Surgical and psychosexual outcome following vaginal reconstruction with pelvic exenteration

The improved prognosis with pelvic exenterative surgery for gynecologic malignancies has resulted in increasing concern for quality of life. Sexual dysfunction is a common sequel to pelvic exenteration and vaginal reconstruction should be considered in all these patients. This case review assesses our experience with three flap techniques for neovaginal construction. Medical charts were reviewed and survivors interviewed. Fourteen patients had vaginal reconstruction with gracilis myocutaneous (n. = 5), bulbocavernosus (n. = 3) or pudendal thigh fasciocutaneous (n. = 6) flaps at the time of pelvic exenteration. Partial or incomplete necrosis occurred in four (24%) and one (7%) patient had complete flap necrosis bilaterally, followed by an entero-vaginal fistula. Two patients developed recto-vaginal fistula in association with a low rectal reanastomosis (n. = 2) and tumor recurrence (n. = 1). Eight patients, seven of whom agreed to an interview and physical examination, are alive at a median of 15.5 months following pelvic exenteration. Three have stenotic and/or foreshortened vaginas. Two patients are apareunic by choice, four have discontinued vaginal intercourse because of dyspareunia and only one patient has satisfactory coitus. Other problems include vulvar pain (n. = 3), vaginal discharge (n. = 3), neovaginal hair growth (n. = 5) and protrusion of flaps (n. = 3). The functional results in this series are disappointing and better methods of vaginal reconstruction should continue to be developed. Patients undergoing neovaginal reconstruction at the time of pelvic exenteration require careful preoperative counselling and ongoing support after surgery with special attention to sexual dysfunction.