Role of Reconstructive Surgery

Courtesy of FIGO

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Dr. John Shepherd:  “Thank you very much indeed, and good morning once again, ladies and gentlemen.  You heard from the two previous speakers about the role of surgery in recurrent disease, and I certainly agree with Dr. Ungar’s comments about the need for the referral of appropriate patients and for trying to pick up recurrent disease early.  I’m going to look at this problem with a slightly broader look at reconstructive surgery across the board for recurrent pelvic cancer and try and show you that now in this day and age we have to think very carefully about further surgical techniques and try and rehabilitate some of these ladies who’ve suffered quite considerably in the past.  This is arguably one of the most beautiful ladies in the world, sitting in the Louvre for now, and I guess it would be a tragedy to try and reconstruct her.  Maybe she should be returned to her original home.  

Cancer is a destructive process and the treatment for cancer be it by radiotherapy or by extirpative surgery is destructive.  The process of recurrence of cancer is even more destructive if it’s for cervical cancer, which may occur centrally and then spread out laterally and locoregionally involve the pelvic sidewalls, bony involvement, etc. That is a destructive process so the pathophysiology leads to destruction and the treatment to try and cure the disease also is destructive.  Surgery has two aims, and you’ve heard both of those this morning.  Dr. Ungar has alluded to trying to cure patients surgically for recurrent cancer, and Dr. Hoskins has indicated that we have to consider very carefully the role of palliative surgery in order to try and help patient’s symptoms in appropriate cases.  

Radiotherapy, whichever way you look at it, destroys the cancer but does have an effect on surrounding tissue, just as much as extirpative surgery by exenteration will have an effect on surrounding tissue.  If we look at pelvic exenteration, this has been well described and historically put into perspective by Dr. Ungar.  There are three parts to this particular procedure - one is the resection of the tumor, which can be by anterior, posterior, or total pelvic exenteration.  The second part involves diverting the urinary and the fecal streams, and traditionally, this has been to stomas.  The third part in this day and age is reconstruction; trying to reconstruct a continent bladder, a functioning vagina, restore rectal continuity, and try and restore some form of cosmetic appearance and function to the vulva.  You can see here the first of the reconstructions - the diversions that were developed which is the formation of a urinary bladder as initially described, of course, by Bricker and this is the method that Leadbetter described when implanting ureters with inevitably a diverting urostomy.  So that was a low-volume, high-pressure conduit if you will to a urostomy, and if one has to divert the fecal stream, one has to have a colostomy.  

Now if you look at reconstruction the aim of reconstruction is to re-establish a functioning organ and at the same time remember, Kasmesus, as part of reconstruction, tried to recreate and restore body image.  We’ve heard from Dr. Ungar about the possibilities for continent bladder reconstruction, and we really are now in the day and age of continent bladder reconstruction, re-anastomosing the rectum.  The good Lord in all his wisdom gave us 10 meters of bowel, the first 2 feet of bowel from top end to the other, it’s true to say some people appear to have more but traditionally the conduit utilizes the terminal ileum.  But we do have a considerable amount more of ileum proximal to that terminal area and indeed, the ascending curve of the cecum.  These can be utilized for reconstructing continent bladders.  The technique that Dr. Ungar referred to that we described from Bart’s which we call the APER procedure or the anterior pelvic exenteration and reconstruction, it seems to be renamed the Budapest procedure now, it involves using 48 cm of terminal ileum and taking the ureters and re-implanting these into a large volume, low pressure conduit.  This does offer the opportunity for retaining the urethra if indeed it is possible.  Remember that the radiotherapy effects on that lower part of the bladder and the trigone and especially the urethra may not be as extensive in cervical cancer as when radiotherapy is administered for either bladder cancers or for rectal cancers and utilizing that portion of the small bowel and re-implanting the ureters with this method that we’ve shown, and tunneling them into the wall of this large volume bladder.  

We’ve modified the technique from the original technique described whereby we used a portion of proximal ileum to re-implant these ureters and have modified that so that we actually are tunneling them directly into the new bladder.  There is less reflux with this technique.  There are other procedures that have been described; we’ve heard about the Budapest method, there is of course, the Miami method, which utilizes more of the ascending colon and cecum.  There’s the mica pouch from Germany which utilizes more of the terminal ileum and there are various other methods including the Indiana pouch.  Just about any large city in the developed world has developed its own particular technique, which indicates that there’s a lot of interest but perhaps not one actual gold standard method.  Therefore, it behooves us if we’re going to utilize these methods, to use the one that suits us and our particular techniques in each accordingly.  So we now have the possibility for bladder reconstruction, what about the vagina?

