Dear Editor: Muscular pelvic floor defects, which can occur after pelvic tumor resection, require primary repair in order to avoid perineal herniation of abdominal contents. Small defects can be repaired with direct approximation of tissue or with gracilis muscle flaps. For large defects formation of either bilateral gluteus maximus advancement myocutaneous flaps, or transpelvic or transabdominal vertical rectus abdominis myocutaneous flaps is required. When additional support is needed, a synthetic mesh can be used. However, synthetic meshes are prone to complications such as infection and bowel adhesion, erosion, and fistula formation. Nowadays, grafts made of porcine dermis cleared of cells, DNA, and RNA are available (CollaMendTM, C. R. Bard Inc., Cranston, USA; PermacolTM, Tissue Science Laboratories, Aldershot, UK). In these grafts, the collagen fibers are chemically cross-linked, what makes collagen resistant to absorption. The three-dimensional collagen matrix allows cellular in-growth, neovascularization, and rapid integration into the surrounding tissue. Grafts made of porcine dermal collagen (PDC) are more resistant to infection and adhesion formation than synthetic material. We report on a 63-year-old woman who presented with a huge perineal and lower pelvic anal cancer recurrence. The patient had undergone radical hysterectomy and lymphadenectomy followed by radiotherapy for invasive cervical cancer 25 years ago. Five years ago, a squamous cell anal cancer was diagnosed. Due to prior radiotherapy, a limited radiation reserve was available. The patient received 30.4 Gy and chemotherapy and subsequently underwent abdominoperineal excision of the anorectum with formation of a permanent colostomy. The cancer recurrence presented as a deep perineal ulcer, the vagina did not exist any more, urine leaked from a bladder fistula. CT, MRI, and PET scans revealed local resectability, there was no evidence of distant tumor spread. The bladder was widely infiltrated; the tumor reached the pubic bones, however there were no signs of osseous infiltration. The patient was informed about the necessity of total pelvic exenteration. Additionally, she was informed that the implantation of a bioprosthetic graft for pelvic floor reconstruction was planned. Laparotomy was performed in the Lloyd–Davis position. The peritoneum at the entrance to the small pelvis was incised and the dissection followed the pelvic wall down to the coccyx, sparing the ureters and the iliac vessels. The bladder was mobilized; the ureters were transsected close to the bladder. The extent of the tumor required resection of most of the muscular pelvic floor. Tumor resection was completed from the perineal approach and included excision of the coccyx, wide lateral excision of the perineum and transsection of the tissue anteriorly of the ostium of the urethra. The specimen was removed, biopsies taken from four points of the resection margins at the patient’s side microscopically revealed no evidence of residual tumor. Both ureters were anastomosed to an ileum conduit which was diverted in the right lower quadrant of the abdominal wall. The huge pelvic floor defect was closed with an 10.2 cm×15.2 cm elliptic graft of PDC, which was sutured to the sacral fascia, to the residual pelvic Int J Colorectal Dis (2009) 24:357–358 DOI 10.1007/s00384-008-0629-3
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Jun 20, 2023
Mohamad Hatem Albarghouth + 2
Open Access