Overview of Vulvar-Vaginal Reconstruction
In 2020, the Centers for Disease Control (CDC) reported that around 6,500 women were diagnosed with a type of cancer known as vulvar cancer. On the other hand, vaginal cancer, which typically develops as a result of invasion from nearby structures, is less common. Each year, about 1 in 100,000 women are diagnosed with in situ (non-invasive) or invasive vaginal cancer.
Vulvar and vaginal cancers are usually diagnosed between the ages of 60 and 70. These cancers generally root from a type of cancerous cell known as squamous cells, which are flat cells that make up the outermost layer of skin.
Certain factors can increase your risk of developing vulvar cancer. These include smoking cigarettes, having had vulvar cancer in the past, developing certain changes in the cells of the cervix (known as cervical intraepithelial neoplasia), having a skin condition called lichen sclerosis, and having a weakened immune system.
Meanwhile, factors that increase the risk of vaginal cancer include HPV (Human Papillomavirus), having multiple sexual partners, engaging in sexual intercourse at an early age, and smoking cigarettes.
Lastly, vulvar cancers are usually detected earlier when the disease is still within the organ of origin, whereas vaginal cancers are often diagnosed at later stages. Half of the patients diagnosed with vaginal cancer are already at stage II or above at the time of diagnosis. Several factors, including the type and stage of cancer, its location, the approach taken by the cancer doctor, and the expected outcome, all help guide surgeons in planning the most effective approach for treatment.
Anatomy and Physiology of Vulvar-Vaginal Reconstruction
The pelvic region in the human body is quite complex and involves various areas and functions. Doctors with different areas of expertise, including cancer specialists, colorectal surgeons, urologists, and plastic surgeons, work together when it comes to surgeries involving pelvic cancers and the reconstruction that follows.
Most cancers in the vulva, which is the term for the external parts of a woman’s sexual organs, are typically found in the surface layers and can be treated with surgery that removes only the area with cancer. The vulva includes parts such as the labia majora and minora, vestibule, introitus, mons pubis, clitoris, and the Bartholin and Skene glands. This area plays a large role in sexual pleasure and protects the internal sexual organs.
The pudendal nerve, a nerve that originates from the lower spine, supplies feeling to the vulva and controls functions such as urination, defecation, and orgasm. This nerve branches into three main parts: the inferior rectal nerve, the perineal nerve, and the dorsal nerve to the clitoris. The blood supply to these external sexual parts is primarily provided by the internal pudendal artery, with the femoral artery supplying blood to the labia majora. The venous drainage, or how blood flows out, follows the pattern of these arteries.
The vagina, which is a flexible, muscular tube that connects the vulva to the cervix (the neck of the womb), is vital for sexual intercourse and childbirth. The blood supply to the vagina comes from the vaginal artery, which branches from the internal iliac artery. The nervous supply to the vagina is largely automatic and involuntary.
The location of the vulva and vagina in relation to the muscles of the pelvic floor, bladder, and rectum is critical to understand how the lower parts of the female reproductive system and urinary tract work together.
Why do People Need Vulvar-Vaginal Reconstruction
The main purpose of vaginal and vulvar reconstruction is to rebuild the structure of female genitalia and pelvic floor, also reinstate self-image and sexual function. This surgery is most commonly needed after the removal of colorectal or gynecologic cancers (cancers affecting the lower digestive system or female reproductive system, respectively). These cancers can be treated through various methods including chemotherapy (using medications to kill cancer cells), radiation (using high-energy particles or waves to kill cancer cells), surgical removal (taking out the cancer through operation), or a combination of these treatments.
Some major surgical procedures for treating these cancers include pelvic exoneration (removing all the organs from the pelvis), abdominoperineal resection (removing the rectum and anus), vulvectomy (removing all or part of the vulva), and vaginectomy (removal of the vagina). Often, these surgical procedures leave complicated wounds that can’t heal by themselves or merely by stitching them closed. These wounds can benefit greatly from flap reconstruction, a kind of surgical technique where a piece of living tissue, together with its blood vessels, is moved from one part of the body to another. Flap reconstruction on pelvic wounds can decrease complications as it fills the vacant space left by the removed organs and brings a fresh supply of blood into the wound area, helping it to heal better.
When a Person Should Avoid Vulvar-Vaginal Reconstruction
There are no hard-and-fast rules preventing a reconstruction surgery of the outer female genitalia and vagina. However, certain factors can increase the risk of complications during and after surgery. These include being in a poorer state of general health as graded by the American Society of Anesthesiologists (ASA), taking a long time in surgery, being overweight, smoking, and having had radiation therapy before the surgery. But it’s important to note that no single risk factor alone will definitely prevent you from having this surgery.
Equipment used for Vulvar-Vaginal Reconstruction
The tools needed for a regular operation outside of the body are the same ones required. For surgeries inside the body, specifically in the vagina or introitus (the opening into the vagina), special kinds of spreading tools called retractors will be necessary. Examples of these retractors are Gelpi or Weitlaner, as well as deeply curved ones like the Deaver. It’s a good idea to have different sizes of these tools and instruments on standby. Most of the time, patients are positioned using leg holders known as stirrups in a posture called lithotomy position. This is the common position for surgeries in the pelvic area where you lie on your back with your knees bent and thighs apart.
Who is needed to perform Vulvar-Vaginal Reconstruction?
It would be best if the team who helps with cleaning and preparing for surgery are trained at the hospital where the surgery will take place. Both the team who specializes in treating cancers of the female reproductive system and the team who helps rebuild or repair body parts should be at the planning meeting. While the patient is in the hospital, nurses who know how to watch over the repaired body part should be involved. It’s very important for the hospital staff to be properly trained to make sure the surgery goes as well as possible.
