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40 Resection ofTumors Involving thePelvic Girdle
455
surgical intervention. They are typically painful
due to the fact that the origins of the adductors
and sometimes hamstring muscles pull on these
areas creating micromotion, which leads to pain
with walking. The sacrum also will be in the radiation eld and is a classic location for an insufciency fracture. A radiograph can identify these
insufciency fractures but the majority require a
combination of MRI and CT to identify. Treatment
options are limited but can include a combination
of cement and screw xation. Nonoperative treatment is used for the majority of the cases.
Hardware Failure/Mechanical Complications
Background
Hardware failure in the setting of previous resection/reconstruction presents a very difcult problem [21, 22]. Outside of acute trauma, the
breakdown of xation may result from the failure
of either hardware or bone. Thus, it is imperative
to provide as robust a construct as possible at the
initial procedure to account for the weakened
state of the bony pelvis at the time of xation as
well as for potential disease progression.
Prevention
The best prevention is to consider not utilizing
hardware or reconstruction at all. Patients can in
fact do quite well with ail extremities, and in
circumstances where the host wound is high risk,
resection arthroplasty may be the more prudent
choice [23].
If reconstruction is considered, then measures
may be undertaken to minimize hardware failure
risk. Infection is a major challenge with hardware
reconstruction of pelvic defects; the use of
extended antibiotic prophlyaxis protocols and
bacteriostatic or resistant substances such as silver may help to minimize this risk. The use of
plastic surgeons to optimize soft tissue coverage
is also of utmost importance.
In resections involving the sacrum, consideration can be made for adding anterior spinal col-
umn xation in conjunction with posterior
instrumentation to minimize the risk of hardware
failure. Finally, custom 3d printed reconstructions may optimize healing to host bone-toimplant interface.
Recognition
Recognition of hardware failure can fall anywhere on a wide spectrum from the complete
breakdown of the construct to minor breakages
such as a single screw, leaving the overall construct intact. Overt structure collapse will typically be easily appreciated on plain radiographs
but, similar to the recognition of fractures as
stated in the section above, advanced imaging
should be obtained in the setting of acute trauma
or change in symptoms absent obvious signs of
hardware failure on basic imaging. However, as
opposed to the previous section, the presence of
existing hardware may obscure subsequent imaging and must be taken into account when choosing which advanced imaging modality to obtain.
Management
Management of hardware failure is often an
extremely difcult task. Treatment will typically
involve a thorough discussion with the patient
and depend on factors including the full extent of
xation degradation, the patient’s symptoms and
goals of care, overall disease prognosis, and current stage of treatment.
Pelvic Cancer Complications Involving Bone
Osteomyelitis
Background
Patients having female pelvic cancers will often
have radiation or compromise to the blood supply
to the bones of the pelvis [24–26]. This places the
area and its contents at high risk for development
of infections and/ or stulas. Additionally, compromised vascularity may predispose poor-
456
A. L. Lazarides et al.
quality bone to infection. Sequelae may include
osteomyelitis of the pelvis or abscesses in the
peripelvic region.
Prevention
Osteomyelitis is difcult to prevent, though radiation techniques that spare the bone and surgical
techniques that preserve the periosteum and
blood supply to the bone while limiting soft tissue stripping may help mitigate these problems
from arising in the future. Osteomyelitis typically occurs via hematogenous spread, direct
contiguous spread from nearby wounds or structures, or direct inoculation. It is a risk in patients
with recurrent bacteremia or sepsis, including
patients with chronic wounds near the bone,
chronic indwelling lines or immunocompromised
or diabetic patients.
Recognition
Typically, when osteomyelitis is suspected or
identied it may or may not be associated with an
abscess. Signs and symptoms of osteomyelitis
may include systemic symptoms such as fever,
hypotension, and tachycardia. Additionally, manifestations may include pain, redness and warmth,
open wounds or sinuses that probe directly to the
bone. Close evaluation is necessary to ensure
patients are not manifesting signs of sepsis, as
this may be an urgency or an emergency.
Management
It is important to recognize osteomyelitis early,
as the rst line of treatment for osteomyelitis
without abscess is antibiotics alone. In early
osteomyelitis, this is frequently sufcient. Often
times the osteomyelitis returns because the
source of the infection was not addressed. In
cases of recurrent osteomyelitis, a stula from
the urogenital or intestinal tract must be considered as this often results in a persistent uid collection bathing the area [27]. Patients can develop
abscess through the obturator foramen or under
the pubic symphysis that can eventually track
into the thigh (Fig.40.1).
