Jinekolojik Onkolojik Cerrahi Sonrası Oluşan Vulva ve Perine Defektlerinin Rekonstrüksiyonu ve Lokal Fleplerin Etkinliği

Abstract

Amaç: Jinekolojik malignitelerin radikal cerrahisi sonrası çoğu defekt primer sütüre edilerek kapatılabilse de rekonstrüksiyon gerektiren geniş defektler oluştuğunda farklı rekonstrüksiyon seçenekleri de mevcuttur. Bu çalışmada, vulva ve perine bölgesinde jinekolojik kanser nedeniyle rezeksiyon sonrası rekonstrüksiyon uygulanan hastalarda uyguladığımız tedavi strateji ve sonuçları sunulmaktadır. Gereç ve Yöntemler: Bu geriye dönük çalışmaya Mayıs 2017 ve Temmuz 2020 arasında rekonstrüksiyon uygulanan toplam 18 hasta dahil edildi. Hastaların demografik ve klinik bilgileri rezeksiyon operasyonu, defekt özellikleri, uygulanan rekonstrüksiyon yöntemleri değerlendirildi. Operasyon sonrası tedavi stratejisi ve komplikasyon oranları değerlendirildi. Bulgular: Hastaların ortalama yaşı 62,3±13,2 (42-83) yıl olarak saptandı. Hastaların %88,9’unda ek hastalık bulunmaktaydı. Beş (%27,8) hastada pelvik egzantasyon, 2 (%11,1) hastada anterior rezeksiyon ve 11 (%61,1) hastada vulvektomi uygulanmıştı. En sık görülen malignite skuamöz hücreli karsinom ve ortalama defekt genişliği 106±97 (12-476) cm2 olarak saptandı. On altı (%88,9) hastada lokal fasyokutan flep, bir (%5,6) hastada pediküllü rektus myokutan flebi ve bir (%5,6) hastada deri grefti ile onarım yapıldı. Beş (%27,8) hastada yara yeri komplikasyonları, bir (%5,6) hastada parsiyel flep nekrozu ve uzun vadede bir (%5,6) hastada nüks gelişti. Sonuç: Jinekolojik onkolojik rezeksiyonlar sonrası vulva ve perine defektlerinin birçoğunun lokal flepler ile başarılı bir şekilde kapatılması mümkündür. Özellikle vulvektomi hastalarında bölgenin özellikleri ve hasta komorbiditeleri dikkate alındığında uzamış yara yeri problemleri görülebileceği akılda bulundurulmalıdır.

Keywords

• Vulvektomi
• Pelvik egzantrasyon
• Rekonstrüktif
• neoplazm
• Morbidite
• Yara

Reconstruction of Vulva and Perineal Defects After Gynecological Oncological Surgery and Effectiveness of Local Flaps

Abstract

Aim: Although most defects can close by primary suturing after radical surgery of gynecological malignancies, different reconstruction options are available when large defects that require reconstruction occur. In this study, we present the treatment strategy and results for patients who underwent reconstruction after resection for gynecological cancer in the vulva and perineum. Material and Methods: A total of 18 patients who underwent reconstruction between May 2018 and July 2020 were included in this retrospective study. Demographics and clinical data, the resection operation, characteristics of the defect, and the reconstruction methods applied were evaluated. Postoperative treatment strategy and complication rates were evaluated. Results: The mean age was 62.3±13.2 (42-83) years. 88.9% of the patients had additional diseases. Pelvic exentration was performed in 5 (27.8%) patients, anterior resection in 2 (11.1%) patients and vulvectomy in 11 (61.1%) patients. The most common malignancy was squamous cell carcinoma, and mean defect size was 106±97 (12-476) cm2. Reconstruction was performed with a local fasciocutaneous flap in 16 (88.9%) patients, pedicled rectus myocutaneous flap in one (5.6%) patient, and skin graft in one (5.6%) patient. Wound complications occurred in 5 (27.8%) patients, partial flap necrosis in one (5.6%) patient, and recurrence in one (5.6%) patient in the long term. Conclusion: It is possible to reconstruction most of the vulva and perineal defects with local flaps after oncological resections, Considering the characteristics of the area and patient comorbidities, it should be kept in mind that prolonged wound problems may be seen, especially in vulvectomy patients.

