Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

Abstract

Objective: To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.

Methods: We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.

Results: We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.

Conclusion: The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Keywords: Algorithm; Perforator Flap; Perineal Reconstruction; Vulvar Neoplasms; Vulvar Reconstruction; Vulvoperineal Reconstruction.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1

Algorithm for flap selection in vulvoperineal reconstruction after vulvar cancer ablative surgery. The five sections are related to the five possible defects associated with the vulvar one. ALT-VL, anterolateral thigh flap with vastus lateralis; c-ALT, cutaneous anterolateral thigh; DIEP, deep inferior epigastric perforator; Fc-ALT, fasciocutaneous anterolateral thigh; RT, radiotherapy; SCIP, superficial circumflex iliac perforator; VRAM, vertical rectus abdominis myocutaneous.

Fig. 2

(A) Tumor on the right hemivulva. (B) Radical vulvectomy, wider on the right side. (C) The flap harvested on the medial surface of the right thigh, pedicled on a medial circumflex femoral artery perforator. (D) The flap advanced in a V-Y fashion. The white arrows indicate the part of the flap that goes beyond the midline to surround the urethra and vagina.

Fig. 3

(A) Vulvar cancer relapse inward toward the pelvis, after previous surgery and radiotherapy, showing chronic radiodermatitis of the perineal skin. (B) Pelvic exenteration with pelvic floor defect and dead space. (C) Anterolateral thigh flap, with Vastus Lateralis, planned on the left thigh with two perforators seen with Doppler sonography. (D) Flap inset. The skin, damaged by radiotherapy, has been removed and replaced by the flap.

Fig. 4

(A-C) Vulvoperineal, mons pubis and groins defect, with femoral vessels exposure and partial removal of the left inguinal ligament for cancer relapse after surgery and radiotherapy. (D) Fasciocutaneous anterolateral thigh flap, from left thigh, repairing the defect. Fascia lata reconstructed the inguinal ligament. The flap has been thinned and split. (E) Postoperative view shows uneventful wound healing of the split part of the flap.

Fig. 5

(A) Massive cancer relapse after vulvectomy and radiotherapy. (B) Pelvic exenteration with wide dead space and complete loss of pelvic floor. (C) Vertical rectus abdominis myocutaneous flap with endopelvic course.

Fig. 6

(A) Wide resection of upper vulva, mons pubis and right groin for cancer relapse after surgery and radiotherapy. (B) Brachytherapy catheters positioned in the surgical bed. The muscular belly of vertical rectus abdominis myocutaneous flap (white arrow) separating subcutaneous fat by catheters. (C) Inset of the flap accomplished.