The infection will not be eradicated unless the
source is removed and in chronic infection, bony
changes occur that will not resolve without surgical management [26, 28]. With pubic symphysis
osteomyelitis or septic arthritis of the pubic symphysis, a simple debridement at that location is
unlikely to resolve the issue in a previously radiated eld. Source control with debridement is the
solution that will eradicate the infection. A simple
washout or mechanical debridement with limited
resection of the pubic symphysis may not be
enough. If the patient has had radiation or has had
long-standing osteomyelitis a radical debridement
may be necessary, which means removing the
unhealthy or dead tissue in the radiated eld and
can require cutting back to the pubic root and
ischial tuberosity to nd healthier bleeding bone.
This resection often requires a plastics surgery
team to place a ap and possible mesh to limit the
hernia likely created. Sometimes the anterior,
inner(medial), and posterior thighs require debridement because an infection can track along the
adductor or hamstring muscles into the distal thigh
(Fig.40.1). Often times after osteomyelitis resection a wound vac can be placed in the front of the
pelvis to temporize and allow the remaining tissue
to declare itself healthy enough to remain. At the
initial presentation of pubic symphysis osteomyelitis, an aspiration for cultures or even a bone culture with a biopsy can help direct appropriate
antibiotics. As long as the patient is stable a drain
can be placed in the abscess or uid collection as a
temporizing method, which allows the appropriate
surgical services to formulate a plan to treat the
infection. Operating immediately in a stable patient
can lead to nonhealing draining wounds that complicate closure at a later time. The key to treating
these infections is to remove the source, and some
stula tracts may not be elongated pathways that
track to the bone at all but rather are plastered to
the side of the bone. If the anterior pelvic bone is
resected patients can usually stand immediately,
although ambulation can be difcult due to the
detachment of the adductors (Fig.40.2). Depending
on age and deconditioning, the patient will require
a walker for about 3 to 4months and typically will
not gain a lot of function or strength back till about
6–8months. However, patients can expect to get
back to work and limited athletic activities such as
golf. Typically, patients with long standing osteomyelitis develop pubic symphysis instability
which causes pain due to the infection degrading
the ligaments ventrally. Patients typically look bet-
40 Resection ofTumors Involving thePelvic Girdle
457
Fig. 40.1 A 51-year-old female who was diagnosed with
stage IIb squamous carcinoma of the cervix in 2006 and
treated with chemotherapy and radiation with recurrence
in 2007 and had anterior pelvic exenteration and ileal
colic continent urinary diversion, plastic ap neovagina,
en bloc hysterectomy and aps, and 4months later a modied radical vulvectomy with lymphadenectomy and aps
Fig. 40.2 A 50-year-old female with recurrent squamous cell carcinoma of vagina previously treated with chemotherapy and radiation that involved the need for anterior bone resection (radical) and ap
with evidence of colonic vaginal stula with subsequent
wound issues with 50.4 Gy of postoperative radiation.
Fistula identied in 2020 later developing osteomyelitis
and discharge in 2021 that progressed to bilateral leg
abscess seen on MRI with associated gas seen on CT and
stula seen on both sagittal CT and MRI
458
A. L. Lazarides et al.
ter 1–2days after surgery because the infection has
been removed.
Radiation Complications
ofPelvicBone
Radiation Osteitis
Radiation osteitis is a complication encountered
in female pelvic cancer patients who have
required radiation during part of their treatment.
The bone can become inamed and develop a
reaction that mimics osteomyelitis. If the periosteum is irritated enough it can be signicantly
painful. This is generally benign and a selflimiting condition.
Recurrent andMetastatic Lesions
Background
Women with soft tissue pelvic cancer can develop
local metastasis to the pelvis through either
hematogenous or lymphatic spread.
Prevention
Appropriate treatment.
Recognition
Patients will typically present with pain, neurologic changes or diminished functional capacity/
activity. Systemically they may manifest symptoms of increased bone resorption and turnover
including hypercalcemia, GI discomfort, kidney
stones, and mental status changes.
Appropriate cancer specic staging and surveillance will typically be sufcient. Evaluation
should begin with radiographs of the area of concern. In circumstances of uncertainty, advanced
imaging, including an MRI with and without
contrast, may help to clarify bony involvement by
metastatic disease.
Management
Single or multiple lesions in the pelvis can be
treated with radiation and/or surgery.
There are some locations of the pelvis that can
be affected by metastases and not affect the loadbearing aspect of the bony pelvis. These lesions
typically will be treated with radiation.
