Vaginal Reconstruction Following Resection of Primary Locally Advanced and Recurrent Colorectal Malignancies

ORIGINAL ARTICLE Vaginal Reconstruction Following Resection of Primary Locally Advanced and Recurrent Colorectal Malignancies

Dougal N. D’Souza, MD; Miguel Pera, MD; Heidi Nelson, MD; Stephan J. Finical, MD; Nho V. Tran, MD

Hypotheses: Vertical rectus abdominus myocutane- Median age was 47 years. Tumors included 9 rectal ous flap reconstruction facilitates healing within the ra- adenocarcinomas, 2 anal squamous cell carcinomas, diated pelvis and preserves the possibility of subsequent and 1 recurrent cecal adenocarcinoma. Surgical proce- sexual function in patients with colorectal cancer who dures included 8 abdominoperineal resections with require partial or complete resection of the vagina. posterior exenteration; resection of pelvic tumor and partial vaginectomy in 2 patients with previous abdomi- Design: A retrospective review of a consecutive series noperineal resection; 1 total exenteration; and 1 total of patients. proctocolectomy with posterior exenteration. The aver- age operative time for tumor extirpation, irradiation, Setting: A tertiary referral center. and reconstruction was more than 9 hours and all patients required blood transfusions. Despite 2 patients Patients: All patients undergoing surgical treatment of having superficial necrosis and 4 having mild wound locally advanced or recurrent colorectal cancer and ver- infections, no patient required reoperation and all tical rectus abdominus myocutaneous flap reconstruc- achieved complete healing. Five patients reported tion of the vagina. resuming sexual intercourse.

Intervention: Vertical rectus abdominus myocutane- Conclusions: The vertical rectus abdominus myocu- ous flap reconstruction. taneous flap can be successfully used for vaginal reconstruction following resection of locally advanced Main Outcome Measures: Operative feasibility, com- colorectal cancer. It provides nonirradiated, vascular- plications, and sexual function. ized tissue that fills the pelvic dead space, allows for stomal placement, and provides a chance for sexual Results: Twelve patients underwent extended resec- function. tion for primary locally advanced or recurrent colorectal cancer including total or near total vaginectomy. Arch Surg. 2003;138:1340-1343

HE AGGRESSIVE, multimodal theoretically facilitates healing within the treatment of locally ad- irradiated pelvis, minimizing postopera- vanced and recurrent col- tive complications. Furthermore, it serves orectal cancer often re- as a portal for early detection of recur- quires partial or complete rence and preserves the possibility for resectionT of the vagina in combination with sexual intercourse. Few of these articles spe- radiation therapy. The goals of subse- cifically have addressed this issue in ad- quent reconstructive surgery are to re- vanced colorectal malignancies. Herein, we duce the morbidity associated with ex- describe our experience with the verti- tended resections and to maintain quality cally oriented rectus abdominus myocuta- of life with preservation of appearance and neous (VRAM) flap for vaginal reconstruc- From the Divisions of Colon function. Multiple techniques of vaginal re- tion following resection of locally advanced and Rectal Surgery construction have been described in the lit- and recurrent lower gastrointestinal tract- (Drs D’Souza, Pera, and erature. These include the split-thickness malignancies. Nelson) and Plastic Surgery skin graft or McIndoe technique,1 the co- (Dr Tran), Mayo Clinic and 2 Mayo Foundation, Rochester, lonic vaginoplasty, and various myocuta- METHODS Minn; and Charlotte Plastic neous flap reconstructions like the graci- Surgery, Charlotte, NC lis,3,4 gluteal and pudendal-thigh,5-7 and We reviewed all patients undergoing VRAM flap (Dr Finical). rectus abdominus flaps.8 Reconstruction for vaginal reconstruction concurrent to pel-

(REPRINTED) ARCH SURG/ VOL 138, DEC 2003 WWW.ARCHSURG.COM 1340

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Figure 1. The myocutaneous flap and associated skin paddle are raised and Figure 2. The myocutaneous flap is spiraled into a neovagina around a mold include the anterior fascia of the rectus sheath. The blood supply is provided or stent and closed using interrupted sutures. Copyright 2001, Mayo Clinic, by the inferior epigastric artery. Copyright 2001, Mayo Clinic, Rochester, Rochester, Minn. Minn.

vic resection for locally advanced primary or locally recurrent colorectal cancer between 1994 and 1998. Patients with primary gynecologic malignancies were not included. Patient medical records were reviewed to establish operative and cancer de- tails, preoperative and intraoperative therapies, postoperative complications, sexual activity, and follow-up.

