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2002 Selected Articles

Vaginal Reconstruction

Ramin Mirhashemi, MD; Nicholas Lambrou, MD

Vaginal reconstruction has its origin in antiquity with the first known description of a surgical repair of a "membranous obstruction" of the vagina attributed to Hippocrates.¹ Several hundred years later, in the first century AD, the great Roman medical writer Celsus detailed a surgical approach to correct imperforate hymen and vaginal atresia. Although several other commentaries on the surgical treatment of vaginal atresia were documented in the ensuing years, it was not until the latter half of the 19th century that operations of a truly plastic and reconstructive nature were performed. These included the use of local flaps from the labia, as well as skin grafts. The aim of the current discussion is to summarize various techniques of vaginal reconstruction and focus on the recent advances in such repairs after radical resection for pelvic malignancies.

Vaginal reconstruction has been expanded to include women who have undergone surgical removal of the vagina, most commonly as part of pelvic exenteration for malignancies of the cervix, vagina, or vulva. Pelvic exenteration is one of the most extensive and potentially most morbid procedures performed in gynecologic oncology (Figures 1 and 2), but it can be curative in up to 50% of properly selected patients.^2,3 Over the past two decades, reconstruction has played an increasingly important role in preserving both function and cosmetic appearance. Of these, continent urinary diversions such as the Miami pouch (Figure 3) and colorectal reanastomosis (Figure 4) have gained acceptance as successful, low-morbidity procedures that decrease the need for external appliances. The most recent advances have been in reconstructions of the vagina.

Figure 1.	Figure 2.
Figure 3.	Figure 4.

Currently, several options are available for reconstructing the vagina and vulva. These include the use of skin grafts (either partial or full thickness), various intestinal substitutes, local flaps, thigh flaps, and abdominal myocutaneous flaps. Each of these methods has its benefits and potential risks. Vertical and transverse rectus abdominis myocutaneous (RAM) flaps are the current frontrunners in popularity.

There are several goals for vaginal reconstruction in patients with malignancies. The first is to restore the anatomy of the surgically created defect without compromising curability of disease. The second is to improve the patient's quality of life by rebuilding a functional vagina. Data indicate that these two goals are intimately related. The largest predictor of patient satisfaction after any type of vaginal reconstruction is control of pelvic disease.⁴ Other important considerations are to minimize intraoperative time and to improve both intra- and postoperative short- and long-term morbidity.

SKIN GRAFTS

McIndoe is credited with popularizing the use of a split-thickness skin graft in creating a neovagina.⁵ In this type of reconstruction, skin grafts from 0.016 to 0.020 inches in thickness are obtained from the thigh or buttock and sutured or glued over a prosthetic vaginal stent.⁶ A space is surgically created between the bladder and rectum, and the stent with the overlying skin graft is then sutured into place. Various stenting materials may be used, including glass dilators, tightly packed gauze, foam in sterile condoms, and partially inflated tissue expanders. The fitting of the stent and proper preparation of the graft are more important than the actual stent type.^7,8 The stent is typically removed 7 days postoperatively, and the patient is discharged with instructions to wear a stent or prosthesis for up to 6 months.⁹ Success rates of 85% to 89% have been reported, with up to 94% patient approval (defined as regular intercourse with satisfaction and adequate vaginal capacity).^2,4

Disadvantages of grafting include contracture, which occurs in up to 42% of patients (compliance with daily stent use in the first 6 months may help to prevent this).² Patients also need to use lubricants during intercourse, and the vaginal configuration is less anatomic. Benefits include low morbidity and mortality, a good cosmetic result with skin graft donor sites from the buttock or thigh, and (because of the vaginal approach) no need for laparotomy. Anatomically, this procedure requires the presence of the bladder and rectum, and may therefore be more applicable to patients with congenital absence of the vagina than to those undergoing exenteration for malignancy.

Full-thickness skin grafts are less likely to contract, and do not require prolonged stenting. Foam rubber in a condom may be worn for the first month while the graft is maturing, and thereafter only at night for the next 3 months.¹⁰ Donor sites include hairless inguinal or gluteal regions that can be closed primarily. In cases where malignancy involves the lower third of the vagina or vulva, these sites should be avoided secondary to the potential for lymphatic metastasis of disease.

When available, the omentum has been employed to protect the pelvis after exenteration. A modification of this includes the use of a split-thickness skin graft in the creation of a neovagina. First described by Wheeless,¹¹ a series of 20 patients undergoing pelvic exenteration was then reported by Kusiak et al¹² in which an omental "J" flap was used with a split-thickness skin graft. The vascular supply from the left gastroepiploic artery is preserved, and the omental flap is draped into the pelvis along the left paracolic gutter. A split-thickness skin graft (0.018 inches thick) is placed on an adjustable vaginal stent with the dermis facing outward, and this is inserted into the pelvis and the omentum is wrapped into a cylinder around it. Kusiak et al¹² reported graft viability in all patients and functional potential (ie, the capability of intercourse) in 80%. Vaginal stents must be worn postoperatively for 4-8 weeks, and results are dependent on an adequate omentum.

