VRAM flap success for dorsal vaginal and perineal reconstruction

Reconstruction of the dorsal vagina or perineum using the vertical rectus abdominus myocutaneous (VRAM) flap following extensive surgery and intraoperative radiotherapy for rectal cancer results in favorable surgical and quality of life outcomes, research shows.

"Due to preoperative (chemo)radiation therapy and often previous surgery, treatment of patients with [locally advanced and locally recurrent rectal cancer] is a challenge for the patient and the surgeon," say Harm Rutten (Catharina Hospital, Eindhoven, the Netherlands) and colleagues.

"Our results show that the VRAM flap is a feasible technique to close the perineal and/or vaginal defect after an extensive APR [abdominoperineal resection] or partial vaginectomy."

The study, reported in Diseases of the Colon & Rectum, included 10 male and 41 female patients treated for locally advanced or locally recurrent rectal cancer between 1994 and 2010.

Following surgery, partial necrosis occurred in three (12%) of the 25 patients with a skin island, all of which were successfully treated. Four (8%) patients also required surgical drainage of a presacral abscess, which resolved without further complication.

However, gynecologic assessment of 10 women after surgery revealed that vaginal stenosis was a common complication, with four women unable to have intercourse due to scarring or the reconstructed vagina being too small.

The authors also collected quality of life data from patients undergoing VRAM reconstruction. They found that the 14 women and five men who responded from the study group reported equal or higher scores on emotional, role functioning, and body image aspects of the questionnaires compared with a control group of patients who had not undergone reconstruction.

Rutten and colleagues say that the low complication rate observed is likely due to the rich vascularization of the VRAM which helps to prevent infection and fistula formation. They add that the technique also has benefits over other reconstructive procedures because it does not require a separate incision to the laparotomy.

According to the authors, the VRAM technique should be performed by colorectal surgeons without the need for a consulting plastic or reconstructive surgeon. However, their results highlight the need for preoperative counseling and postoperative treatment by a gynecologist to help prevent the common complication of vaginal stenosis, they conclude.

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