Primary Vaginal Reconstruction at the Time of Pelvic Exenteration for Gynecologic Cancer: Morbidity Revisited

Abstract

The aim of this study is to analyze our experience about the benefits and morbidity of primary vaginal reconstruction in pelvic exenteration. Over a 10-year period, 64 patients underwent a pelvic exenteration for gynecologic cancer, except for ovarian and fallopian cancer. Twenty-nine patients underwent pelvic exenteration with vaginal reconstruction [21 cases with transverse rectus-abdominis myocutaneous (TRAM) flap and eight cases with Singapore fascio-cutaneous flap]. Thirty-five patients did not undergo vaginal reconstruction. Postoperative morbidity was recorded and a comparative analysis of morbidity between groups was made. Pelvic abscess and small bowel fistula occurred more frequently in the no neovagina group (20% versus 6.9% and 20% versus 3.4%, respectively). There were no differences between groups regarding fever, colorectal anastomosis (CRA) dehiscence-leakage, prolonged ileus, deep venous thrombosis, pulmonary embolism or wound complications. Surgery time was significantly longer for the neovagina group. There was only one perioperative death, which occurred in the neovagina group. Vaginal stenosis, necrosis, and shortness occurred less frequently for TRAM flap compared with Singapore flap (19.0% versus 28.6%, 14.5% versus 50% and 0% versus 100%, respectively). CRA dehiscence-leakage appeared more frequently (83.3% versus 28.6%) in the Singapore group. Nevertheless, this complication was statistically associated (p = 0.0009) with low CRA (<5 cm). TRAM flap seems to be the preferable option for reconstructing the vagina after pelvic exenteration. The Singapore fascio-cutaneous flap carries a higher rate of complications, does not work as functional neovagina after pelvic exenteration, and does not seem to be a good choice in cases of low colorectal anastomosis.

Chronic Pelvic Pain Reveals Sacral Osteomyelitis Three Years after Abdominal Hysterectomy

“…This infection is rarely described postoperatively, but it can have serious local and systemic sequelae [7,8,18]. In gynecology, the most common procedure complicated by SOM is abdominal sacral colpopexy (five cases reported) [4,[7][8][9]. In fact, the sacrum alone is rarely infected; it is more precisely described as lumbosacral spondylodiskitis [11,[13][14][15][16].…”

“…However, sacral osteomyelitis (SOM) has rarely been reported; most cases are seen after abdominal sacral colpopexy for correcting vaginal vault prolapse [4,[7][8][9][10]. To our knowledge, no case of SOM has been reported after an abdominal hysterectomy.…”

“…D eep pelvic abscess is a well-known infective complication in gynecologic practice [1][2][3][4][5][6]. However, sacral osteomyelitis (SOM) has rarely been reported; most cases are seen after abdominal sacral colpopexy for correcting vaginal vault prolapse [4,[7][8][9][10].…”

Low Colorectal Anastomosis After Pelvic Exenteration for Gynecologic Malignancies: Risk Factors Analysis for Leakage

“…When a very low anastomosis had been performed, to avoid the pressure that a bulky flap such as the TRAM flap could exert on the anastomosis, the latter technique was preferred. 12 Proximal diversion for preventing anastomotic breakdown was not routinely performed, not even in patients with previous RT, but only in one patient. Absence of tension and reliability of the anastomotic technique were the main requirements for omitting the diverting colostomy or ileostomy in every case.…”

“…4,5,7,9Y11 A less well-known theoretical risk factor is the vaginal reconstruction during this surgery, as it has been hypothesized that bulky flaps may exert some pressure on the anastomosis that may jeopardize healing. 12,13 Reported rates of anastomotic leak in the gynecologic oncology vary from 2.1% to 53.8% depending on the type of tumor, with the lowest average rate (2.1%) for ovarian cancer and the highest (14% to 53.8%) when series include a proportional number of cervix and ovarian cancers in addition to a few vaginal or uterine cancers 1,2,4,5,14,15 The aim of this study was to analyze the risk factors contributing to anastomosis breakdown in a series of patients who underwent a low CRA during pelvic exenteration.…”