INTESTINAL SUBSTITUTES

Intestinal substitutes have been used since the early 1900s with the introduction of ileal segments for vaginal reconstruction. However, the small bowel mucosa does not tolerate trauma well, and may bleed during intercourse. In 1955, Alexadrov¹³ published his series of 175 patients undergoing sigmoid neovaginal reconstruction, reporting a success rate of 89%. Sigmoid neovaginal reconstruction has been described using a loop technique¹⁴ or an isolated segment15 of sigmoid colon (Figure 5). The benefits of the sigmoid neovagina include no need for postoperative stenting and a large lumen with little tendency for stenosis. Dilators are sometimes required (especially in the pediatric population), and prolapse of the distal segment can occur, requiring surgical repair.¹⁶ Major disadvantages are voluminous secretions and an unpleasant odor that can be ameliorated with daily vaginal douching.

Figure 5.

More recently, Filipas et al¹⁷ have reported on their series of 17 patients undergoing vaginal reconstruction with a segment of cecum and ascending colon. The most common indication for vaginal reconstruction in this series was congenital anomaly. Four of the patients had previously undergone vaginal reconstruction. The operative technique incorporates a 15-cm segment of cecum and ascending colon, with preservation of the ileocolic artery. The proximal end is closed, the segment rotated into the pelvis, and the distal end anastomosed to the vulva. The majority of patients in this series (13 of 14) reported minimal to no secretions and overall satisfaction with the vaginal reconstruction, both sexually and cosmetically (12 of 14). In three patients, a continent urinary diversion was also created with the use of either transverse colon or rectosigmoid. This alternative technique for vaginal reconstruction may prove advantageous in selected patients, but it would have limited utility in centers where continent urinary diversions incorporate the cecum and ascending colon.^18,19 In addition, a majority of the patients had gastrointestinal complications postoperatively, most likely related to the multiple gastrointestinal anastomoses and diversion of large segments of bowel for both the neovagina and urinary diversion.

FLAP TECHNIQUES

Local Flaps

Vulvoperineal fasciocutaneous flaps have been used for reconstruction of the vagina, most often in cases of vaginal agenesis. The paired flaps are based on the terminal vessels of the internal pudendal artery. These are small flaps, and are not recommended for irradiated or extensive defects. Other local flaps include the perineal artery fasciocutaneous flap²⁰ and labial flaps, but these are fragile and subject to necrosis without offering much benefit for either filling the pelvic defect or restoring sexual function.

Gracilis Flaps

Gracilis myocutaneous flaps have been used in reconstruction of the vagina since the first publication in 1976 by McCraw et al.²¹ The flap derives its blood supply from the medial femoral circumflex artery, and flap viability has been consistently reported at 80% to 90%.^22,23 Advantages of this technique include the ability to fill a large pelvic defect with well-vascularized tissue, and multiple series have reported decreased postoperative morbidity in patients undergoing pelvic exenteration with reconstruction. Disadvantages of this flap include the bilateral scars on the inner thighs from the donor sites and a propensity to prolapse (Figure 6). Modifications have included the use of shorter flaps and attachment to levator, presacral, or retropubic fascia.

Figure 6.

Rectus Abdominis Flaps

Since the adoption of the gracilis myocutaneous flap with its notable improvements over skin grafts and local flaps by providing a bulk of healthy tissue, attention was turned to other sources for myocutaneous flaps. Tobin and Day²⁴ were among the first to report on their success with the use of the RAM flap in vaginal reconstruction. The RAM flaps can be used for reconstruction of the vulva or vagina, as well as for pelvic and lower abdominal-wall defects. These flaps are based caudally on the deep inferior epigastric vascular pedicle to the rectus abdominis muscle, and carry a myocutaneous paddle from the upper abdomen (Figures 7 through 9). The skin paddle can be oriented vertically, obliquely, or horizontally to fit the size and shape of the defect. There are several anatomic advantages of the distally based RAM flaps. The entire rectus abdominis muscle may be used, allowing for a long arc of rotation deep into the pelvis without compromising the vascular pedicle. The muscle provides a bulk of healthy tissue to fill the empty pelvic cavity. The fascial donor defect is located above the linea semicircularis, thus minimizing the potential for hernia formation; the posterior rectus sheath remains intact. The skin donor site is located in the upper abdomen, away from the colostomy and urinary conduit stomas. Cosmetically, the RAM neovagina yields excellent results, and the majority of patients appear to be satisfied with both the cosmetic and functional outcome.

Figure 7.

Figure 8.

Figure 9.