SURGICAL TECHNIQUE

The extensive tumor resection involved a partial or total vaginectomy, requiring reconstruction. The technique of the distally based VRAM flap has been described both anatomically and clinically.8,9 Briefly, the flap extends vertically from the costal margin to below the umbilicus and includes the skin, sub- cutaneous tissue, anterior rectus sheath, and rectus abdominis muscle. The skin ellipse measures approximately 15 cmϫ9 cm and incorporates the midline incision (Figure 1). The in- Anterior feriorly based rectus muscle is released from the costal margin Vaginal and dissected distally to its insertion on the pubic bone. At all Wall times, the vascular pedicle, the inferior epigastric artery, is pre- served and the flap checked for viability. The muscle is iso- lated on its insertion into the pubic bone and the pedicle skel- Figure 3. The flap is delivered through the pelvis to the perineal defect. Care etonized to allow for rotation into the pelvis without tension is taken to avoid stretch or torsion on the inferior epigastric blood supply. or kinking. To prevent a potential vascular stricture, the peri- Inset, The skin paddle is secured with interrupted sutures to the anterior toneum is incised at the point where the muscle is rotated into vaginal wall and posterior perineal wound. Copyright 2001, Mayo Clinic, the pelvis. When total vaginectomy is performed, a neovagina Rochester, Minn. is created by inverse tubing of the skin paddle (Figure 2), which is transposed into the pelvis and anastomosed to the vaginal cuff (Figure 3). When reconstruction of the posterior vagi- median age was 47 years (range, 29-68 years). Eight nal wall is necessary, the flap is sutured to the anterior vaginal patients had recurrent and 4 had locally advanced pri- wall, with the cephalad portion becoming the new introitus (Fig- mary colorectal cancer. Tumors included rectal adeno- ure 3 inset). The rectus fascia below the umbilicus is pre- served, allowing for stomal placement and preventing hernia carcinoma (n=9), anal squamous cell carcinoma (n=2), formation. The posterior rectus sheath above the umbilicus is and pelvic recurrence of cecal adenocarcinoma (n=1). approximated to the contralateral anterior fascia without the For the 8 patients with recurrent cancer, this was the aid of synthetic mesh. The cutaneous donor site is closed di- first recurrence in 7 and the second recurrence in 1. rectly and incorporated into the laparotomy incision. Previous operations in those 8 patients included low anterior resection (n=3), abdominoperineal resection RESULTS (n=1), total proctocolectomy and Brooke ileostomy (n=1), Hartmann procedure (n=1), right hemicolec- Twelve patients underwent the VRAM flap procedure tomy (n=1), and diverting colostomy (1 patient with for vaginal reconstruction during the study period. The anal cancer and anovaginal fistula treated with chemo-