Preparing for Vulvar-Vaginal Reconstruction
Just like with any operation, the doctor will need your complete medical history before the surgery. They will also carefully check your overall health. If you have any other health issues, the doctor will make sure these are under control before the operation. These are important steps to ensure your safety during the surgery. To reduce the chance of developing pressure sores, pads will be placed on the parts of your body where bones are close to the skin, like elbows or knees. Lastly, before the surgery starts, the team will prepare and clean the area for the operation to keep everything sterile and germ-free.
How is Vulvar-Vaginal Reconstruction performed
If necessary, minor surface wounds can be mended through a process known as split-thickness skin grafting. This method requires a well blood-supplied wound area and cannot be performed if radiation therapy has been previously administered. This technique is all about drawing upon nearby skin to mend the wound or blemish.
When it comes to reconstructing a damaged perineum, the particular method used depends on a few factors. These include the size and location of the damage, the end goal of the procedure, whether radiation therapy has been previously carried out, and any other existing conditions, such as prior abdominal surgery. Regardless of these factors, the selected method must ensure a reliable blood supply and offer enough tissue to heal the damaged area completely.
In reconstructing the vulva, the size and depth of the damaged area is taken into account. Smaller areas can be mended using nearby skin without any significant loss of shape or function, while larger areas might require skin that is moved from a more distant part of the body. The area known as the vulva can be further divided into three parts; the upper third, which includes the mons and upper labia, the middle third which includes the proper labia, and the lower third which is the vaginal orifice and perineum.
The blood supply to the perineum functions very much like that of the face, giving surgeons many options for making a repair using skin from nearby areas. The blood that reaches the vulva comes from a few different arteries. Small to medium-sized shallow areas of damage to the vulva and vagina can most often be treated with what’s called rotational flaps, or a lotus flap, due to their leaf-like design. These “flaps” of skin come from the internal pudendal artery and can be used to treat one or both sides of the vulva or vagina.
When it comes to treating the upper areas of the vulva, a mons pubis or suprapubic flap can be used. These flaps of skin come from an artery called the superficial external pudendal artery and an area called the superficial inferior epigastric artery, and their respective veins. These flaps are primarily utilized for defects of the upper, anterior vulva, front seam and labia minora/majora.
Vaginal wounds can be classified as partial (Type 1) or circumferential (Type 2). Partial defects can be further classified as anterior or lateral defects (Type 1A), which arise from the surgical removal of primary vaginal or bladder cancers, and posterior defects (Type 1B), arising from invading rectal or anal cancers. Circumferential defects can be further divided into upper two-thirds (Type 2A) or total vaginal defects (Type 2B). For both types of defects, there are multiple methods for reconstruction using pedicled flaps, or skin attached to a reliable blood supply, such as pudendal, gracilis, and rectus flaps.
The methods used for vaginal or vulvar reconstruction that include use of the gracilis muscle – the most superficial of the muscles – that starts from the pubic bone and stretches to the inner surface of the shin bone. The rectus flap technique is ideal for serious defects and it utilizes the deep inferior epigastric artery, a branch of the external iliac artery. This method is very versatile as the skin can be designed or tubed for various types of defects.
Possible Complications of Vulvar-Vaginal Reconstruction
Vaginal reconstructive surgery can sometimes come with complications. These issues can be minor, like a wound coming open, skin dying, or losing part of a surgical flap (a piece of tissue moved from one body part to another). More serious complications are possible too, like total failure of the flap, abnormal holes called fistulas, or hernias. If you’ve had radiation treatment before surgery, you might be more likely to have complications.
Getting a flap reconstruction right away can lower the chance of serious problems, but it doesn’t remove all risk. That’s why, before the operation, it’s important for patients to understand all possible problems that could come up.
While losing part or all of a surgical flap can happen, it’s a pretty low-risk complication. This is because pedicled flaps (flaps that stay connected to their original blood vessels) that are often used in this type of surgery are pretty strong. With the right planning before surgery and careful attention to avoid putting strain on the flap or bending or twisting the blood vessels, most flap problems can be avoided.
For some people, especially those who underwent a surgery called pelvic exenteration, major issues like tissues sticking out of the abdomen (evisceration) or deep pelvic abscess (a pocket of pus in the pelvis) can occur. To prevent these, surgeons often use healthy, well-blood-supplied tissue to fill any empty spaces and replace tissue, instead of just stitching the area tightly closed.
What Else Should I Know About Vulvar-Vaginal Reconstruction?
Defects in the female genital area, specifically the vulva and vagina, can occur due to the removal of cancerous tumors. These defects often happen when the cancer is advanced and has spread to areas around the genitals or bladder, which is a more common scenario.
Dealing with such defects can have significant mental and physical effects on the patient, as they are usually battling late-stage cancer in an incredibly personal part of their body. Lifestyle changes may also be required, even if the reconstruction surgery is successful.
The vulva and vagina are composed of specific anatomical parts. To achieve the best possible look and functionality after reconstruction, each of these parts needs to be considered individually in the plans for reconstruction.
Local skin flaps, skin and tissue moved from nearby areas, are a primary method of reconstruction for the genital area, especially when the patient hasn’t had any radiation therapy in that area. This is because the ample blood supply in the area facilitates the use of larger skin flaps.
However, when the patient has previously had radiation therapy in the pelvic area, it may become necessary to transfer tissue from distant areas of the patient’s body to achieve successful reconstruction.