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Fahy MR. A review of functional and surgical outcomes of gynaecological reconstruction in the context of pelvic exenteration. Surg Oncol 2024; 52:101996. [PMID: 38096764 DOI: 10.1016/j.suronc.2023.101996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/02/2023] [Accepted: 09/17/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship of patients undergoing exenterative surgery remain. This is especially important in the context of vulvovaginal resection, where patients are often younger and surgery can have a profoundly negative impact on quality of life, body image and overall wellbeing. Reconstructive procedures are an important means of mitigating these adverse effects but outcomes are poorly described. AIM To define the outcomes associated with gynaecological reconstructive procedures following pelvic exenterative surgery and to compare them with the outcomes of those patients who did not undergo reconstruction. METHODS An international, multicentre retrospective investigation comparing the outcomes of reconstruction with no reconstruction. The protocol was prospectively registered (NCT05074069). RESULTS 334 patients were included. 77 patients had a neovagina reconstructed, 139 patients underwent flap reconstruction and 118 were not reconstructed. Patients who underwent reconstruction had a longer operative time and hospital stay with an increased risk of minor perineal complications. Reconstruction did not confer an increased risk of surgical reintervention, and overall complication rates were equivalent. Procedure-specific major morbidity was 5.2 % and 11.5 % for neovaginal and flap reconstruction, respectively. 66 % of patients undergoing neovaginal reconstruction experienced no long term morbidity. 7 % developed neovaginal stenosis and 12 % suffered disease recurrence. CONCLUSION Neovaginal reconstruction is safe in carefully selected patients and offers specific advantages over alternative techniques, with few patients requiring reoperation. Primary closure does not increase perineal morbidity.
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2
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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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Kulkarni A, Dogra N, Zigras T. Innovations in the Management of Vaginal Cancer. Curr Oncol 2022; 29:3082-3092. [PMID: 35621640 PMCID: PMC9139564 DOI: 10.3390/curroncol29050250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 11/16/2022] Open
Abstract
Primary vaginal cancer is a rare gynecologic malignancy. Given the rarity of the disease, standardized approaches to management are limited, and a great variety of therapeutic conditions are endorsed. This paper reviews advances in surgical approaches, radiation, chemoradiation, and immunotherapy. Advances in surgical management including the increasing use of laparoscopic and endoscopic approaches, as well as the novel techniques in vaginal reconstruction, are reviewed. Concurrent chemoradiation remains a mainstay of treatment for vaginal cancer and has improved local control of disease and overall survival. Additionally, with metastatic disease or situations where toxicity from CCRT is unacceptable, systemic therapies including immunotherapy approaches are reviewed.
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Affiliation(s)
- Anjali Kulkarni
- Division of Gynecologic Oncology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
| | - Nupur Dogra
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada;
| | - Tiffany Zigras
- Trillium Health Partners, Division of Gynecologic Oncology, Mississauga, ON L5M 2N1, Canada
- Correspondence:
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Botter C, Favier A, Aubry G, Canlorbe G, Méningaud JP, Belghiti J, Hersant B. [How I do…to repair posterior perineal tissue loss with a posterior vaginal mucosa flap after vulvectomy]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:333-337. [PMID: 34871787 DOI: 10.1016/j.gofs.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 06/13/2023]
Affiliation(s)
- C Botter
- Department of maxillofacial and plastic, reconstructive, and aesthetic surgery, Henri-Mondor hospital, Créteil, France
| | - A Favier
- Department of gynecological and breast surgery and oncology, Pitié-Salpêtrière university hospital, Paris, France.
| | - G Aubry
- Department of gynecological and breast surgery and oncology, Pitié-Salpêtrière university hospital, Paris, France
| | - G Canlorbe
- Department of gynecological and breast surgery and oncology, Pitié-Salpêtrière university hospital, Paris, France
| | - J-P Méningaud
- Department of maxillofacial and plastic, reconstructive, and aesthetic surgery, Henri-Mondor hospital, Créteil, France
| | - J Belghiti
- Department of gynecological and breast surgery and oncology, Pitié-Salpêtrière university hospital, Paris, France
| | - B Hersant
- Department of maxillofacial and plastic, reconstructive, and aesthetic surgery, Henri-Mondor hospital, Créteil, France
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Dupré P, Legoupil D, Vigouroux C, Conan‐Charlet V, Kergastel I, Merviel P, Kerfant N. Laparoscopy-assisted immediate vaginal reconstruction with a vertical pedicled deep inferior epigastric perforator flap for primary melanoma of the vagina. Clin Case Rep 2021; 9:e04183. [PMID: 34194773 PMCID: PMC8223693 DOI: 10.1002/ccr3.4183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 02/08/2021] [Accepted: 04/02/2021] [Indexed: 11/26/2022] Open
Abstract
The vagina is a rare site for primary melanoma. Here, we report on a case of laparoscopy-assisted immediate vaginal reconstruction with vertical pedicled deep inferior epigastric perforator flap.
