1. Perineal & Vaginal Reconstruction Perineal and Vaginal Reconstruction

2. Perineal & Vaginal Reconstruction Reconstruction of pelvis and perineum is required only under certain circumstances. Reconstruction of pelvis and perineum is required only under certain circumstances. n Extended skin loss n Extensive pelvic floor loss n Partial/complete vaginal removal n AP/pelvic clearance n Excision after radiotherapy Immediate pelvi-perineal reconstruction

3. Perineal & Vaginal Reconstruction n Split skin graft n Skin flaps n Omentum n Gracilis muscle, either as a muscle flap or myocutaneous flap n rectus abdominis flap, in either myofascial or myocutaneous form Immediate pelvi-perineal reconstruction

4. Perineal & Vaginal Reconstruction Immediate pelvi-perineal reconstruction Radical extrasphincteric proctectomy

5. Perineal & Vaginal Reconstruction Immediate pelvi-perineal reconstruction Delayed skin grafting

6. Perineal & Vaginal Reconstruction n Vertical rectus abdominis flap (VRAM) n Transverse rectus abdominis flap (TRAM) n Gracilis flap n Gluteal flaps n Posterior thigh flaps Immediate pelvi-perineal reconstruction

7. Perineal & Vaginal Reconstruction Immediate pelvi-perineal reconstruction Omentoplasty and gracilis muscle transposition

8. Perineal & Vaginal Reconstruction Immediate pelvi-perineal reconstruction

9. Perineal & Vaginal Reconstruction minimal functional disturbance pelvic floor repair“internal benefit” perineal repair“external benefit” neo-vaginal reconstruction urethral reconstruction Advantages of immediate gracilis muscle reconstruction

10. Perineal & Vaginal Reconstruction n Transpositional n Rotational n Advancement Immediate pelvi-perineal reconstruction Skin flap reconstruction of perineal/vaginal defects

11. Perineal & Vaginal Reconstruction Exenterative pelvic surgery – eleven year experience of the Swansea Pelvic Oncology Group. Nguyen DQA et al, EJSO 2005 Exenterative pelvic surgery – eleven year experience of the Swansea Pelvic Oncology Group. Nguyen DQA et al, EJSO 2005 n 130 patients – mixed group of rectal and gynaecological cancers (median follow up 14 months) n No deaths within 30 days n Morbidity rate 28% n Predicted 5y survival 53% Perineal and Vaginal Reconstruction

12. Perineal & Vaginal Reconstruction Perineal and Vaginal Reconstruction n Bell et al, Brit J Surg 2005 31 patients – one stage flap, VRAM 31 patients – one stage flap, VRAM 26 – recurrent or persistent epidermoid cancer or low rectal cancer. 26 – recurrent or persistent epidermoid cancer or low rectal cancer. 21 – high dose preoperative radiotherapy 21 – high dose preoperative radiotherapy 3 weeks post op – perineal wound healed in 27 of 31 3 weeks post op – perineal wound healed in 27 of 31 9 flap related complications 3 partial flap necrosis 9 flap related complications 3 partial flap necrosis 2 vaginal stenosis 2 vaginal stenosis n Soper JT et al, Int J Gynecol Cancer 2005 n 32 cases – 14 vs. 18, TRAM vs. VRAM n 1988-2003 n 88% previous radiotherapy, 66% urinary conduit n Rectosigmoid resection/anastomosis 25% n Median survival 14 months n 6% post operative mortality n 15% flap-specific complications – not design related n12% vaginal stricture/stenosis

13. Perineal & Vaginal Reconstruction n Meticulous case selection with input from all members of the multidisciplinary team. n Careful and thorough counselling of the patient and relatives. n Appropriate facilities for post operative monitoring and management. n High level of consultant input from all disciplines is necessary for a successful outcome. Perineal and Vaginal Reconstruction