Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy

Björn Bolmstrand,Gabriella Palmer,Pehr Sommar,Torbjörn Holm,Per J Nilsson,Jakob Lagergren,Diana Zach,Anna Martling,Daniel Schain

doi:10.1007/s13304-021-01211-3

Abstract

The purpose of this study is to present and evaluate a surgical method using gluteal flap for combined perineal and vaginal reconstruction after abdominoperineal excision (APE) with partial vaginectomy for anorectal malignancy. The method is a two-centre study of consecutive patients undergoing APE including partial vaginectomy for anorectal tumours, with immediate combined perineal and vaginal reconstruction using gluteal flaps. Follow-up data were retrieved via retrospective review of medical records, questionnaires and gynaecological examinations. Some 34 patients fulfilled the inclusion criteria. At the time of follow-up, 14 (78%) of the 18 patients alive responded to questionnaires. Seven (50%) of the survey responders agreed to undergo gynaecological examination. Major flap-specific complications (Clavien–Dindo > 2) were observed in 3 (9%) patients. Among survey responders, 11 (79%) had been sexually active preoperatively of which five (45%) resumed sexual activity postoperatively and three (27%) resumed vaginal intercourse. These three patients had all implemented an active vaginal health promotion strategy postoperatively. Perineo-vaginal reconstruction using gluteal flap after extended APE for anorectal malignancy is feasible. Although comparable to other methods of reconstruction, the rate of perineo-vaginal complications is high and post-operative sexual dysfunction is substantial. Postoperative strategies for vaginal health promotion may improve sexual function after vaginal reconstruction.

Highlights

Extended abdominoperineal excision (APE) including resection of the posterior vaginal wall can be necessary to obtain clear resection margins (R0) in patients with locally advanced rectal or anal cancer
As primary closure of the vaginal defect may be insufficient for anatomical restoration, flap reconstruction is used for selected patients with the aim to restore anatomy and sexual function
Dorsal defects are classified as type 1b and the recommended flap for reconstruction is the rectus abdominis flap

Summary

Introduction

Extended abdominoperineal excision (APE) including resection of the posterior vaginal wall can be necessary to obtain clear resection margins (R0) in patients with locally advanced rectal or anal cancer. Reported methods for perineo-vaginal reconstruction after APE are versions of the rectus abdominis myocutaneous (RAM) flap [1,2,3], the gracilis flap [4,5,6], and, to a lesser extent, different versions of gluteal flaps [7,8,9]. The most probable site for vaginal involvement in locally advanced anorectal cancer is the dorsal vaginal wall. Dorsal defects are classified as type 1b and the recommended flap for reconstruction is the rectus abdominis flap.

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Conclusion