%), with a partial vulvovaginal dehiscence in 2 cases. Morbidities included secondary infection in 3 (18.8%), partial necrosis in 3 (18.8%), and partial stenosis in 5 (31.6%); the last was significantly associated with a gracilis flap (P = 0.015). There were no statistical differences between neovagina and nonneovagina groups with respect to the rate of fever, small bowel fistula, bowel obstruction, wound infection or dehiscence, hernia, colorectal leak, colostomy or urostomy prolapse, deep vein thrombosis, pulmonary embolism, intraoperative blood transfusions, or hospital stay. There were no pelvic abscesses in the neovagina group compared with 27% (6/29) in the other group (P = 0.050). Surgery was significantly longer (P = 0.019) for the reconstructive surgery group, with no statistical difference between different kinds of flaps. There were no deaths in either group. CONCLUSIONS: Reconstruction of the vagina and pelvic floor at the time of pelvic exenteration can be done safely. Although this increases surgical time, morbidity is not significantly increased. The rectus abdominis flap seems to be the preferable option for primary vaginal and pelvic floor reconstruction.     

Gynecologic Reconstruction with a Rectus Abdominis Myocutaneous Flap: An Update

This series reports the outcomes and significant complications associated with the rectus myocutaneous flap when used for pelvic or inguinal reconstruction in patients with gynecologic cancers. Perioperative variables were retrospectively reviewed to identify social and medical risk factors as well as intraoperative and postoperative complications that predisposed to rectus flap failure. Fifteen patients with gynecologic malignancies underwent reconstructive procedures using a vertically oriented rectus abdominis myocutaneous flap for either vaginal (n= 14) or inguinal (n= 1) reconstruction. The patients’ primary cancers were cervical (n= 11), rectal (n= 1), ovarian (n= 1), vulvar (n= 1), and vaginal (n= 1). The median age was 50 years. The median follow-up was 17 months. All flaps were mobilized in conjunction with a radical salvage operation. There were no cases of vaginal prolapse and no abdominal wound infections. However, 4 patients (27%) had major postoperative morbidity in this small series. There was one wound dehiscence and three episodes of necrosis of the subcutaneous and cutaneous portions of the flap. All 4 of these patients required additional operative intervention or debridement. Eleven patients had complete healing of the flap. The rectus abdominis myocutaneous flap is a valuable option for gynecologic reconstructive procedures. Perioperative strategies for improving flap viability include the identification of risk factors that may compromise flap perfusions such as prior abdominal incisions, peripheral vascular disease, and obesity. Meticulous surgical technique is required to preserve the vascular pedicle. These strategies may be useful in preoperative counseling, the perioperative evaluation, and the intraoperative management.     

Reconstructive surgery after mastectomy--the anatomical prerequisites

Reconstructive surgery of the breast after mastectomy occupies an important place in the complex treatment of breast cancer. The aim of the present study is to determine the capacity of the dermo-muscular flaps and to study the anatomical premises for their use under breast reconstructions. On the base of putrid material are created operative models of reconstructions of the breast with myocutaneous flaps m. rectus abdominis, m. latissimus dorsi and m. gluteus maximus. A study of the anatomical parameters of 64 female individuals, at an age from 51 to 73 years, has been conducted. It was found out that the myocutaneous flap m. rectus abdominis has an average volume of 590 cc and is formed basically of dermo-subdermal tissue (more than 80%). The myocutaneous flap m. latissimus dorsi has an average volume of 290 cc and is formed basically of muscular tissue (85%). The myocutaneous flap m. gluteus maximus has an average volume of 650 cc and is formed of subdermal and muscular tissue in the correlation 65/35%. The most suitable for breast reconstructions turns out to be the myocutaneous flap from m. rectus abdominis, since it provides sufficient amount of new tissue and uncomplicated surgical technique.     

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence. Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.     