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Affiliation(s)
- Pierre‐François Dupré
- Gynecology and Obstetrics DepartmentBrest University HospitalBrestFrance
- INSERM UMR 1078Faculté de MédecineUniversité de Bretagne OccidentaleBrest Cedex 2France
| | | | - Camille Vigouroux
- Gynecology and Obstetrics DepartmentBrest University HospitalBrestFrance
| | | | - Isabelle Kergastel
- Radiology and Medical Imaging DepartmentBrest University HospitalBrestFrance
| | - Philippe Merviel
- Gynecology and Obstetrics DepartmentBrest University HospitalBrestFrance
| | - Nathalie Kerfant
- Plastic and Reconstructive Surgery DepartmentBrest University HospitalBrestFrance
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6
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Propeller Flap Perineal Urethrostomy Revision. Urology 2020; 148:302-305. [PMID: 33309704 DOI: 10.1016/j.urology.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.
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Bacalbasa N, Balescu I, Vilcu M, Dima S, Brezean I. The Impact of the Preoperative Status on the Short-term Outcomes After Exenteration and Pelvic Reconstruction. In Vivo 2020; 33:2147-2152. [PMID: 31662550 DOI: 10.21873/invivo.11716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The aim of this study was to analyse the influence of the preoperative status on the perioperative outcomes of patients submitted to pelvic reconstructions after exenteration. MATERIALS AND METHODS Between January 2017 and December 2018, pelvic exenteration was performed in 86 cases; patients were classified according to their age, nutritional status and association of reconstructive surgery. RESULTS The median age was 56 years, while the median level of serum albumin was 3.6 g/dl. Reconstructive surgery was more frequently performed in younger patients, while the rate of postoperative complications was similar between the two groups, while the rate of postoperative complications was significantly higher among cases with lower serum albumin levels. CONCLUSION Reconstructive surgery should be performed in selected patients. Elderly cases as well as those presenting a poorer nutritional status are at higher risk of developing postoperative complications.
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Affiliation(s)
- Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania.,"Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | | | - Mihaela Vilcu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Simona Dima
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | - Iulian Brezean
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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Kiiski J, Räikkönen K, Vuento MH, Hyöty MK, Kallio J, Kuokkanen HO, Kaartinen IS. Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:1632-1637. [DOI: 10.1016/j.ejso.2019.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/03/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
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Quality of Life and Sexual Functioning After Vulvar Reconstruction With the Lotus Petal Flap. Int J Gynecol Cancer 2019; 28:1728-1736. [PMID: 30157166 DOI: 10.1097/igc.0000000000001340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Resection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic. METHODS A cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women. RESULTS Twenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16-141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported. CONCLUSIONS Patients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.
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Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2016; 137:1602-1613. [PMID: 26796372 DOI: 10.1097/prs.0000000000002107] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications. METHODS A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure. RESULTS Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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11
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Pelvic Exenteration in Gynecologic Cancer: La Paz University Hospital Experience. Int J Gynecol Cancer 2016; 25:1109-14. [PMID: 25853383 DOI: 10.1097/igc.0000000000000435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pelvic exenteration is an ultraradical surgery involving the en bloc resection of the pelvic organs, including the internal reproductive organs, the distal urinary tract (ureters, bladder, urethra), and/or anorectum. It is mainly applied as a salvage surgery for recurrent gynecologic tumors of any origin (vulva, vagina, cervix, uterine, and also ovary). Our aim was to establish the most favorable cases for this type of surgery by means of a review of our institution experience. METHODS Retrospective analyses of all patients treated with pelvic exenteration for recurrent gynecologic cancer from 2008 to 2014 at La Paz University Hospital. RESULTS Ten patients underwent pelvic exenteration for recurrent gynecologic cancers including uterine, cervical, vaginal, vulvar, and ovarian cancer. All patients had received prior treatment: surgery, radiotherapy, and/or chemotherapy. Eight patients underwent total pelvic exenteration, one anterior and one posterior pelvic exenteration. Urinary diversions technique consisted of ileal conduits in all cases. Permanent colostomy was performed in all cases. Postoperative complications were related to the urinary diversion in 50% of the cases, to the reconstructive technique in 30%, and to systemic or pelvic infections in 20%. CONCLUSIONS Despite the high morbidity and mortality rates, pelvic exenteration is feasible, and in selected cases of cancer recurrence is the last possible treatment.
