Primary Vaginal Reconstruction at the Time of Pelvic Exenteration for Gynecologic Cancer: Morbidity Revisited

The aim of this study is to analyze our experience about the benefits and morbidity of primary vaginal reconstruction in pelvic exenteration. Over a 10-year period, 64 patients underwent a pelvic exenteration for gynecologic cancer, except for ovarian and fallopian cancer. Twenty-nine patients underwent pelvic exenteration with vaginal reconstruction [21 cases with transverse rectus-abdominis myocutaneous (TRAM) flap and eight cases with Singapore fascio-cutaneous flap]. Thirty-five patients did not undergo vaginal reconstruction. Postoperative morbidity was recorded and a comparative analysis of morbidity between groups was made. Pelvic abscess and small bowel fistula occurred more frequently in the no neovagina group (20% versus 6.9% and 20% versus 3.4%, respectively). There were no differences between groups regarding fever, colorectal anastomosis (CRA) dehiscence–leakage, prolonged ileus, deep venous thrombosis, pulmonary embolism or wound complications. Surgery time was significantly longer for the neovagina group. There was only one perioperative death, which occurred in the neovagina group. Vaginal stenosis, necrosis, and shortness occurred less frequently for TRAM flap compared with Singapore flap (19.0% versus 28.6%, 14.5% versus 50% and 0% versus 100%, respectively). CRA dehiscence–leakage appeared more frequently (83.3% versus 28.6%) in the Singapore group. Nevertheless, this complication was statistically associated (p = 0.0009) with low CRA (<5 cm). TRAM flap seems to be the preferable option for reconstructing the vagina after pelvic exenteration. The Singapore fascio-cutaneous flap carries a higher rate of complications, does not work as functional neovagina after pelvic exenteration, and does not seem to be a good choice in cases of low colorectal anastomosis.