Outcomes of Partial Vaginal Reconstruction with Pedicled Flaps Following Oncologic Resection

Background

Immediate flap reconstruction (IFR) for partial vaginal resection (PVR) is commonly performed with radical resection of colorectal, gynecologic and urologic malignancies. Surgical and functional outcomes are not well described in the literature. We hypothesized PVR with pelvic oncologic resection has a high incidence of early, minor complications but provides good long-term results.

Methods

We reviewed all consecutive IFRs for PVR at M. D. Anderson Cancer Center between 2000 and 2009. Demographic, treatment and outcome data were collected from a prospectively entered database then retrospectively analyzed. Statistical analysis was performed to evaluate factors associated with postoperative complications.

Results

Seventy-two female patients were included in the study (mean age 57 years). The most common pathologic diagnoses were rectal adenocarcinoma (63%), anal squamous cell carcinoma (24%). Eighty-nine percent of patients received preoperative radiotherapy and 87.5% preoperative chemotherapy. The mean follow-up was 26.5 months. Vaginal defects (mean=74 cm2) were most commonly located posteriorly (72%) and reconstructed with a vertical rectus abdominis myocutaneous flap (87%) or a thigh-based flap (13%). Forty-nine complications occurred in 44 (61%) patients. Donor- site complications included wound dehiscence (n=6), hernia (n=5), infection (n=3), enterocutaneous fistula (n=1) and hematoma (n=1). Recipient site complications included wound dehiscence (n=23), partial flap loss (n=4), vaginal fistula (n=2), perineal hernia (n=1), infection (n=1), seroma (n=1) and vaginal stenosis (n=1). Only 8% of complications required hospital readmission or reoperation. The incidence of complications was significantly higher in those patients receiving preoperative radiation therapy (66 % vs 25%, p=0.05) and those with posterior/lateral rather than anterior/apex defects (66% vs 30%, p=0.04). Postoperative complications were significantly associated with increasing radiation dose (p=0.014). Reliable preoperative/postoperative data regarding sexual activity were available in 24 patients. Fifteen of 22 patients (68%) who had penile-vaginal intercourse (PVI) preoperatively were able to postoperatively. Of patients who did not have PVI postoperatively, 22% also did not preoperatively. Reasons for not having PVI included dyspareunia, stenosis, lack of partner/desire, and fistula.

Conclusions

PVR with IFR has a high incidence of early complications, many of which are minor. Preoperative radiation therapy may be associated with increased complications. Sexual function (PVI) can be preserved in select patients. PVR with IFR should be considered for patients undergoing oncologic resection, however, patients should be counseled regarding relevant risks and functional outcomes.