(REPRINTED) ARCH SURG/ VOL 138, DEC 2003 WWW.ARCHSURG.COM 1341

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 radiation). Five of the 8 patients with recurrent cancer ment. In addition, the donor thigh incisions are a source had received adjuvant irradiation or chemotherapy for of morbidity and cosmetic problems postoperatively. On management of the primary tumor before this surgical the other hand, results from the pudendal-thigh flap (modi- procedure. fied Singapore flap) for vaginal reconstruction6 have been Ten patients received external beam radiation therapy impressive. The flap is more reliable than the gracilis, tech- (dose range, 0.45-0.55 rad [45-55 Gy]) and concurrent nically simple, and achieves good function and cosmesis. chemotherapy before the current surgery. Intraopera- However, it requires harvesting tissue from a donor site tive radiation therapy (dose range, 0.10-0.20 rad [10-20 in the groin that may be irradiated and provides little bulk Gy]) was indicated in 10 patients owing to the extent of after an exenteration. Moreover, when monitoring the flap, disease. Surgical procedures included abdomino- the most distal portion is the furthest away from exami- perineal resection with posterior exenteration (n=8), re- nation and is the deepest and most difficult to see post- section of pelvic tumor and partial vaginectomy in pa- operatively. tients with previous abdominoperineal resection (n=2), Another alternative for vaginal reconstruction is the total exenteration (n=1), and total proctocolectomy with VRAM flap. Our experience with this flap for closure of posterior exenteration in 1 patient with colonic Crohn perineal wounds following resection of pelvic malignan- disease and mucinous rectal adenocarcinoma. No sacrec- cies has been reported previously.9 In our previous se- tomy was necessary in this group of patients. Surgical re- ries, 13 patients underwent VRAM reconstruction fol- section margins were negative in 9 patients. The poste- lowing abdominoperineal resection with or without pelvic rior presacral and right pelvic fascia microscopic margins exenteration. In 4 cases, sacrectomy was also per- were positive in 2 and 1 patients, respectively. The av- formed. The use of myocutaneous flaps was associated erage operative time for tumor extirpation, irradiation, with a reduction in serious wound complications with- and reconstruction was more than 9 hours, and all pa- out a significant increase in operating times or length of tients required blood transfusions. stay compared with primary skin and pelvic closure or There were no perioperative deaths, and only mini- the use of an omental flap. mal complications were directly associated with the flap. Here we present our experience with this tech- Two patients had superficial wound necrosis and 4 had nique for vaginal reconstruction following resection of mild wound infections; none required reoperation. De- primary locally advanced and recurrent colorectal can- spite the adverse conditions, no flaps failed and all healed cer. In our small experience, no flap failed, 6 patients had without additional surgery. One patient had a postop- minimal complications, and no patient required reop- erative ventral hernia. The mean length of hospital stay eration. Furthermore, 5 patients reported returning to was 12 days (range, 10-20 days). sexual activity. During follow-up, 5 patients reported resuming regu- Proper patient and surgical selection is important lar sexual intercourse. Ultimately, 2 patients died of their for obtaining good results. This technique is particu- disease, 7 had disease progression to other sites, and 3 larly indicated in patients without significant comorbid- showed no evidence of recurrence. ity and interested in preservation of sexual function. Be- cause the VRAM flap is indicated in very select patients, COMMENT most series reported to date include a limited number of cases. Smith et al13 have reviewed reports of cases of VRAM Aggressive therapy, including multiple operations and both flaps for vaginal and pelvic floor reconstruction and found intraoperative and perioperative irradiation, is the only 118 cases, most of them for gynecologic malignancies. chance for cure or palliation of pelvic malignancies.10 Ad- Few of these reports include patients with advanced col- verse conditions such as prior surgery, advanced tumor, orectal malignancies. and prior irradiation make the surgical management of ad- The advantages of the VRAM flap for vaginal recon- vanced colorectal cancer a challenging problem. Pelvic re- struction are many. The flap is commonly used by plas- construction becomes important not only for the theo- tic surgeons, so it is fast and easy to perform. The blood retic advantages of filling the pelvic dead space and supply is reliable, based on the large-caliber inferior epi- promoting healing but also for restoring the body image gastric artery, and it provides pliable tissue to fill the pel- of the patient. Multiple techniques of vaginal reconstruc- vis and avoid neovaginal stenosis. In contrast to the bi- tion have been described in the literature suggesting that lateral gracilis and pudendal-thigh flaps, the VRAM no single procedure is ideal. The use of split-thickness skin reconstruction technique restores the vagina with a single grafts results in a thin neovagina with poor elasticity, little flap. In addition, the skin paddle is far away from the ra- bulk, and a greater tendency for stenosis1,11; furthermore, diation fields, and the existing midline laparotomy inci- it requires patient compliance with a stent or obturator for sion leaves no additional donor defects or site compli- several months. Reconstruction with segments of bowel cations. Furthermore, it allows for secure placement of is not always satisfactory because of the excessive produc- stomas that are frequently required. A modification of this tion of mucus and odor, and it may cause additional mor- technique has recently been described using a peritoneal- bidity associated with the bowel anastomosis.12 We have lined rectus abdominis flap. It has been suggested that a previously reported our experience with the gracilis myo- musculoperitoneal flap is particularly useful when deal- cutaneous flap and the modified Singapore flap for vagi- ing with a nonexenterated pelvis in which there is not nal reconstruction.3,6 Although the gracilis muscle itself enough room for bulkier musculocutaneous flaps.14 is reliable, the blood supply to the skin attachment is un- The VRAM flap for vaginal reconstruction is reli- predictable, requiring frequent reoperations and debride- able; it fills the pelvic defect with nonirradiated tissue,

