Rectus abdominis vaginoplasty after anterior exenteration for urologic malignancy

SURGICAL TECHNIQUES IN UROLOGY

RECTUS ABDOMINIS VAGINOPLASTY AFTER ANTERIOR EXENTERATION FOR UROLOGIC MALIGNANCY J. KELLOGG PARSONS, ANTHONY TUFARO, BERNARD CHANG,

AND

MARK P. SCHOENBERG

ABSTRACT Introduction. Vaginal resection is occasionally required in female patients who undergo anterior exenteration for invasive lower urinary tract malignancy. We have used a rectus abdominis myocutaneous flap to reconstruct the vagina and perineum after extensive local resection of bladder and urethral carcinoma. Technical Considerations. Either a left or right rectus flap is used. Once anterior exenteration, partial vaginectomy, and urinary diversion are completed, the median infraumbilical incision is extended superiorly to form an elliptical skin paddle centered over the superior half of the muscle. The superior epigastric vessels are ligated, the cephalad end of the muscle is divided at the level of the costal margin, and the flap is progressively elevated out of the rectus sheath by sequentially dividing the lateral perforating nerves and vessels. As the muscle is elevated, the inferior epigastric pedicle is carefully preserved and followed inferiorly to its origin from the external iliac artery. Once a length of muscle sufficient for it to reach the perineum is mobilized, the flap is carried transpelvically. For complete vaginal reconstruction, the flap may be inverted into a tube, with the cephalic portion anchored to the perineum. Alternatively, the skin paddle may be used to fill tissue defects in the vagina and pelvic floor. The anterior abdominal wall fascia and skin edges at the donor site are closed primarily. We have successfully applied this technique in 4 patients who underwent anterior exenteration for invasive bladder and urethral carcinoma. Conclusions. Rectus abdominis vaginoplasty is a viable surgical option for reconstruction after anterior exenteration with vaginal resection for invasive cancer of the bladder and urethra. UROLOGY 61: 1249–1253, 2003. © 2003 Elsevier Inc.

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lassic anterior exenteration remains the standard of care for female patients presenting with invasive bladder carcinoma in whom preservation of the urethra is not technically possible or in whom orthotopic reconstruction is not a goal.1 Occasionally, these patients—as well as those with urethral carcinoma—will present with local extension of disease that necessitates partial or complete vaginectomy, leaving significant tissue defects that cannot be closed primarily. The techniques for vaginal reconstruction after extensive pelvic resection include skin grafts, peritoneal grafts, bowel vaginoplasties, and omental pedicle grafts. These methods have achieved only variable success in

terms of tissue integrity and quality of life after surgery.2–5 Myocutaneous flaps are a more consistently reliable form of tissue reconstruction. Historically, the favored form of flap for genitourinary reconstruction has been the gracilis. An alternative template, which has been successfully used in gynecologic surgery, is the distally based rectus abdominis flap.2,6 We outline the technique for constructing a rectus flap for vaginal and perineal reconstruction, and relate our experience with its use in patients after anterior exenteration with vaginectomy for invasive bladder and urethral carcinoma. SURGICAL TECHNIQUE

From the James Buchanan Brady Urological Institute and Department of Plastic Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland Reprint requests: Mark P. Schoenberg, M.D., Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Marburg 150, 600 North Wolfe Street, Baltimore, MD 21287-2101 Submitted: March 2, 2001, accepted (with revisions): January 22, 2003 © 2003 ELSEVIER INC. ALL RIGHTS RESERVED

Based caudally on the inferior epigastric pedicle to the rectus abdominis muscle, the rectus abdominis myocutaneous flap carries a muscular paddle with a skin island from the upper abdomen transpelvically to the perineum. A single flap is normally sufficient for adequate reconstruction. The selection of a right or left flap is individualized 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00147-X 1249

FIGURE 1. Steps in the elevation of the rectus abdominis myocutaneous flap for vaginal reconstruction. (A) After anterior exenteration, an infraumbilical incision is extended to create elliptical skin paddle and harvest muscle. (B) The muscle is elevated with the skin paddle and perforating vessels in place. (C) The flap is rotated into position in the perineum, and the vascular pedicle is carefully preserved. (D) The incision is closed.

