Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration:: A study of morbidity

Purpose. The purpose of this study was to analyze our experience with the influence of reconstructive techniques at the time of pelvic exenteration on morbidity. Materials and Methods. Between June 1986 and December 1998, 60 pelvic exenterations for gynecologic malignancies were performed in our hospital. Forty-five were selected for this study because they met two criteria: they were performed by the same team (gynecologic oncologist), and they had similar primary tumors. There were 38 cervical, 2 vaginal, and 5 uterine malignancies. Sixteen patients underwent reconstructive surgery: 11 (68.8%) with placement of a myocutaneous flap with left rectus abdominis, 3 (18.8%) with gracilis muscle, and 2 (12.5%) with the Singapore fasciocutaneous flap. Twenty-nine patients had no reconstruction. Records were reviewed and statistical analysis was performed. Results. Attachment of the grafts was complete in 14 of 16 (87.5%), with a partial vulvovaginal dehiscence in 2 cases. Morbidities included secondary infection in 3 (18.8%), partial necrosis in 3 (18.8%), and partial stenosis in 5 (31.6%); the last was significantly associated with a gracilis flap (P = 0.015). There were no statistical differences between neovagina and nonneovagina groups with respect to the rate of fever, small bowel fistula, bowel obstruction, wound infection or dehiscence, hernia, colorectal leak, colostomy or urostomy prolapse, deep vein thrombosis, pulmonary embolism, intraoperative blood transfusions, or hospital stay. There were no pelvic abscesses in the neovagina group compared with 27% (6/29) in the other group (P = 0.050). Surgery was significantly longer (P = 0.019) for the reconstructive surgery group, with no statistical difference between different kinds of flaps. There were no deaths in either group. Conclusions. Reconstruction of the vagina and pelvic floor at the time of pelvic exenteration can be done safely. Although this increases surgical time, morbidity is not significantly increased. The rectus abdominis flap seems to be the preferable option for primary vaginal and pelvic floor reconstruction. (C) 2000 Academic Press.