The portions of the pelvis that are required to
be structurally sound in order to walk are the pelvic ring and acetabulum. These portions of the
bone include S1, S2, the posterior column and
superior dome of the acetabulum and the sciatic
buttress from the acetabulum into the bone of the
sacroiliac joints. These sections if affected by
disease often require some form of surgical treatment in combination with radiation. If a single
lesion (either metastasis or local recurrence) is
identied and it has been some time since the
index treatment with no other metastasis then
surgical resection can be considered(Figs. 40.3
and 40.4). If there is early local recurrence or
metastasis to the bone with or without distant
metastasis, removal down to residual micro-
Fig. 40.3 A 60-year-old female with a history of vulvar
cancer resected in 2016 with recurrence involving inferior
and superior rami and adjacent soft tissue requiring
hemipelvectomy and compassionate reconstruction in
2020 that allows her to walk
40 Resection ofTumors Involving thePelvic Girdle
459
Fig. 40.4 A 59-year-old female with uterine/endometrial
cancer who had a resection and vaginal radiation in 2012
who developed a local recurrence with no other metasta-
Fig. 40.5 60-year-old female with a history of well-differentiated endometrial adenocarcinoma resected in 2016 with
pathologic fracture due to high-grade recurrence with large soft tissue component involving the iliac vessels
scopic disease and stabilization of the weightbearing bone is undertaken (Fig.40.5).
ses and underwent resection and custom reconstruction in
2020 who walks with a cane and is disease free 3years
from surgery
men. Techniques to spare surrounding tissues
may help to mitigate some of this risk. In younger
patients, the long-term morbidity of radiotherapy
should be weighed carefully against the need for
Radiation Associated Sarcomas
local control and overall survival from the primary cancer.
Background
The female pelvic cancer patient often has had a
combination of surgery, radiation and chemotherapy to address the primary site of cancer. Having
radiation can, for a small subset of patients, lead
to the development of a radiation-associated sarcoma in the pelvis. This typically occurs around
7–10 years out and can be seen as early as
3–4years out from radiation [29].
Prevention
Preventing radiation-associated sarcomas can be
difcult if treatment of the initial cancer necessitates radiotherapy as part of the treatment regi-
Recognition
It is important to understand this phenomenon
because surgeons may think a recurrence has
happened and not recognize that an entirely different cancer has formed that requires a different approach for treatment. An open biopsy
would be inappropriate in this scenario with a
sarcoma as it could signicantly affect the morbidity of the resection due to contamination and
if a radiation- associated sarcoma is being considered, appropriate and early referral to a specialist should be made by sending it to the
appropriate orthopaedic oncologist or sarcoma
surgeon.
460
A. L. Lazarides et al.
Fig. 40.6 A 49-year-old female with cervical cancer
treated in 2004 with radiation and developed a mass in
2017 thought to be recurrence but was found to be consis-
Management
These are treated with some form of adjuvant
treatment and surgery with the majority undergoing resection alone. If the tumor involves bone
the orthopaedic oncologist can resect the affected
parts of the pelvis (i.e., a hemipelvectomy) and
reconstruct parts of the pelvis that are needed to
ambulate (Fig.40.6). Parts of the pelvis can be
resected that do not need to be reconstructed. The
bony pelvis itself serves as a way to contain the
viscera and serves as a foundation for weight
bearing and muscle origins to ambulate. If the
front of the pelvis, not involving the joint, is
affected and resected and not replaced the plastic
surgery team can place a ap and mesh with the
aid of suture anchors to limit the development of
a hernia. If the hip joint is involved and is resected
it can be reconstructed with both custom and
compassionate use devices.
tent with radiation-associated sarcoma that underwent
resection and reconstruction with allograft and hip
reconstruction
Wound Healing Considerations
Background
Surgical wound complications are a common
outcome of oncologic surgery [1–4]. Multiple
factors may contribute to this such as a patient’s
nutritional/medical status, previous surgeries in
the same location, radiation, prolonged surgical
time, and type and timing (staged vs. primary
closure) of plastic surgery intervention.
Prevention
Prevention of wound dehiscence and supercial
infection is the rst and foremost important part
of care. It is important to consider all aspects,
such as discussing with patients their periopera-
40 Resection ofTumors Involving thePelvic Girdle
461
tive nutrition. One purpose of ERAS (enhanced
recovery after surgery) is to increase the perioperative nutritional intake. Proper wound care
education also needs to be discussed with the
patient prior to surgery and postoperatively.
Previous surgeries and radiation to the surgical site prior to a hemipelvectomy do increase the
risk of wound breakdown [30, 31]. Typically,
these surgeries and treatments were done in the
past with no thought of the patient possibly needing a large pelvic reconstruction in the future.
Carefully planning surgical incision and reconstruction with the team is imperative to optimize
soft tissue closure over the reconstruction, to
decrease tension on the soft tissues.