Distally based rectus abdominis flap for reconstruction in radical gynecologic procedures

The distally based rectus abdominis myocutaneous flap is an important adjunct to radical pelvic surgery. It can be used to fashion a functional neovagina or to create a patch to cover perineal defects created by exenterative surgery. This report reviews the technical aspects of the creation of this flap and our experience with 22 patients who have undergone this procedure. The flap has been found to be technically easy to create. It is reliable with little tissue loss, and donor site complications are acceptable. Healing is aided by filling the pelvic dead space, thereby decreasing bowel complications, and by bringing a new blood supply into the operative site which has often been heavily irradiated. Operative time is minimized since the procedure requires only unilateral mobilization. Subsequent abdominal surgery has been performed without fascial complications.     

Reconstructive techniques in radical pelvic surgery.

The use of reconstructive surgical techniques accelerates recovery from radical pelvic surgery. It also allows the surgeon greater latitude in the type of procedure and the selection of patients for extended pelvic surgery. The techniques involved in three such reconstructive procedures are described, and their applicability is illustrated with care reports. The use of the compound myocutaneous flap, the axial cutaneous flap, and the omental island flap is discussed.     

The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration

This study was undertaken to evaluate the morbidity and potential benefits of concurrent gracilis myocutaneous graft with exenteration. All patients undergoing exenteration from 1962-1986 were reviewed, of whom 24 had concurrent grafts. The mean operative time, blood loss, and hospital stay were not different in patients with versus without grafts. The rate of fistula formation in the hospital was less in the graft group (P = .004) but was not different when compared with contemporary patients only. The total infection rate (wound and pelvic) was decreased in the graft group (P = .04) when graft infections were excluded. The major problem with the graft was significant necrosis of the flap(s) in nine of the 24 patients. There were no life-threatening complications attributed to concurrent placement of gracilis myocutaneous flaps. Experience with the technique is improving the cosmetic and functional outcome of the neovagina formed with the graft. Patients most likely to benefit from this procedure include those requiring immediate reconstruction or those with potentially poor healing due to high-dose pelvic radiation, including intraoperative radiation.     

Primary repair of rectovaginal fistulas complicating pelvic surgery by gracilis myocutaneous flap

Objectives

Complex rectovaginal fistulas repair are extremely challenging. Various surgical options have been suggested; nevertheless, none had been universally accepted as the procedure of choice. This prospective study discusses a novel surgical technique using gracilis myocutaneous flap interposition.

Methods

Eleven patients had fistulas post-resection of pelvic malignancy (n = 10) and rectal endometriosis (n = 1). Primary treatment was pelvic resection; nevertheless, 6 cases had adjuvant chemo-irradiation, 2 cases had post-operative irradiation and 2 patients had chemotherapy only. Fistulas mean diameter was 2 ± 0.24 cm (1-3) and 8 patients (72.7%) had their fistulas in the middle vaginal third.Repair was wide debridement of fistulas margins followed by gracilis myocutaneous flap interposition with synchronous diverting stomas. Success was defined as healing of fistula after stomal closure.

Results

Five patients were repaired by single gracilis myocutaneous flaps, 2 cases by simple gracilis muscle and 4 cases by double gracilis myocutaneous flaps. Patients had a mean follow-up time of 34.8 ± 5.03 months (12-67) and all patients had definitive healing of their fistulas (100%). Median time to stoma closure was 2 months (1-5). Four women (36.4%) had at least one early postoperative complications including temporary leak (n = 3), vaginal sepsis (n = 1), partial skin paddle necrosis (n = 1) and donor limb deep venous thrombosis (n = 1). Late morbidities were seen in 3 cases (27.3%) including vaginal stricture, anorectal anastomotic stricture and anastomotic tumor recurrence.

Conclusion

Rectovaginal septum repair requires adequate debridement of necrotic devascularized tissues, tissue transposition and reconstruction of vaginal wall. Gracilis myocutaneous flaps are ideal for this issue.     

