Secondary post-oncologic vulvar reconstruction - a simplified algorithm

Anna Amelia Caretto; Maria Servillo; Luca Tagliaferri; Valentina Lancellotta; Simona Maria Fragomeni; Giorgia Garganese; Giovanni Scambia; Stefano Gentileschi

doi:10.3389/fonc.2023.1195580

Secondary post-oncologic vulvar reconstruction - a simplified algorithm

Front Oncol. 2023 Jun 20:13:1195580. doi: 10.3389/fonc.2023.1195580. eCollection 2023.

Authors

Anna Amelia Caretto¹, Maria Servillo², Luca Tagliaferri³, Valentina Lancellotta³, Simona Maria Fragomeni⁴, Giorgia Garganese^{1

4}, Giovanni Scambia^{1

4}, Stefano Gentileschi^{1

5}

Affiliations

¹ Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Rome, Italy.
² Casa di Cura Villa Stuart, BAC Center, Rome, Italy.
³ Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Diagnostica per Immagini Radioterapia Oncologica ed Ematologia, Rome, Italy.
⁴ Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità Ginecologia Oncologica, Rome, Italy.
⁵ Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Unità di Chirurgia Plastica, Rome, Italy.

Abstract

Introduction: Surgical treatment is the gold standard of care for vulvar cancer and is burdened by a high risk of wound complications due to the poor healing typical of the female genital area. Moreover, this malignancy has a high risk of local relapse even after wide excision. For these reasons, secondary reconstruction of the vulvoperineal area is a relevant and challenging scenario for gynecologists and plastic surgeons. The presence of tissue already operated on and undermined, scars, incisions, the possibility of previous radiation therapy, contamination of urinary and fecal pathogens in the dehiscent wound or ulcerated tumor, and the unavailability of some flaps employed during the primary procedure are typical complexities of this surgery. Due to the rarity of this tumor, a rational approach to secondary reconstruction has never been proposed in the literature.

Methods: In this observational retrospective study, we reviewed the clinical data of patients affected by vulvar cancer who underwent secondary reconstruction of the vulvoperineal area in our hospital between 2013 and 2023. Oncological, reconstructive, demographic, and complication data were recorded. The primary outcome measure was the incidence of wound complications. The secondary outcome measure was the indication of the different flaps, according to the defect, to establish an algorithm for decision-making.

Results: Sixty-six patients were included; mean age was 71.3 ± 9.4 years, and the mean BMI was 25.1 ± 4.9. The mean size of the defect repaired by secondary vulvar reconstruction was 178 cm² ± 163 cm². Vertical rectus abdominis myocutaneous (VRAM), anterolateral thigh (ALT), fasciocutaneous V-Y (VY), and deep inferior epigastric perforator (DIEP) were the flaps more frequently employed. We observed five cases of wound breakdown, one case of marginal necrosis of an ALT flap, and three cases of wound infection. The algorithm we developed considered the geometry and size of the defect and the flaps still available after previous surgery.

Discussion: A systematic approach to secondary vulvar reconstruction can provide good surgical results with a low rate of complications. The geometry of the defect and the use of both traditional and perforator flaps should guide the choice of the reconstructive technique.

Keywords: flap reconstruction; groin reconstruction; gynecological cancer; secondary vulvar reconstruction; vulvar cancer; vulvar reconstruction; vulvoperineal reconstruction.