Extended abdominoperineal resection in carcinoma involving the anal canal : a 3-year experience of vaginectomy and transverse rectus abdominis myocutaneous flap reconstruction

Background: Carcinoma of the vulva and vagina involving the anus as well as carcinoma of the anal canal infiltrating the vagina and vulval skin may require an extended abdominoperineal technique which can provide challenges in reconstruction. Patients and Methods: Over a 3 year period at a single institution in Barbados, 18 cases have presented who were treated by extended abdominoperineal excision with high vaginectomy or by primary perineal reconstruction of total pelvic exenterations using a transverse rectus abdominis myocutaenous (TRAM) flap. All patients had preoperative radiotherapy. Results: There was no perioperative mortality. Sixteen patients are alive with no evidence of disease at follow-up (median 14 months; range 10-36 months) with one patient dying of a cerebral metastasis and one alive with recurrent pelvic disease. One patient undergoing a TRAM flap had partial flap necrosis and there was one incisional hernia of the TRAM flap site. One patient had perineal breakdown after vaginectomy which was successfully treated by graciloplasty.Conclusion: Simple vaginal reconstruction is used when the cancer involves the posterior vaginal wall and when the patients are not sexually active. TRAM flap reconstruction as a primary procedure is reserved for sexually active patients undergoing extensive vaginectomy with introital reconstruction or those undergoing total pelvic exenteration.