A surgeon's help with the management of bowel problems related to gynecology is truly needed – Comparison of two periods spanning 24 years

ObjectiveColorectal surgeons are frequently on call to provide help to gynecologists who are managing bowel problems that occur either during or following gynecological surgery. This is a retrospective analysis of a single surgeon’s experiences associated with such instances. The analysis focuses on whether there have been any changes in referral patterns, surgical techniques and/or results.Materials and MethodsFrom July 1984 to June 2008, 282 patients were operated on by a single colorectal surgeon, for problems that were related to gynecology. These consisted of 137 patients operated on during the first 12-year period, from July 1984 to June 1996. During this first period, 85 patients were operated on for cervical cancer related problems, 39 patients were operated on for problems related to other gynecological malignancies and nine patients were operated on for iatrogenic bowel injury during surgery. During the second 12-year period, from July 1996 to June 2008, 145 patients were operated on. Of these, 85 patients were operated on for cervical cancer related problems, 44 patients were operated on for problems related to other gynecological malignancies and eight patients were operated on for iatrogenic bowel injury during surgery.ResultsDuring the first 12-year period, six operations were pelvic exenterations for primary gynecological malignancies or recurrences. One hundred and one patients received stomas during their first operation. Twenty-five patients encountered various complications. Postoperative death occurred in five patients. During the second 12-year period, 12 operations were pelvic exenterations for primary gynecological malignancies or recurrences. Eighty-seven patients received stomas during their first operation. Thirty-seven patients encountered various complications. Postoperative death occurred in six patients.ConclusionGynecological problems frequently involve the colon or rectum. Cervical cancer related problems remain the most common type necessitating help from a colorectal surgeon. In spite of advances in surgical management, stomas are still frequently unavoidable in order to cure a patient or improve the patient’s quality of life. Appropriate management of problems by a colorectal surgeon in relation to gynecology is important and in the best interests of the patient.     

Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer

BACKGROUND:Recurrent vulvar cancer involving the femoral artery after groin radiation is usually considered inoperable. A patient with such recurrent vulvar cancer successfully treated by femoral vascular graft and rectus abdominis myocutaneous flap reconstruction with limb salvage is described. CASE: A 51-year-old woman had recurrent vulvar cancer involving the right femoral vessels 6 months after a radical vulvectomy plus inguinal lymphadenectomy and postoperative pelvic and groin radiation. Radical en bloc excision of tumor along with the involved femoral artery and vein followed by Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction led to a complete remission. However, occlusion of the grafted vessels occurred 21 months following bypass surgery. Since the compensatory collaterals were established, debridement and removal of the occluded graft were carried out. The patient has been clinically free of disease for more than 48 months since graft reconstruction surgery. CONCLUSION: It is highlighted that aggressive tumor resection with limb salvage is feasible even for patients with vulvar cancer of the groin recurrence involving the femoral artery after primary surgery and groin radiation.     

Modifizierter doppelt gestielter VRAM-Lappen zur simultanen Rekonstruktion eines Perineum- und posterioren vaginalen Defekts

The management of locally advanced pelvic tumors regularly requires radical surgical resection. The resection results in significant intrinsic and extrinsic pelvic defects. The advent of composite flaps has revolutionized vaginal and perineal reconstruction. Flaps provide bulky tissue to obliterate dead space, recruit vascularized tissue to an irradiated area and facilitate the skin closure. The authors present a modified vertical rectus abdominis myocutaneous (VRAM) flap for simultaneous reconstruction of a perineal and posterior vaginal defect following radical pelvic and abdominoperineal resection, based on two individual perforators off the inferior epigastric artery and vein with an excellent outcome. The English full-text version of this article is available at SpringerLink (under supplemental).     

Gracilis myocutaneous flap as a life-saving procedure in control of necrosis following radiotherapy and radical surgery for pelvic malignancy

Gracilis myocutaneous flap has been used extensively in gynecologic oncology patients for sexual rehabilitation. This paper presents a case history of a patient with life-threatening malnutrition secondary to multiple fistulae status post total pelvic exenteration. After all other attempts at rehabilitation failed, gracilis myocutaneous flaps were placed in the pelvic defect to obtain healthy tissue and new blood supply and indeed the patient was successfully rehabilitated after a prolonged and progressive postoperative course of pelvic necrosis and infection.