Reconstrucción vulvoperineal en cáncer vulvar / Vulvoperineal reconstruction in vulvar cancer

Resumen ANTECEDENTES: Los estadios clínicos avanzados del cáncer vulvar representan un reto quirúrgico y un abordaje que requiere ser multidisciplinario, con cirugía plástica que provea márgenes quirúrgicos adecuados, con menor tasa de complicaciones, cierre primario de la herida e inicio temprano de la terapia oncológica coadyuvante. OBJETIVOS: Describir y exponer las alternativas de reconstrucción vulvoperineal para pacientes con cáncer vulvar, atendidas en el Instituto Nacional de Cancerología de México. MATERIALES Y MÉTODOS: Análisis descriptivo y retrospectivo de casos de pacientes a quienes se hizo reconstrucción vulvoperineal en el Instituto Nacional de Cancerología, México, entre enero y diciembre de 2015, por el mismo cirujano plástico. Se muestra el algoritmo basado en su experiencia. RESULTADOS: Se analizaron 11 casos de pacientes operadas con diferentes técnicas de reconstrucción vulvoperineal, por defectos quirúrgicos del cáncer vulvar y se expuso el algoritmo utilizado y la experiencia del cirujano. CONCLUSIONES: Se revisaron las diferentes alternativas de reconstrucción para subsanar defectos quirúrgicos en pacientes con cáncer vulvar. Los algoritmos de tratamiento quirúrgico previamente publicados son confusos y complejos, quizá por la baja incidencia del cáncer vulvar y las diversas opciones de procedimientos de reconstrucción.

Abstract BACKGROUND: Vulvar cancer is a relatively infrequent disease, that constitutes 1-5% of all gynecological cancers. Surgery is the mainstay treatment is adequate resection, and lymph node evaluation, often have a high risk of relapse that may reach 65%. ADVANCED: Stages are a surgical challenge and multidisciplinary ap proach with plastic surgery will provide adequate surgical margins, less complications, adequate wound closure, and early adjuvant treat ment starting; as well as excellent cosmetic results, with functional, psychological and sexual morbidity decreased. OBJECTIVES: To describe and present the alternatives of vulvoperineal reconstruction in vulvar cancer at Instituto Nacional de Cancerología, Mexico. METHODS: A retrospective descriptive analysis of eleven cases of vulvoperineal reconstruction in vulvar cancer was performed from January 2015 to December 2015, at Instituto Nacional de Cancerología, Mexico; for one plastic surgeon; and demonstrated the algorithm base don their experience. RESULTS: We performed 11 patients of vulvar reconstruction with different reconstructive techniques, such as gracilis flapping, pudend, with a high success rate. as well as, to propose an algorithm based in our experience with vulvar cancer reconstruction at Instituto Nacional de Cancerología, Mexico. CONCLUSION: The present article aims to review the reconstructive alternatives in Vulvar Cancer, several algorithms for surgical treatment have been published before; but they tend to be complex, in part be cause of the low incidence of Vulvar Cancer and the several options of reconstructive procedures.

Surgical therapy of vulvar cancer: how to choose the correct reconstruction? / 부인종양

OBJECTIVE: To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect. METHODS: We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer. RESULTS: We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall. CONCLUSION: The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Vulvoperineal Reconstruction Using Various Fasciocutaneous Flaps

The reconstruction after radical vulvectomy presents a difficult challenge. Ideal flap for vulvoperineal reconstruction has thin character, constant vascular supply, and presents concealed scar after reconstruction. Various flaps are used for reconstruction of the vulvar area, have their own advantages and disadvantages. The authors performed 15 vulvoperineal reconstructions using three kinds of different 28 fasciocutaneous flaps. Gluteal fold fasciocutaneous island flap seems like labia major and remains concealed donor scar along the gluteal fold. But secondary debulking procedure is sometimes required. Vulvoperineal V-Y advancement fasciocutaneous flap is thin, reliable, easily elevated, and matches with regional skin quality, but donor site scar is conspicuous on medial thigh. Gluteal fold V-Y advancement fasciocutaneous flap is also reliable, easily elevated, and matches with regional skin quality with thin flap and concealed donor scar on gluteal fold. Also, it can be advanced even a long distance. Through our experiences, these flaps are very useful for vulvar reconstruction, but in the aspect of donor site scar, thickness, and degree of advancement, gluteal fold V-Y advancement fasciocutaneous flap is superior to the other two patterns for the reconstruction of the large sized vulvoperineal defect.