Data seem to support several advantages of the RAM neovagina over other types of vaginal reconstruction in patients who have undergone pelvic exenteration. This may be particularly true in patients with previous pelvic irradiation. Graft viability is 82% to 91% in the largest reported series.^2,25,26 Smith et al² identified potential risk factors for graft compromise (either partial or complete graft loss), including preexisting stomas on the same side as the donor site, previous abdominal incision, and prolonged operative time. Factors such as obesity, smoking, and peripheral vascular disease may reduce graft viability, so appropriate patient selection is important.

The majority of patients undergoing exenteration have had previous pelvic irradiation. The incidence of fistula formation in this population is 16% when no pelvic reconstruction is performed, and may carry mortality of up to 40%, especially in the immediate postoperative period.^3,27 Miller et al¹⁶ reported on the benefits of routinely using either an omental pedicle graft or a gracilis myocutaneous flap in pelvic reconstruction, and demonstrated a reduction in the incidence of fistula formation from 16% to less than 5%. One of the largest predictors of fistula formation in that group was pelvic infection.¹⁶ The use of RAM vaginal reconstruction appears to decrease the risk of fistula formation as well.⁴ The deep inferior epigastric artery originates from the external iliac artery and is generally spared the damaging effects of pelvic irradiation. This offers a reliable blood supply to the rectus abdominis muscle from the symphysis to the costal arch,²⁸ and provides a bulk of healthy tissue for the evacuated pelvis.

Jurado et al¹⁷ reported their results from a series of 16 patients who underwent vaginal reconstruction with an RAM flap (68.8%), gracilis flap (12.5%) or Singapore fasciocutaneous flap (12.5%). They demonstrated a reduction in the incidence of postoperative pelvic abscess from 27% (6/29) in patients who had no vaginal reconstruction compared with no pelvic abscesses in the group who underwent vaginal reconstruction. There were no significant differences between the neovagina and nonneovagina groups with respect to other postoperative morbidities.

Fascial dehiscence is an unusual but potentially life-threatening complication of pelvic exenteration. The donor site of RAM flaps generally includes a paddle of skin, subcutaneous tissue, anterior rectus fascia, and underlying rectus muscle with dimensions of approximately 12 x 20 cm. The donor site is taken from above the linea semicircularis in a vertical flap, and therefore the posterior rectus sheath remains intact. If the anterior rectus sheath is closed, mesh may occasionally be required, or a modification employed involving a narrower donor site that permits easier fascial closure.⁴ Alternatively, a horizontal donor site can be obtained from below the umbilicus to allow for anatomic closure of the anterior rectus sheath.

POSTRECONSTRUCTION SEXUAL FUNCTION

Data concerning sexual function after vaginal reconstruction are limited. In the report by Smith et al,⁴ nearly 85% of cancer survivors who underwent vaginal reconstruction with RAM flaps reported sexual satisfaction after the procedure—an improvement over the 47.5% of patients who reported sexual satisfaction after vaginal reconstruction with gracilis myocutaneous flaps.²⁹ The majority of published reports on sexual function after vaginal reconstruction are confounded by an absence of formal preoperative sexual assessment and by small numbers of patients. More attention must be directed toward prospective analysis of sexual function after vaginal reconstruction.

CONCLUSION

Recent advances in radiation and chemotherapy have improved response rates and survival in women with gynecologic malignancies. Nonetheless, radical resection of pelvic tumors remains a crucial part of the gynecologic oncologist's armamentarium. In the properly selected patient, pelvic exenteration may be the only real hope for women who have not responded to more conservative treatments. The past 30 years have demonstrated improvements in patient selection, perioperative supervision in the intensive care unit setting, and surgical reconstructive techniques. Just as the creation of continent urinary diversions is becoming a standard practice among qualified gynecologic surgeons when removing the bladder for gynecologic malignancy (eliminating the need for an external urinary appliance) so too may vaginal reconstruction become the option of choice in properly selected patients. The challenge for the surgeon is to successfully remove the invading cancer so as not to compromise cure, and to select a reconstructive technique that reduces postoperative morbidity and provides lasting sexual function. Recent advances in the use of myocutaneous flaps appear to offer promise in this arena.

Efforts continue to meet the needs of women faced with this emotionally and physically devastating threat to their well-being. For the general internist or OB/GYN, a sensitivity to these needs and an understanding of vaginal reconstruction are essential to ensure that patients know about the alternatives available to them. This includes annual vaginal examinations and cytology, as the risk of recurrence or a second skin-related primary malignancy must not be overlooked. In addition, the periodic use of vaginal dilators, lubricants, and local estrogen supplements may be indicated.

Ramin Mirhashemi, MD, is associate professor, division of gynecologic oncology at the University of Miami College of Medicine, Fla. Nicholas Lambrou, MD, is senior gynecologic oncology fellow, University of Miami School of Medicine, Fla.

References

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