(REPRINTED) ARCH SURG/ VOL 138, DEC 2003 WWW.ARCHSURG.COM 1342

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 allows for stomal placement, incorporates into the ex- cular pudendal-thigh flaps: a preliminary report. Plast Reconst Surg. 1989;83: isting midline laparotomy incision, and is functional in 701-709. 6. Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction motivated patients. utilizing the modified Singapore flap. Plast Reconst Surg. 1992;90:270-274. 7. Judge B, Garcı´a-Aguilar J, Landis G. Modification of the gluteal perforator- Accepted for publication May 16, 2003. based flap for reconstruction of the posterior vagina. Dis Colon Rectum. 2000; Corresponding author: Heidi Nelson, MD, Division of 43:1020-1022. 8. Tobin G, Day TG. Vaginal and pelvic reconstruction with distally based rectus Colon and Rectal Surgery, Mayo Clinic, 200 First St SW, abdominis myocutaneous flaps. Plast Reconst Surg. 1988;81:62-69. Rochester, MN 55905 (e-mail: [email protected]). 9. Radice E, Nelson H, Mercill S, Farouk R, Petty P, Gunderson L. Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies. Br J Surg. 1999;86:349-354. REFERENCES 10. Suzuki K, Dozois RR, Devine R, et al. Curative reoperations for locally recurrent cancer. Dis Colon Rectum. 1996;39:730-736. 1. Beemer W, Hopkins M, Morley G. Vaginal reconstruction in gynecologic oncol- 11. Benson C, Soisson AP, Carlson J, Culbertson G, Hawley-Bowland C, Richards F. ogy. Obstet Gynecol. 1988;72:911-914. Neovaginal reconstruction with a rectus abdominis myocutaneous flap. Obstet 2. Franz R. Sigmoid colon vaginoplasty: a modified method. Br J Obstet Gynaecol. Gynecol. 1993;81:871-875. 1996;103:1148-1155. 12. Magrina J, Masterson B. Vaginal reconstruction in gynecologic oncology: a re- 3. Heath PM, Woods JE, Podratz K. Gracilis myocutaneous vaginal reconstruction. view of techniques. Obstet Gynecol Surv. 1981;36:1-9. Mayo Clin Proc. 1984;59:21-24. 13. Smith HO, Genesen MC, Runowicz CD, Goldberg GL. The rectus abdominis myo- 4. Ratliff C, Gershenson DM, Morris M. Sexual adjustment of patients undergoing cutaneous flap: modifications, complications, and sexual function. Cancer. 1998; gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic ex- 83:510-520. enteration. Cancer. 1996;78:2229-2235. 14. Niazi ZB, Kutty M, Petro JA, Kogan S, Chuang L. Vaginal reconstruction with a 5. Wee JTK, Joseph V. A new technique of vaginal reconstruction using neurovas- rectus abdominis musculoperitoneal flap. Ann Plast Surg. 2001;46:563-568.

Announcement

he Archives of Surgery will give priority review and T early publication to seminal works. This policy will include basic science advancements in surgery and criti- cally performed clinical research.

(REPRINTED) ARCH SURG/ VOL 138, DEC 2003 WWW.ARCHSURG.COM 1343