RECONSTRUCTION OF DEFECT AFTER RADICAL VULVECTOMY BY THE USE OF FOUR-FLAP LOCAL TRANSFER – A CASE REPORT

INTRODUCTION

Malignant tumors of the vulva are not frequent and comprise about 3% of all malignant gynecological tumors. While the incidence is relatively low (3–4 cases in 1000 women), the mortality is very high (2–2.5 in 100 women) (1). This high mortality is caused mainly by the age distribution of its incidence, which sharply grows after the sixth decade of a woman’s life. Older patients do not pay attention to early symptoms and tend to undervalue them. They may attempt to treat their clinical symptoms independently and feel too embarrassed to seek medical help. Consequently, in the majority of cases treatment is started in the later stages of the disease. The method of choice in treatment of early stages of malignant vulvar tumors is surgery, and the results depend on how radical the surgery is and the extent to which it is possible to remove the tumor with enough of the healthy surrounding tissue (2). In advanced stages resection of the tumor is sometimes not technically possible because removal of the tumor with all the external female genitalia causes a considerable defect involving the external genitalia, perineum and the perianal area. In such cases the patient has to be treated by radiotherapy (3, 4, 5), which is not as effective and involves multiple complications due to radiation of lower urinary tract, the rectosigmoid and the anus. These complications can include urinary and fecal incontinence as well as post radiation colitis (6).

To close the defects after radical vulvectomy it is possible to use a variety of surgical procedures; from the simplest, such as skin graft transplants, to extensive local skin transfers or fasciocutaneous or muscle flaps and complicated free flap transfers from distant areas (7, 8, 9, 10, 11). A routine formula applies, according to which we choose the surgical procedure which has the least impact on the system and at the same time the highest possible functional benefit (12, 13, 14). This means minimal impact on the whole status of the patient, low morbidity of the donor area and at the same time the benefit of good quality coverage as required at the particular area.

CASE REPORT

A 74-year-old female patient was diagnosed with vulvar carcinoma in the pT2 stage, pN0 (according to the FIGO classification stage 2). Despite the fact that the tumor was 120 x 85 mm and 45 mm deep, it was favorably localized in the mid vulva and did not infiltrate to the base of the perineum. Therefore, a radical vulvectomy was indicated, or removal of the external genitalia and associated lymph nodes in the inguinofemoral area (Fig. 1, 2) with immediate reconstruction.

One significant complication during anesthesia was the fact that the patient had a history of ictus. She was treated for arterial hypertension and type II diabetes.

In the first phase of the surgery a radical vulvectomy was performed with removal of regional lymph nodes. This part of the surgery took 3 hours and was completed by a team of gynecologists. This created a defect 27 x 14 cm from the mons pubis to the edge of anus with exposed vagina (Fig 3, 4). The defect was immediately addressed by a plastic surgeon. Reconstruction with four-flap local transfer was chosen. The first flap was harvested from the low left area with the incision in the area of vagina to the inner thigh and further towards the left buttock, the other similarly from the low right area. These flaps were used to reconstruct the area between the vagina and anus. The area between the mons pubis and upper area of the vagina was closed with two other flaps harvested from the upper parts of inner thighs (Fig. 5). These flaps were also inserted obliquely against each other (Fig. 6). The whole reconstruction phase lasted 1.5 hours. Perisurgical blood loss was replenished by blood transfusions (total of 5x erythrocyte mass, 3x plasma). The urinary catheter with respect to the sutures was removed on the 21^st day after the surgery. Five days after the patient left the intensive care unit she was hospitalized for another 18 days on a standard postsurgical unit. After that she was discharged and seen as an outpatient. In the postsurgical period she suffered only partial dehiscence of the wound on the perineum, which was addressed with a suture without further complications. The patient did not have problems with urinating, emptying the bowels or incontinence immediately after the surgery or later due to scar formation. She did not have any other complications. (Fig. 7.) Fifteen months after the surgery the patient is without signs of a relapse and has no problems with functions. Histological evaluation revealed well differentiated corneous squamous cell carcinoma of the vulva. No carcinoma angioinvasion was identified. The carcinoma did not reach the edges of the surgical incision. Three lymph nodes were evaluated without metastases (pT2, pN0, M0, G1).