Attention to the manor of closure also needs to
be addressed to decrease adverse outcomes.
Patients can be primarily closed without plastic
reconstruction versus complex closure with large
aps to ensure plenty of muscular and soft tissue
coverage between the implant and subcutaneous
tissue. Again, decreasing tension at surgical incisions and soft tissue coverage are key. At times an
incisional wound vac can be used to protect the
area from drainage that may help decrease maceration of the incision edges during the healing
process. The use of creams or ointments on the
surgical areas are not recommended as the edges
of skin become swollen. The powder is not recommended as it often becomes a paste.
Recognition
As with most complications related to surgery,
early recognition is important. Frequent wound
checks while the patient is recovering in the hospital and checks during the rst 6–8 weeks are
important. Most commonly skin healing fails
between weeks 6–8 regardless of how the skin
looks at week 4. Patient’s incisions can be followed in person and via serial photographs.
Recommendations for follow-up will depend
on the type of closure. The common areas for
breakdown are at the apexes of the incision and
incisions that are in soft tissue creases and under
skin folds due to skin tension and increased moisture, respectively.
Educating the patient on signs and symptoms
of early breakdown when they are a recovering
outpatient is also key, and patients should be
instructed to contact the surgical team at rst
sight of concern. An enlarging uid collection
(seroma/hematoma), redness, warmth, or new/
increased active drainage, a large area of eschar
sloughing off the incision, and darkening of the
skin (necrosis) should be addressed or watched
closely for changes. Early use of antibiotics is
warranted especially in patients that have had
radiation in the past.
Management
Depending on how the wound is breaking down,
different methods can be used to address the
problem. All patients who have had a history of
radiation should be on prophylactic oral antibiotics until their wound is healed.
Simple and small areas of wound dehiscence
can usually be addressed with a drying agent
such as Betadine wash BID, leave dry to air, then
cover with light nonstick dressing and paper tape.
Larger and deeper areas can be cared for with
wet-to-dry dressings.
Areas of soft tissue necrosis are often watched,
and the large eschar is not removed until it declares
itself. Evaluation by the surgeon is needed to
determine if bedside debridement followed by
wound care or surgical intervention is needed.
Large wound dehiscence with metal prostheses exposed requires immediate attention via the
oncologic orthopaedic surgeon and plastic surgery. Cultures should also be done intraoperatively with ID consult and IV antibiotics.
References
1. Schwab JH, Healey JH, Rose P, Casas-Ganem J,
Boland PJ.The surgical management of sacral chordomas. Spine (Phila Pa 1976). 2009;34(24):2700–4.
2. Zeifang F, Buchner M, Zahlten-Hinguranage A,
Bernd L, Sabo D.Complications following operative
treatment of primary malignant bone tumours in the
pelvis. Eur J Surg Oncol. 2004;30(8):893–9.
3. Tunn PU, Fehlberg S, Andreou D, Kettelhack
C. Endoprosthesis in the operative treatment of
bone tumours of the pelvis. Z Orthop Unfall.
2007;145(6):753–9.
4. Capanna R, van Horn JR, Guernelli N, Briccoli A,
Ruggieri P, Biagini R, et al. Complications of pel-
462
A. L. Lazarides et al.
vic resections. Arch Orthop Trauma Surg (1978).
1987;106(2):71–7.
5. Jakubowicz M. Topography of the femoral nerve
in relation to components of the iliopsoas muscle in human fetuses. Folia Morphol (Warsz).
1991;50(1–2):91–101.
6. Kalinin RE, Suchkov IA, Klimentova EA, Shanaev
IN. Clinical anatomy of deep femoral vessels in
the area of femoral triangle. Angiol Sosud Khir.
2021;27(1):17–23.
7. Ribeiro FS, Bettencourt Pires MA, Silva Junior
EX, Casal D, Casanova-Martinez D, Pais D, et al.
Rethinking sciatica in view of a bilateral anatomical variation of the sciatic nerve, with low origin
and high division: historical, anatomical and clinical
approach. Acta Medica Port. 2018;31(10):568–75.
Epub 20181031
8. Eastlack J, Tenorio L, Wadhwa V, Scott K, Starr A,
Chhabra A. Sciatic neuromuscular variants on MR
neurography: frequency study and interobserver performance. Br J Radiol. 2017;90(1079):20170116.
Epub 20170822.
9. Schraffordt SE, Tjandra JJ, Eizenberg N, Dwyer
PL. Anatomy of the pudendal nerve and its terminal branches: a cadaver study. ANZ J Surg.
2004;74(1–2):23–6.