There are many methods of reconstructing the vagina either as a delayed procedure or concurrent reconstruction with exenteration surgery.  Perhaps the most well known straightforward simple procedure is the Williams vulvo-vaginoplasty, which utilizes either the labia or if they’ve been removed, can utilize the inner aspects of the thigh if there’s enough flexible tissue and, of course, the split thickness graph, a well-known procedure.  But at the same time as exenteration, it is quite feasible to utilize myo-cutaneous grafts, either the gracilis, rectus abdominus, or the gluteal muscles all tentatively to utilize other bits of bowel, part of that 32 feet; again, 10 meters can be used to reconstruct a functional vagina either using the ileum and the sigmoid, or the cecocolon which are certainly our preferred preference.  The McIndoe-Reed procedure would be straightforward; you remember it requires an obturator or mold, which is placed into the vaginal space between the bladder and the rectum.  This is a good procedure for primo genesis but less straightforward because of scarring and constriction and radiotherapy effects, I have to say, for after exenteration.  So the procedure that we have favored as having utilized part of the terminal island to reconstruct a continent bladder is to take the next part of the bowel, the cecum, and the colon and to mobilize this and to use this to bring down as a functioning ceco-colon vaginoplasty first described by Turner Warick who brought down the hepatic flexor end of the colon.  We’ve slightly modified this and instead of turning it, we bring it down and bring the cecum down.  We have to take the appendix off otherwise you may have a second vaginal orifice and pouch which can be a little bit confusing and bring this down and then re-anastomosing it.  

This particular technique as we’ve described here avoids the need for a urostomy and at the same time does give a functioning vagina.  This particular lady has had a slightly different form of continent bladder reconstruction, utilizing a  technique that utilizes a catheter as a spout out unto the anterior abdominal wall but has also had a vaginoplasty.  Now some exenterative surgeries, you can see here, involves intra levator resection of the vulva and the vagina and the perineum leaving large deficiencies which require a thinning with musculocutaneous flaps which can be mobilized as is shown here in order to try and close that particular defect.  We must remember that the majority of flaps in reconstruction that need to be used, of course, are for vulva cancers.  On occasions we can be presented with huge tumors replacing the vulva, the inner thigh, a fierce change of paramedial tissue is affected by cancer in some circumstances, and trying to resect this is certainly possible and feasible but provides an enormous challenge for the pelvic surgeon to try and get primary closure.  He’ll turn to leave this to granulate which, of course, in this day and age especially when bed days at hospital are being counted, is unacceptable, let alone from the body image point of view.  

Some of those circumstances we have to use our imagination and learn the message from the reconstructive surgeons who have taught us with the dreadful problems they’ve had to deal with over the last few wars that have occurred with burns and tissue destruction.  We can actually now utilize musculocutaneous flaps either as rotational flaps or indeed free flaps or graphs with a microvascular reanastomosis but we can now virtually fill any defect by imaginative reconstruction and rotation of tissue as you can see here this large potential defect from this huge vulva tumor.  The plan here is having carried out a bilateral DELETE vulvectomy, as shown here.  Utilize rex abdominus flaps, as you can see here.  Bring them down as is being shown here to cover this large defect that has resulted.  The flaps are then brought down, and this is a picture three months later, as you can see here, with some intricate cosmetic reconstruction that is being carried out here.  This gives a functioning organ that needs to be utilized and the patient encouraged to use, and we’ll discuss that shortly.  But there are many other flaps that can be mobilized and used including the gluteus maximus, the iliotibial tract, and the gracilis muscle.  Indeed, there are free flaps utilizing the pectoral muscles and latissimus dorsi much in the way that breast surgeons do.  This is a larger flap.  We’re now in a day and age whereby we have to offer our patients reconstructive surgery, the day and age of traditional destruction to extirpate cancer has gone.  We now have to consider these reconstructive techniques, and we must remember that on occasions we may have to carry out reconstructional diversion following the effects of radiotherapy, again, for palliative purpose.  We have to counsel these patients very, very carefully.  We need to prepare these patients for their surgery, their family for the understanding of the natural history of the disease and, therefore, why such treatment is necessary.  We have to plan our surgery, we have to include reconstruction in the armamentarium of the potential treatment management plan, and we have to remember as Dr. Ungar pointed out that there are potential complications, and it is certainly true that the reoperation rate for many of these procedures is not small.  We have to rehabilitate these patients, teaching them, and encouraging them to use their reconstructed organs.  This particular patient has got a reconstructed continent bladder; she’s got a reconstructed vulva, a reconstructed functioning cecocolon vagina.  I would like to say she’s had a rectal reconstruction as well but in fact to that date she hadn’t.  This is a management plan that involves a multidisciplinary team in oncology units but the most important member of that team is the part that we can read in the middle and that, of course, is the patient.  In this way, we can overcome these huge challenges that are in front of this central part of our management team, the patient and her disease.  

Thank you very much indeed for your attention.”