Elsevier

Gynecologic Oncology

Volume 107, Issue 3, December 2007, Pages 578-582
Gynecologic Oncology

Case Report
Reconstruction of the pelvic floor and perineum with human acellular dermal matrix and thigh flaps following pelvic exenteration

https://doi.org/10.1016/j.ygyno.2007.08.063Get rights and content

Abstract

Background

Patients who undergo pelvic floor resection as treatment for recurrent cancer following radiation therapy have increased rates of complications, particularly if permanent prosthetic mesh is used for reconstruction. Human acellular dermal matrix (HADM), commonly used for reconstruction in other torso locations, is associated with lower rates of complications (including infection, adhesions and cutaneous exposure) than synthetic mesh. We describe an effective technique to reconstruct the pelvic floor and perineum with HADM and thigh-based flaps following pelvic exenteration and radical vulvectomy.

Case

A 75-year-old woman underwent radical resection of the pelvic floor and perineum to treat recurrent vulvar squamous cell carcinoma and osteoradionecrosis. The pelvic floor and perineal soft tissue defect were reconstructed with HADM (AlloDerm; LifeCell Corporation, Branchburg, NJ) and bilateral, thigh-based tissue flaps, respectively. Despite a large resection, previous irradiation therapy and bacterial contamination the wounds healed without complications.

Conclusion

Reconstruction of pelvic floor defects using HADM is an option when wound conditions are unfavorable for the use of permanent prosthetic meshes.

Introduction

A major challenge of pelvic reconstructive surgery is restoring support for intra-abdominal organs. Failure to do so has been reported to result in such sequelae as perineal hernias, pelvic organ prolapse and even perineal evisceration. Implantable mesh materials have been used to address several inherent aspects of pelvic floor reconstruction including prevention of abdominal and pelvic organ prolapse, pelvic floor resuspension after oncologic resection and augmentation of bladder function. The implantable materials used are principally constrained by three factors: the durability of repair, tissue biocompatibility and material-related complications. Historically, surgical repairs of the pelvic floor have included synthetic absorbable and non-absorbable mesh materials. The use of non-absorbable synthetic meshes has been reported to yield effective, long-lasting surgical repairs in the pelvis [1]. Unfortunately, permanent synthetic materials are prone to infection, extrusion, adhesions and foreign body reactions [2]. The use of absorbable synthetic materials results in limited durability of the repair because the tissue plane remaining after their resorption is not sufficiently strong. Repairs performed with absorbable mesh have been reported to have recurrence rates as high as 100%.

Bioprosthetic mesh materials, including human acellular dermal matrix (HADM), have the potential to provide the durability of permanent synthetic meshes with markedly improved tissue biocompatibility [3]. These materials are processed to remove host cells but preserve the native three-dimensional biologic tissue matrix thereby preserving its tissue conductivity (ability to incorporate into recipient wounds with cellular incorporation and revascularization). AlloDerm (HADM, Lifecell Corporation, Branchburg, NJ) is derived from human dermis, is not chemically cross-linked and has been shown to become remodeled by the surrounding tissue to a well-vascularized, cellularized, structurally intact layer with preservation of adequate tensile strength [3], [4], [5], [6], [7]. HADM has been used for chest, pelvic and abdominal wall repair with durable results and relatively few complications, even given such adverse circumstances such as prior radiation therapy, wound contamination and placement directly over bowel [4], [5], [8], [9]. Bioprosthetic mesh materials such as HADM have the potential to provide the durability of the permanent synthetic meshes with markedly improved tissue biocompatibility [3]. Despite an increasing body of experience in abdominal wall reconstruction using HADM, however, its application in pelvic reconstruction has not been as widespread. Challenging pelvic floor reconstructions are not uncommon and the use of bioprosthetic mesh materials may offer an optimal solution. We report a surgical technique using HADM and thigh-based flaps for pelvic floor and perineal reconstruction following radical resection for the treatment of recurrent vulvar cancer and severe osteoradionecrosis. To our knowledge, this specific technique has not been reported.

Section snippets

Case report

A 75-year-old woman with squamous cell carcinoma (SCC) of the vulva was initially treated with wide excision followed by radiation therapy and chemotherapy. She returned 6 months later with locally recurrent SCC and full-thickness osteoradionecrosis of the vagina and vulva, along with chronic drainage from a rectovaginal fistula (Fig. 1). She had required numerous hospitalizations over a 2-month period for pain management and treatment of local and systemic infections before transfer to our

Discussion

In this case, resection of recurrent, radiated vulvar cancer resulted in a massive pelvic floor defect which posed a significant risk of pelvic organ herniation. Durable reinforcement was deemed necessary, and this was accomplished at the time of resection using HADM in conjunction with two thigh-based soft tissue flaps. Most pelvic and perineal defects following cancer resection can be repaired with local tissue rearrangement and/or tissue flaps, without the use of prosthetic mesh. However,

References (15)

  • M. Huebner et al.

    The use of graft materials in vaginal pelvic floor surgery

    Int J Gynaecol Obstet

    (2006)
  • J.M. Choe et al.

    Autologous, cadaveric, and synthetic materials used in sling surgery: comparative biomechanical analysis

    Urology

    (2001)
  • J.J. Disa et al.

    Advantages of autologous fascia versus synthetic patch abdominal reconstruction in experimental animal defects

    Plast Reconstr Surg

    (1996)
  • C.E. Butler et al.

    Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications

    Plast Reconstr Surg

    (2005)
  • C.E. Butler

    The role of bioprosthetics in abdominal wall reconstruction

    Clin Plast Surg

    (Apr 2006)
  • R.P. Silverman et al.

    Ventral hernia repair using allogenic acellular dermal matrix in a swine model

    Hernia

    (2004)
  • A. Gobin et al.

    Repair and regeneration of the abdominal wall musculofascial defect using silk fibroin–chitosan blend

    Tissue Eng.

    (2006)
There are more references available in the full text version of this article.

Cited by (0)

View full text