Surgical Outcomes of VRAM vs Gracilis Flaps in Vulvoperineal Reconstruction following Oncologic Resection: A Proportional Meta-Analysis

Abstract

Introduction: Pelvic exenteration and abdomino perineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy. Neo-adjuvant chemotherapy and/or radiotherapy has been shown to decrease local recurrence rates and increase cancer-specific survival by allowing resection of locally advanced neoplasm. However, it leads inevitably to increased morbidity rates due to large pelvic defects Healthy, well vascularized, non-irradiated tissues are required to fill the pelvic dead space and minimize complication rates. We conducted a proportional meta-analysis to compare Vertical Rectus Abdominus Myocutaneous flap (VRAM) vs Gracilis flap for vulvo-perineal reconstruction following oncologic resection. Materials and Methods: A systematic review of Embase, PubMed, Cochrane Library, Research gate and Google Scholar was conducted aiming at all articles reporting VRAM and gracilis surgical outcomes after oncologic abdomino-perineal resection. Proportional meta-analysis of surgical outcomes was performed using the Freeman-Tukey transformation and random-effect model. Results are expressed in proportions with a 95%CI. Pooled proportions were compared between VRAM and Gracilis using a two-sided Z-test. Results: Our review yielded 17 eligible studies (11 for VRAM and 6 for Gracilis), involving 898 patients (756 VRAM and 142 Gracilis). Pooled proportion of overall donor site complications for VRAM flap is 0.584 [95% CI 0.521, 0.647], which is significantly higher than Gracilis flap rate (0.154[95% CI 0.066,0.266]). The pooled rate of overall recipient site complications for VRAM is 0.387 [95% CI 0.305, 0.473], similar to that of the Gracilis flap (0.313 [95% CI 0.194, 0.444]). Pooled flap failure rate were low for VRAM (0.025 [95% CI 0.012-0.042]) and Gracilis (0.064 [95% CI 0.003-0.171]). There was no statistically significant difference between the minor and major complications for both flaps. Conclusion: We demonstrate that both flaps can be used safely for vulvo perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.