Keywords

• vulvectomy
• pelvic exenteration
• reconstructive
• neoplasm
• morbidity
• wounds

References

1. Salgado CJ, Chim H, Skowronski PP, Oeltjen J, Rodriguez M, Mardini S. Reconstruction of acquired defects of the vagina and perineum. Semin Plast Surg. 2011;25(2):155-62.
2. Fin A, Rampino Cordaro E, Guarneri GF, Revesz S, Vanin M, Parodi PC. Experience with gluteal V-Y fasciocutaneous advancement flaps in vulvar reconstruction after oncological resection and a modification to the marking: Playing with tension lines. Int Wound J. 2019;16(1):96-102.
3. Hollenbeck ST, Toranto JD, Taylor BJ, Ho TQ, Zenn MR, Erdmann D, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg. 2011;128(5):551e-63e.
4. Salgarello M, Farallo E, Barone-Adesi L, Cervelli D, Scambia G, Salerno G, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54(2):184-90.
5. Mughal M, Baker RJ, Muneer A, Mosahebi A. Reconstruction of perineal defects. Ann R Coll Surg Engl. 2013;95(8):539-44.
6. John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, Malata CM. An algorithmic approach to perineal reconstruction after cancer resection--experience from two international centers. Ann Plast Surg 2013;71(1):96-102.
7. Gentileschi S, Servillo M, Garganese G, Fragomeni S, De Bonis F, Scambia G, et al. Surgical therapy of vulvar cancer: how to choose the correct reconstruction? J Gynecol Oncol. 2016;27(6):e60.
8. Chokshi RJ, Kuhrt MP, Arrese D, Martin EW Jr. Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure. Am J Surg. 2013;205(1):64-70.

9. Saleh DB, Liddington MI, Loughenbury P, Fenn CW, Baker R, Burke D. Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach. J Plast Reconstr Aesthet Surg. 2012;65(11):1537-43.
10. Martin AL, Stewart JR, Girithara-Gopalan H, Gaskins JT, McConnell NJ, Medlin EE. Trends and complications of vulvar reconstruction after vulvectomy: a study of a nationwide cohort. Int J Gynecol Cancer. 2018;28(8):1606-15.
11. Dias-Jr AR, Soares-Jr JM, de Faria MBS, Genta MLND, Carvalho JP, Baracat EC. Secondary healing strategy for difficult wound closure in invasive vulvar cancer: a pilot case-control study. Clinics (Sao Paulo). 2019;74:e1218.
12. Huang JJ, Chang NJ, Chou HH, Wu CW, Abdelrahman M, Chen HY, et al. Pedicle perforator flaps for vulvar reconstruction--new generation of less invasive vulvar reconstruction with favorable results. Gynecol Oncol. 2015;137(1):66-72.
13. Chen YC, Scaglioni MF, Kuo YR. Profunda artery perforator based V-Y rotation advancement flap for total vulvectomy defect reconstruction--A case report and literature review. Microsurgery. 2015;35(8):668-71.
14. Ito R, Huang JJ, Wu JC, Lin MC, Cheng MH. The versatility of profunda femoral artery perforator flap for oncological reconstruction after cancer resection-clinical cases and review of literature. J Surg Oncol. 2016;114(2):193-201.
15. Peiretti M, Corvetto E, Candotti G, Angioni S, Figus A, Mais V. New Keystone flap application in vulvo-perineal reconstructive surgery: A case series. Gynecol Oncol Rep. 2019;30:100505.
16. Ramesh HS, Boase T, Audisio RA. Risk assessment for cancer surgery in elderly patients. Clin Interv Aging. 2006;1(3):221-7.
17. De Hullu JA, Hollema H, Lolkema S, Boezen M, Boonstra H, Burger MP, et al. Vulvar carcinoma. The price of less radical surgery. Cancer. 2002;95(11):2331-8.
18. Llueca A, Herraiz JL, Del Moral R, Piquer D, Maazouzi Y, Segarra B, et al. Use of negative pressure wound therapy after infection and flap dehiscence in radical vulvectomy: A case report. Int J Surg Case Rep. 2017;41:370-2.
19. Imas GE, Sola MPB, Gomez MTG, Etulain CL. Prevalence study on vulvar neoplasia in Navarre from 2007 to 2015. Nurse Care Open Acces J. 2017;3(3):255-8.