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Zhang W, Zeng A, Yang J, Cao D, He X, Wang X, You Y, Chen J, Lang J, Shen K. Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies. BMC Cancer 2015; 15:851. [PMID: 26542779 PMCID: PMC4635970 DOI: 10.1186/s12885-015-1792-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 10/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background The use of flaps in vulvar cancer-related reconstruction has been increasing, but few studies have evaluated the outcome and quality of life of patients after this surgery. The purpose of this study was to evaluate the outcomes of vulvar reconstruction using musculocutaneous/skin flaps in patients with advanced and recurrent vulvar malignancies. Methods Patients with vulvar malignancies who underwent vulvar reconstruction using different types of flaps were retrospectively reviewed. Patient outcomes were evaluated with a focus on quality of life and prognosis. Results Thirty-six patients were enrolled, 58.33 % of them used anterolateral thigh flap (ALT), 16.67 % of them used pudendal thigh flap (PTF), 11.11 % of them used deep omferior epigastric perforator (DIEP) and gracilis myocutaneous flap were used in 2.78 % of the patients, the other 11.11 % patients used two types of flaps. Eleven patients (30.56 %) developed complications, including 5 patients (13.89 %) with partial necrosis, 5 (13.89 %) with minimal wound dehiscence and 1 (2.78 %) with flap cellulitis. All patients who developed partial necrosis (13.89 %) underwent reoperation. The mean verbal rating scale score was 1.44 before reconstruction and 0.17 after surgery (P < 0.0001). The mean performance status was 1.67 before surgery and improved to 0.31 after surgery (P < 0.0001). The median overall follow-up time after vulvar reconstruction was 9 months. Twenty-one patients (58.3 %) developed recurrence at a median interval of 5 months after vulvar reconstruction. After a median follow-up time of 14 months, 41.7 % of the patients were living and disease-free. The 5-year survival of the 36 patients was 53.8 %. Conclusion Soft tissue reconstruction in patients undergoing resection of advanced/recurrent vulvar malignances is associated with a low rate of postoperative complications, decreased pain, and improved functional status. Although the recurrence rate in this patient population is high, a reasonable proportion of patients who undergo resection for advanced/recurrent vulvar cancer and reconstructive surgery appear to benefit.
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Affiliation(s)
- Wei Zhang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Ang Zeng
- Departments of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jiaxin Yang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Dongyan Cao
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Xiaodong He
- Departments of General Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Xiaojun Wang
- Departments of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Yan You
- Departments of Pathology,
- Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jie Chen
- Departments of Pathology,
- Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jinghe Lang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Keng Shen
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
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Ferron G, Gangloff D, Querleu D, Frigenza M, Torrent JJ, Picaud L, Gladieff L, Delannes M, Mery E, Boulet B, Balague G, Martinez A. Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series. Gynecol Oncol 2015; 138:603-8. [PMID: 26121919 DOI: 10.1016/j.ygyno.2015.06.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/20/2015] [Accepted: 06/22/2015] [Indexed: 01/11/2023]
Abstract
Vaginal reconstruction after pelvic exenteration (PE) represents a challenge for the oncologic surgeon. Since the introduction of perforator flaps, using pedicled vertical DIEP (deep inferior epigastric perforator) flap allows to reduce the donor site complication rate. From November 2012 to December 2014, 27 PEs were performed in our institution. 13 patients who underwent PE with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies were registered. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients have a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. A vertical DIEP flap was performed in 10 patients using one or two medial perforators. The reasons for abortion of vertical DIEP flap procedure were: failure to localizing perforator vessels in two cases, and unavailability of plastic surgeon in one case. A vertical fascia-sparring rectus abdominis myocutaneous flap was then harvested. Median length of surgery was 335min, and 60min for DIEP harvesting and vaginal reconstruction. No flap necrosis occurred. One patient in the VRAM (vertical rectus abdominis myocutaneous) group experienced a late incisional hernia and one patient in the DIEP flap group required revision for vaginal stenosis. In our experience, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. To achieve a high reproducibility, the technically demanding pedicled vertical DIEP flap has to be harvested by a trained surgeon, after strict evaluation of the preoperative imaging with identification and localization of perforator vessels.