RESULTS AND DISCUSSION

Treatment of defects after a radical tumor removal in the area of external genitals in women is among the most complicated reconstructive surgeries (15). This is mainly due to the possibility that the patient may develop problems with excretion caused by the surgery or by subsequent scar formation. Defects of a small extent without the use of radical approach after tumor extirpations can be resolved by local transfers or occasionally by a direct suture. In the majority of cases it is necessary to use local flap transfer or free tissue transfer from a distant area to close the defect. Covering the defect by autologous skin grafting leads to contracting scar formations, which can dislocate the anus, urethra and vagina or cause incontinence. The area covered by the skin graft can also be easily injured. During ambulation friction and moisture in the area leads to infected abrasions which only heal with great difficulty. Moreover, urine, stool and vaginal secretions increase the risk of secondary ulceration formation. Therefore a skin graft is the first choice method only for older defects with a great scarring of the surrounding tissues and chronic granulation tissue after previous surgeries. Free flaps require many hours of surgery and mean considerable stress for the older patient whether it is in the form of fasciocutaneous or muscle flaps. The extent or size of the free flap represents a further limitation. Mainly TRAM-DIEP can be considered, which has a high layer of subcutaneous fat and therefore is not suitable for the described indication (16). Scapular of parascapular fasciocutaneous flaps lead to a large secondary defect. Its closure would require a skin graft. Together with the increase of surgery time, secondary deformation of the harvest area is a great disadvantage. In addition, free tissue flaps tend not to be sensitive enough. Covering the defect by transposition of m. gracilis with a skin island means that both thigh muscles must be moved with only a limited amount of skin to cover the defect (17, 18). Transposition of the axial groin flap can be also considered an alternative. Due to the size of the defect it would be necessary to use both groin flaps. The great distance from the defect, irregularity of blood vessels pedicle and high layer of subcutis comprised a high risk. Another technique considered was V-Y transfer or anterolateral thigh flap (19, 20, 21, 22). These flaps are often used to close defects in the perineal area. The advantage of these flaps is good sensory innervation (in V-Y transfers it is via pudendal and posterior cutaneous femoral nerves and in the anterio-lateral thigh flap via lateral cutaneous femoral nerve). However, the defect we were addressing reached high to the mons pubis, and it would have been necessary to combine this type of flap with another local transfer. Although it is much more complicated, we must admit that even this technique would avoid one complication of the described case, which was dehiscence of the perineal wound. Lee et al. describes 17.6% of dehiscence in reconstructions addressed by a simple suture (23). Landoni et al., in his comparison study of closure of defects by a simple suture, describes 26% of dehiscence compared to 64% when skin flaps are used (24). Fanfani et al. describes this early post-surgical complication in 65.2% of patients (25). A great many of the post-surgical complications are caused most frequently by a combination of microbial flora, insufficient flap mobilization with suture under tension and vascular or metabolic intercurrent diseases, which is a serious factor considering the higher age of patients.

CONCLUSION

Use of four flaps forming the immediate proximity of the defect after radical vulvectomy allows for a very fast and definitive closure of extensive defects in the perineal area. The main advantages of this approach are easy access to the surgical field without the need to change the patient’s positions after the first phase of the surgery; short surgery time; simple and safe mobilization of the flaps; good quality sensory supply and good functional and esthetic results.

Address for correspondence:

Andrej Sukop, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Univ. Hospital Královské Vinohrady
Šrobárova 50, 100 34 Prague 10
Czech Republic
E-mail: andrej.sukop@centrum.cz