and should consider the reconstructive needs of the surgery, as well as any previous abdominal incisions. In the case of an anticipated urinary diversion procedure with ostomy placement, the rectus muscle contralateral to the proposed ostomy site should be used. The patient is placed in the relaxed dorsal lithotomy position with padded Allen stirrups. Initially, we use an infraumbilical median incision for the anterior exenteration, vaginal resection, and ileal conduit diversion. Once these are complete, the incision is then extended superiorly to form the skin paddle and mobilize the flap (Fig. 1A). The skin paddle of the flap is designed as a vertical ellipse, centered over the superior half of the muscle, with a vertical axis that extends from just inferior to the costal margin to a few centime1250

ters below the umbilicus. If complete circumferential vaginal reconstruction is anticipated, the horizontal axis should be made approximately 10 to 12 cm wide, which corresponds to a vaginal diameter of 3 to 4 cm when the paddle is later tubularized.2 If only partial vaginal reconstruction is planned, the harvested area of skin may be tailored to the needed size. A portion of the rectus sheath directly underneath the skin paddle is incised and left attached to rectus abdominis muscle. The muscle is then carefully elevated out of the rectus sheath. The superior epigastric vessels are ligated, the cephalad end of the rectus divided at the level of the costal margin, and the flap is progressively elevated by sequentially dividing the lateral perforating nerves and UROLOGY 61 (6), 2003

cinoma of the bladder, 1 patient with transitional cell carcinoma of the urethra, and 1 patient with clear cell carcinoma of the urethra—who underwent anterior exenteration, partial vaginectomy, and ileal conduit urinary diversion at our institution. The specifics of each case are summarized in Table I. Patient age ranged from 71 to 76 years (mean 74). None of the patients were sexually active before surgery. For all the patients, the wide extent of vaginal resection necessitated rectus flap reconstruction to close the defect and bolster the pelvic floor. The duration of follow-up in our patients varied between 6 months and 3 years. One patient died as a result of recurrent disease. All four of the flaps evinced good outcomes with no tissue ischemia, flap necrosis, herniation at the donor or recipient sites, or wound breakdown. In 2 cases, the flaps remained completely viable even after the application of adjuvant external beam radiotherapy to the pelvis. COMMENT FIGURE 2. Rectus flap sutured into position in perineum after partial vaginectomy. Retractor placed in vaginal vault (A) and skin paddle (B) on rectus flap, which will be sutured to skin.

vessels (Fig. 1B). A fat pad on the deep surface of the muscle is identified, through which the inferior epigastric vessels may be palpated and isolated. As the muscle is progressively elevated, the inferior epigastric pedicle is carefully preserved and followed inferiorly until it exits the rectus sheath to its origin from the external iliac artery. Once a length of muscle sufficient for it to reach the perineum is mobilized, the flap is transposed through the midline peritoneal incision and carried transpelvically (Fig. 1C). The anterior abdominal wall fascia and skin edges at the donor site are closed primarily (Fig. 1D). If needed, Marlex mesh or similar materials may be used to reinforce the donor site closure. For complete vaginal reconstruction, the flap is inverted into a tube so as to approximate the vagina, with the skin paddle forming the inner lining. The cephalic portion of the paddle is anchored to the perineum and forms the new introitus. Alternatively, the skin paddle may be sutured to the remaining portions of the vagina and pelvic floor to fill defects and preserve tissue continuity (Fig. 2). RESULTS We have successfully used rectus flap vaginal reconstruction in 4 patients with lower urinary tract malignancy—2 patients with transitional cell carUROLOGY 61 (6), 2003

Effective vaginal reconstruction after extensive resection strengthens the pelvic floor, promotes proper healing, and— especially in younger patients—may allow for the resumption of sexual activity. The first type of myocutaneous flap to be widely used in vaginal reconstruction was the bilateral gracilis flap.7 Gracilis flaps, however, suffer from a relatively high frequency of flap loss (10% to 20%), are prone to prolapse, and leave additional donor site scars on the ipsilateral thigh.6,8 The efficacy of the distally based rectus abdominis flap for perineal reconstruction was first described by Tobin and Day2 in a series of patients who required extensive tissue reconstruction as a result of perineal burns or resection of gynecologic malignancy. Subsequently, rectus abdominis flaps have also been effectively used for penile and scrotal reconstructive surgery9 –11 and in the treatment of complex urethrovaginal fistulas.12 For vaginal reconstruction after resection of urinary malignancy, however, there remains a dearth of material. Urologic published data contain many descriptions of neovaginal reconstructive methods that use bowel segments or ureter.4,13,14 However, these techniques are primarily intended for use in patients with congenital absences or deficiencies of the vagina. Esrig et al.15 described a method of anterior vaginal wall reconstruction after anterior exenteration that combined a greater omental pedicle graft with polyglycolic mesh. Older reports advocated the use of skin grafts or gracilis flaps to close large ablative perineal defects.5 More recently, Schlossberg et al.16 used a rectus abdominis flap in 1 patient to obtain perineal coverage after anterior exenteration for a genital malignancy. We have 1251