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Affiliation(s)
- Gwénael Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France.
| | - Dimitri Gangloff
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Denis Querleu
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France; Department of Surgical Oncology, Institut Bergonie, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Melanie Frigenza
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Juan Jose Torrent
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France; Departement of Gynecology, Hospital Universitari Germans Trias y Pujol, Carretera de Canyet, 08916 Badalona, Barcelona, Spain
| | - Laetitia Picaud
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Laurence Gladieff
- Departement of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Martine Delannes
- Departement of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Eliane Mery
- Department of Surgical Pathology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Berenice Boulet
- Department of Radiology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Gisele Balague
- Department of Radiology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France
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14
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Krill L, Randall LM. Cancer of the Vulva and Vagina. Gynecol Oncol 2015. [DOI: 10.1007/978-1-4939-1976-5_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology. Gynecol Oncol 2014; 134:172-80. [DOI: 10.1016/j.ygyno.2014.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 04/26/2014] [Accepted: 04/30/2014] [Indexed: 11/23/2022]
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Tjalma WAA. Vaginal reconstruction with labia minora after an anterior exenteration: a novel and simple technique. Eur J Obstet Gynecol Reprod Biol 2013; 170:578-9. [PMID: 23915761 DOI: 10.1016/j.ejogrb.2013.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 06/15/2013] [Accepted: 07/02/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Wiebren A A Tjalma
- University Multidisciplinary Breast Clinic Antwerpen, Multidisciplinary Gynaecologic Oncology Clinic; Obstetrics and Gynaecology, University Hospital Antwerp and University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium.
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Backes FJ, Tierney BJ, Eisenhauer EL, Bahnson RR, Cohn DE, Fowler JM. Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: Time to change back? Gynecol Oncol 2013; 128:60-64. [DOI: 10.1016/j.ygyno.2012.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 08/03/2012] [Accepted: 08/04/2012] [Indexed: 10/28/2022]
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Hage JJ, Beurden MV. Reconstruction of acquired perineovulvar defects: a proposal of sequence. Semin Plast Surg 2012; 25:148-54. [PMID: 22547972 DOI: 10.1055/s-0031-1281484] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acquired perineovulvar defects are usually the result of excision of vulvar intraepithelial neoplasia (VIN) or invasive squamous cell carcinoma. Because both VIN and vulvar carcinoma have a tendency toward local recurrence, future reconstructive options should be reckoned with during treatment of the primary and all subsequent (pre-) malignant perineovulvar lesions. Hence, a proposal of sequence of reconstructive options for these defects is called for. In cases where local skin flaps suffice, these are preferably designed in such a fashion as not to sever the branches of the internal pudendal vascular system. In cases where either a pudendal thigh flap or an infragluteal flap may be used to close the perineovulvar defect, the pudendal thigh flap is to be preferred to preserve the infragluteal flap for future use. Only when these flaps no longer are available or sufficient to cover the defect should the gluteal thigh flap be applied. The use of myocutaneous flaps is rarely indicated to close isolated superficial perineovulvar defects.
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Martínez A, Filleron T, Vitse L, Querleu D, Mery E, Balague G, Delannes M, Soulie M, Pomel C, Ferron G. Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage? Gynecol Oncol 2011; 120:374-9. [PMID: 21215437 DOI: 10.1016/j.ygyno.2010.11.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 11/19/2010] [Accepted: 11/22/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pelvic exenteration (PE) remains one of the most mutilating surgical procedures with important postoperative morbidity. Laparoscopic approach has emerged in an attempt to reduce postoperative complications. The aim of the present study was to compare outcomes between laparoscopic pelvic exenteration combined with a vaginal or perineal approach, versus classical approach. METHODS A cohort study was performed by identifying patients who underwent laparoscopic pelvic exenteration, and retrospectively comparing data with open cases from the same period of time, from 2000 to 2008. RESULTS Fourteen patients underwent laparoscopic PE and 29 patients underwent an open exenterative procedure. All patients except one (97.6%) had received prior radiotherapy. Eighteen patients (41.9%) underwent total PE, 17 anterior PE (39.5%), and 8 posterior PE (18.6%). Urinary diversion (UD) technique consisted of 24 Miami pouch (68.6%), 9 Bricker diversion (25.7%), 1 Kock pouch (2.9%), and 1 ureterostomy (2.9%). Most frequent postoperative complications were related to the urinary diversion (45%) and bowel reconstruction (27.9%). Median estimated blood loss for the laparoscopy and laparotomy group was 400 ml (range 200-700 ml) and 875 ml (range 200-1600 ml), respectively. Transfusion rate was also significantly higher in the laparotomy group. Operative time, margin status, length of hospital stay, operative and postoperative morbidity, and disease and overall survival were not significantly different between both groups. CONCLUSIONS Laparoscopic PE is feasible with curative intent to selected patients. Potential postoperative advantages of laparoscopic approach when compared to classical approach, oncological safety of the procedure, and QOL considerations need to be further investigated.
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Affiliation(s)
- A Martínez
- Department of Surgical Oncology, Claudius Regaud Comprehensive Cancer Center, Toulouse, France
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