Pelvic exenteration involves radical en bloc resection of the adjacent anatomical structures affected by a tumor. The procedure was first described in 1948 by Alexander Brunschwig and applied in the treatment of pelvic malignancy. According to the site of recurrence, pelvic exenteration mainly comprises three types: 1. Anterior pelvic exenteration for tumors affecting the bladder and urethra requiring the resection of the entire bladder (including urethra), uterus, and vagina are resected; 2. posterior pelvic exenteration for tumors affecting the rectum, in which the vagina, uterus and affected rectum are resected; and 3. total pelvic exenteration for tumors affecting the bladder and rectum, in which the bladder (including urethra), vagina, uterus, and rectum are resected. Based on the resection area, pelvic exenteration is classified into three types: type I involves the resection margin above the levator ani; type II is the resection area that includes the levator ani; and type III is the resection margin extending below the levator ani.1
Previous studies revealed that patients who underwent post-exenteration have a low 5-year survival rate. Along with the confirmation of surgical indications, mastery of surgical techniques, and improved diagnosis and treatment for perioperative complications, the postoperative 5-year survival rate has increased from 20% in an earlier period to 64%.3 A systematic review indicated that a positive surgical margin is an important prognostic indicator in pelvic exenteration. However, presurgical evaluations through magnetic resonance imaging and positron emission tomography-computed tomography cannot predict the surgical margin condition. Therefore, the author proposed that radical exenteration (type III exenteration) may achieve a more negative margin result.4 In patients undergoing type III pelvic exenteration, a large area of perineal skin and subcutaneous tissues is missing, thereby preventing the perineum from closing and requiring flaps for perineal reconstruction.
Pelvic exenteration is a complicated procedure with a high risk of complications with intraoperative and postoperative comorbidity-related mortality rate of 0–12%. Previous studies showed that the survival rate of patients with postoperative complications is significantly shortened.3 Resection of pelvic tissues that received radiotherapy may lead to various fistulas, poor wound prognosis, and secondary problems caused by ureteral or intestinal obstruction. However, type III exenteration could reduce the incidence of complications,5 such as intestinal obstruction, pelvic abscess, and fistula formation,6,7,8 in patients who need pelvic floor reconstruction.
Therefore, pelvic floor reconstruction after type III exenteration is crucial to the success of the entire treatment. At present, the most popular technique for pelvic floor reconstruction is the application of rectus abdominis flaps, including the vertical rectus abdominis flap, transverse rectus abdominis flap, and deep inferior epigastric perforator flap.9–13 However, abdominal flaps will destroy the integrity of the abdominal wall, resulting in weak abdominal wall, asymmetric abdominal wall contour, and abdominal hernia. It may also cause a series of flap-related complications. In addition, many patients undergoing pelvic exenteration require urethrostomy and/or enterostomy. The incomplete abdominal wall will limit the choice of the stoma location and increase the difficulty of ostomy.14 The gracilis flap is currently used to repair perineal defect, wound, or fistula. Compared with the rectus abdominis, the gracilis has many synergistic muscles. Harvesting the gracilis will lead to mild effects on the thigh function. The muscle flap has normal tensile resistance and tension with long blood vessel and nerve pedicles in a superficial anatomical position. Hence, it is simple and feasible to harvest, which makes it an ideal donor muscle.15
From July 2014 to January 2022, we performed pelvic floor reconstruction with unilateral or bilateral skinless gracilis adipofascial flaps in 31 post-exenteration patients and achieved good outcomes.
Clinical Data
A total of 31 patients requiring pelvic floor reconstruction with gracilis flaps after pelvic exenteration in our hospital from July 2014 to January 2022 were enrolled in this study. Twenty patients underwent unilateral gracilis surgery, and the eleven other patients underwent bilateral surgery. The patients were 31 to 68 years old, with an average age of 53.87±9.70 years. Twenty two cases were cervical cancers, four cases were endometrial cancers, and five cases were vaginal cancers. All patients did not elect to undergo vaginal reconstruction. This study was approved by the Ethics Committee of Peking University Third Hospital. The patients were followed up for 4-12 months after surgery.