TABLE I. Patient characteristics Age (yr)

Primary Disease

Adjuvant Therapy

Follow-up

Flap Complications

76

TCC of bladder

Systemic chemotherapy, pelvic radiation

3 yr

None

77

TCC of urethra

None

2 yr

None

71

TCC of bladder

Systemic chemotherapy

6 mo

None

73

Clear cell carcinoma of urethra

Systemic chemotherapy, pelvic radiation

6 mo

None

Comment Vaginoplasty not initially performed; had recurrent mass at vaginal cuff 6 mo after surgery, requiring wider excision of vaginal wall with concomitant reconstruction Experienced transient local discomfort from retained vaginal sutures at 4 mo postoperatively (symptoms resolved after suture removal) Died shortly after follow-up of aggressive local recurrence of disease Uterus and ovaries left in situ; abdominal wall donor site closed with Marlex

KEY: TCC ⫽ transitional cell carcinoma.

successfully used this flap in 4 patients to reconstruct the vagina and perineum after extensive local excision of lower urinary tract malignancies. Two of the major advantages of the rectus myocutaneous flap are the high degree of flap viability and a low wound infection rate. In one survey, the rectus flap ranked among the highest of all myocutaneous flaps with respect to the frequency of flap survival, and the gracilis ranked among the lowest.17 This makes the rectus flap a favorable choice in patients with genitourinary cancer, a population at substantial risk of poor wound healing secondary to suboptimal nutritional status, medical comorbidities, and the systemic stresses imposed by chemotherapy and radiation on an anatomic area inherently challenged by abundant bacterial flora. Other advantages of the rectus flap over the gracilis flap include the prevention of small bowel herniation into the pelvis by blockage of the pelvic inlet by the rectus muscle; a straightforward, technically simple approach that expedites operative time; minimization of scar tissue by incorporation of the flap incision into the laparotomy incision; and more effective obliteration of potential endopelvic dead space.2 CONCLUSIONS The rectus abdominis myocutaneous flap is an effective form of reconstructing vaginal and pelvic floor defects after wide excision for aggressive lower urinary tract malignancy. REFERENCES 1. Marshall FF: Radical cystectomy in the female. AUA Update Series 27: 1–8, 1997. 2. Tobin GR, and Day TG: Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 81: 62–73, 1988. 1252

3. Skene AI, Gault DT, Woodhouse CR, et al: Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap. Br J Surg 77: 635–637, 1990. 4. Hensle TW, and Chang DT: Vaginal reconstruction. Urol Clin North Am 26: 39 –47, 1999. 5. Lesavoy MA: Vaginal reconstruction. Urol Clin North Am 12: 369 –379, 1985. 6. Carlson JW, Soisson AP, Fowler JM, et al: Rectus abdominis myocutaneous flap for primary vaginal reconstruction. Gynecol Oncol 51: 323–329, 1993. 7. McCraw JB, Massey FM, Shanklin KD, et al: Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 58: 176 –183, 1976. 8. Benson C, Soisson AP, Carlson J, et al: Neovaginal reconstruction with a rectus abdominis myocutaneous flap. Obstet Gynecol 81: 871–875, 1993. 9. Davies DM, and Matti BA: A method of phalloplasty using the deep inferior epigastric flap. Br J Plast Surg 41: 165– 168, 1988. 10. Santi P, Berrino P, Canavese G, et al: Immediate reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap. Plast Reconstr Surg 81: 961–964, 1988. 11. Young WA, and Wright JK: Scrotal reconstruction with a rectus abdominis muscle flap. Br J Plast Surg 41: 190 –193, 1988. 12. Bruce RG, El-Galley RE, and Galloway NT: Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas. J Urol 163: 1212–1215, 2000. 13. Hendren WH, and Atala A: Use of bowel for vaginal reconstruction. J Urol 152: 752–757, 1994. 14. Gosalbez R, Castellan M, and Kim C: The use of ureter for vaginal reconstruction. J Urol 160: 2143–2144, 1998. 15. Esrig D, Freeman JA, Stein JP, et al: New technique of vaginal reconstruction following anterior exenteration. Urology 49: 768 –771, 1997. 16. Schlossberg SM, Jordan GH, and McCraw JB: Myocutaneous flap reconstruction of major perineal and pelvic defects, in McAninch J (Ed): Traumatic and Reconstructive Urology. Philadelphia, WB Saunders, 1996, pp 715–725. 17. Mathes SJ, and Nahai F: Muscle and myocutaneous flaps, in Goldwyn RM (Ed): The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Boston, Little Brown, 1984, pp 111–115. UROLOGY 61 (6), 2003