Abstract
Although oncogynaecological management of bulky vulvar tumors tends to minimally-invasive approaches preceded by neoadjuvant therapies, ultra-radical surgery with curative intent may still have an important role. These procedures remain associated with significant short and long-term complications, imposing the need for novel reconstructive techniques [Brown et al., 2017, Di Donato et al., 2017, Moreno-Palacios et al., 2015, Oonk et al., 2017].
We present a video highlighting the crucial surgical steps of a successful pelvic exenterative procedure followed by perineal reconstruction with a muscle-sparing flap technique.
A 72-year woman with history of stage II vulvar epidermoid carcinoma, treated with radical surgery and adjuvant radiotherapy. At two-year follow-up local recurrence was diagnosed, handled with large excisional surgical treatment. Within four years a second local recurrence occurred, with infiltrative and bulky dimensions extending to perianal region and vaginal wall.
A multidisciplinary surgical approach with curative intent was performed, involving gynecologists, colorectal and plastic surgeons: radical bilateral vulvectomy with distal colpectomy, abdominoperineal resection with colostomy, perineal reconstruction with deep inferior epigastric perforators (DIEP) flap. No major intraoperative or postoperative complications occurred, and the patient was discharged within two weeks with no readmissions for wound care. At two-year follow up she remains in complete remission of the disease. No flap complications occurred during this period.
In highly selected patients with recurrent vulvar cancer previously submitted to multiple surgeries and radiotherapy, pelvic exenterative procedures followed by reconstructive techniques allow free surgical margins minimizing morbidity and pelvic disfiguring surgery. Association of reconstructive techniques to radical vulvo-vaginal surgery can shift the paradigm of oncological treatment approach, improving outcomes and quality-of-life.
Keywords: Vulvar cancer, Recurrence, Pelvic exenteration, Reconstruction
Highlights
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In selected cases of recurrent vulvar cancer, radical procedures still play a role.
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A multidisciplinary surgical approach is crucial for better outcomes.
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Novel reconstructive techniques improve patient satisfaction and quality-of-life.
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The DIEP flap is a complex but feasible option for large perineal defects.
Author contributions
AC and MR conceived the idea for this surgical video. VP, RM, AD, JC and AC actively participated in the surgical and post-operative management of the patient. MR elaborated the surgical video and the manuscript. VP, RM, AD, JC and AC reviewed both the video and the manuscript. AC supervised the project.
Declaration of Competing Interest
The authors declare no conflicts of interest. No funding sources supported this investigation.
The following are the supplementary data related to this article.
Recurrence of vulvar carcinoma: A multidisciplinary approach
Supplementary data to this article can be found online at https://doi.org/10.1016/j.gore.2019.06.004.
Acknowledgements
The authors would like to express their sincere gratitude to Raquel Portugal, due to her paramount contribution on the pathologic evaluation and images provided.
References
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Supplementary Materials
Recurrence of vulvar carcinoma: A multidisciplinary approach