Management of leiomyosarcomas of the spermatic cord: the role of reconstructive surgery

Abstract

BACKGROUND: Leiomyosarcomas (LMS) of the spermatic cord are extremely rare. Radical inguinal orchiectomy and high ligation of the cord is the standard primary surgical procedure. The extent of surrounding soft tissue excision required and the precise role of adjuvant radiotherapy, however, remains unclear. In addition, recurrence is a commonly encountered problem which might necessitate further radical excision of adjacent soft tissues. METHODS: This article reviews the pathophysiology of spermatic cord leiomyosarcomas (LMS), and discusses the various reconstructive surgical options available to repair the inguinal region and the lower anterior abdominal wall after excision of the tumour and the adjacent soft tissues. RESULTS: There is paucity of literature on LMS of spermatic cord. The majority of paratesticular neoplasms are of mesenchymal origin and up to 30% of these are malignant. In adults, approximately 10% of spermatic cord sarcomas are LMS. Approximately 50% of these tumours recur loco-regionally following definitive surgery; however, the incidence decreases if resection is followed by adjuvant radiotherapy. CONCLUSION: It is therefore important to achieve negative histological margins during the primary surgical procedure, even if adjuvant radiotherapy is instituted. If extensive resection is required, either during the primary procedure or following recurrence, reconstructive surgery may become necessary. This article reviews the pathophysiology of spermatic cord LMS, the reasons for recurrence, and discusses the management options including the role of reconstructive surgery.

Figure 1

Layers of the anterior abdominal wall

Figure 2

Formation of the rectus sheath in horizontal section, above [A] and below [B] the arcuate line

Figure 3

Defect created after removal of the tumour along with lower part of the abdominal wall including the inguinal canal, part of rectus sheath and external oblique aponeurosis, subcutaneous tissue and skin

Figure 4

Reconstructive ladder in wound closure

Figure 5

Some reconstructive options (tensor fasciae latae flap, gracilis flap, rectus abdominus flap, groin flap) available to repair defects in the inguinal region and the lower anterior abdominal wall