Pelvic and Perineal Reconstruction After Bowel, Gynecological or Sacral Tumor Resection: A Case Series

Abstract

Background/Aim: Perineal, pelvic and urogenital reconstruction presents a challenge, not only due to defect size but also due to high morbidity resulting from surgery and post-operative complications. The purpose of this study is to review the surgical approach and evaluate the results regarding pelvic/perineal reconstruction after advanced tumor resection. Patients and Methods: The total number of patients was 34 (11 males, 23 females). The histology varied, including sixteen rectal-anal squamous cell carcinomas, five Buschke-Lowenstein tumors, four vulvar-vaginal carcinomas, four sacral chordomas, two cutaneous squamous cell carcinomas, two soft tissue sarcomas and a case of Paget's disease. Most patients had previously been treated with colectomies and/or gynecological resections and received a full dose of radiotherapy. Reconstruction was performed with the following flaps: oblique/vertical rectus abdominis myocutaneous flap (ORAM/VRAM), gracilis myocutaneous flap, inferior gluteal artery perforator flap (IGAP), internal pudendal artery perforator flap (IPAP) and lotus petal flaps. Results: Most patients had a relatively uncomplicated post-operative course. Surgical site infection and wound dehiscence occurred more commonly with the thigh flaps rather than the abdominal flaps. However, the aggression and the frequent recurrences of these tumors had as a result, only 15 out of 34 patients achieved a five-year disease-free survival. Conclusions: Pelvic and perineal defects are usually massive and the use of myocutaneous flaps to eliminate the dead space is of paramount importance. Although these are mainly salvage operations with a low survival rate, they promote patients' quality of life. A frequent challenge is the simultaneous achievement of tumor radical resection and pelvis functionality.

Keywords: gracilis flap; pelvic reconstruction; perineal tumors; perineum; rectus abdominis flap; sacral chordoma.

Figure 1

Abdominoperineal resection of perianal SCC and reconstruction with ORAM flap. A 45-year-old female patient with a recurrent perianal SCC extending to the perineum. The patient had previously undergone loop colostomy and received radiotherapy (A). Pre-operatively marking of the right ORAM myocutaneous flap and the area of the right deep inferior epigastric vessels (B). Abdominal view of the huge volume defect and dead space in the pelvis created after abdominoperineal resection, including sigmoidectomy with end colostomy, proctocolectomy and total hysterectomy (C). Harvesting of right ORAM myocutaneous flap (D). The whole length of the ORAM flap with its pedicle (E). Perineal defect after wide-field surgical resection of the perineum, anus, posterior wall of the vagina and posterior part of labia majora and labia minora (F). Transfer of ORAM flap from the abdominal wall, through the pelvis, to the perineal defect (G). Post-operative result after perineal reconstruction with ORAM flap (H).

Figure 2

Vulvar-vaginal carcinoma resection and reconstruction with bilateral gracilis flaps. A 52-year-old female patient with an extended vulvar and vaginal squamous cell carcinoma (A). The patient underwent wide-field surgical resection of the tumor, including bilateral excision of labia majora, labia minora and vagina (B). Harvesting of V-Y bilateral pedicled gracilis myocutaneous flaps (C,D). The final post-operative result of vulvar-vaginal and perineal reconstruction (E). The patient’s hospitalization was uncomplicated and seven days post-operatively, both flaps survived (F). Two weeks post-operatively, the flaps had a normal healing process without any signs of infection or wound dehiscence. The patient also had an end colostomy, which minimizes post-operative complications in perineal reconstruction (G).

Figure 3

Sacral chordoma resection and sacrum reconstruction with VRAM flap. A 58-year-old male patient with a sacral chordoma. Pre-operative marking of the wide-field resection margins (A). T2-weighted and T2-weighted fat sat MR images of the sacrum with intravenous contrast. Sacral chordoma is demonstrated as a hyperintense lesion with irregular margins (B). En-block resection of tumor and sacrum (C). The patient is in prone position. Tissue and volume defect was created after sacral chordoma wide-field resection. The small intestine is visible, as the defect is connected with the peritoneal cavity (D). Transfer of VRAM flap from the abdominal wall, through the peritoneal cavity and pelvis, to the sacral area (E). Post-operative result after sacrum reconstruction with transpelvic VRAM flap (F). Application of negative pressure wound therapy (NPWT) aiming at a proper wound healing process and avoidance of wound dehiscence (G).

Figure 4

Left inguinal fold SCC resection and reconstruction with VRAM flap. A 67-year-old male patient with a cutaneous SCC in the left inguinal fold. Pre-operative marking of the tumor resection margins, as well as drawing of the left VRAM flap (A). Defect after tumor resection with visible left testicle, epididymis and spermatic cord (B). Harvesting of left VRAM myocutaneous flap (C). Abdominal wall closure in layers, starting from the posterior wall of the rectus abdominis sheath (D). Post-operative result of left inguinal fold reconstruction with VRAM flap (E). The patient’s hospitalization was uncomplicated and 10 days post-operatively, the flap survived (F).