10. Yoshida T, Nakamoto T, Kamibayashi T.Ultrasoundguided obturator nerve block: a focused review on
anatomy and updated techniques. Biomed Res Int.
2017;2017:7023750. Epub 20170209.
11. Hasija R, Kelly JJ, Shah NV, Newman JM, Chan
JJ, Robinson J, et al. Nerve injuries associated
with total hip arthroplasty. J Clin Orthop Trauma.
2018;9(1):81–6. Epub 20171028.
12. Malone DL, Hess JR, Fingerhut A.Massive transfusion practices around the globe and a suggestion for
a common massive transfusion protocol. J Trauma.
2006;60(6 Suppl):S91–6.
13. Tang X, Guo W, Yang R, Tang S, Ji T.Risk factors for
blood loss during sacral tumor resection. Clin Orthop
Relat Res. 2009;467(6):1599–604. Epub 20080910.
14. Yoo TK, Min SK, Ahn S, Kim SY, Min SI, Park YJ,
et al. Major vascular injury during nonvascular surgeries. Ann Vasc Surg. 2012;26(6):825–32. Epub
20120622.
15. Moran D, Zadnik PL, Taylor T, Groves ML, Yurter
A, Wolinsky JP, et al. Maintenance of bowel, bladder, and motor functions after sacrectomy. Spine J.
2015;15(2):222–9. Epub 20140906.
16. Hammer N, Hoch A, Klima S, Le Joncour JB,
Rouquette C, Ramezani M. Effects of cutting the
sacrospinous and sacrotuberous ligaments. Clin Anat.
2019;32(2):231–7. Epub 20181121.
17. Guo Y, Palmer JL, Shen L, Kaur G, Willey J, Zhang T,
etal. Bowel and bladder continence, wound healing,
and functional outcomes in patients who underwent
sacrectomy. J Neurosurg Spine. 2005;3(2):106–10.
18. Rose PS, Sciubba DM. Technique of oncologic
sacrectomy. In: Sciubba DM, editor. Spinal tumor
surgery: a case-based approach. Springer; 2019.
19. Wellings EP, Houdek MT, Owen AR, Bakri K,
Yaszemski MJ, Sim FH, etal. Comparison of free vascularized bular aps and allograft bular strut grafts
to supplement spinopelvic reconstruction for sacral
malignancies. Bone Joint J. 2021;103-B(8):1414–20.
20. Chung YK, Lee YK, Yoon BH, Suh DH, Koo
KH.Pelvic insufciency fractures in cervical cancer
after radiation therapy: a meta-analysis and review. In
Vivo. 2021;35(2):1109–15.
21. Fisher NE, Patton JT, Grimer RJ, Porter D, Jeys L,
Tillman RM, etal. Ice-cream cone reconstruction of
the pelvis: a new type of pelvic replacement: early
results. J Bone Joint Surg Br. 2011;93(5):684–8.
22. Fujiwara T, Medellin Rincon MR, Sambri A, Tsuda
Y, Clark R, Stevenson J, et al. Limb-salvage reconstruction following resection of pelvic bone sarcomas involving the acetabulum. Bone Joint J.
2021;103-B(4):795–803.
23. Beadel GP, McLaughlin CE, Aljassir F, Turcotte RE,
Isler MH, Ferguson P, et al. Iliosacral resection for
primary bone tumors: is pelvic reconstruction necessary? Clin Orthop Relat Res. 2005;438:22–9.
24. Micha JP, Goldstein BH, Rettenmaier MA,
Caillouette JT, Fee MJ, Brown JV 3rd. Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical
carcinoma. Gynecol Oncol. 2006;101(2):349–52.
Epub 20060126.
25. Ambrosini F, Zegna L, Testino N, Vecchio E, Mantica
G, Suardi N, et al. Management of osteomyelitis of
the pubic symphysis following urinary stula in
patients with radiation-induced urethral strictures
after prostate cancer treatment. Cent European J Urol.
2022;75(3):284–9. Epub 20220916.
26. Dudareva M, Ferguson J, Riley N, Stubbs D, Atkins
B, McNally M. Osteomyelitis of the pelvic bones:
a multidisciplinary approach to treatment. J Bone Jt
Infect. 2017;2(4):184–93. Epub 20171009.
27. Mandava A, Koppula V, Sharma G, Kandati M,
Raju K, Subramanyeshwar RT.Evaluation of genitourinary stulas in pelvic malignancies with etiopathologic correlation: role of cross sectional
imaging in detection and management. Br J Radiol.
2020;93(1111):20200049. Epub 20200615.
28. Gupta S, Zura RD, Hendershot EF, Peterson
AC. Pubic symphysis osteomyelitis in the prostate
cancer survivor: clinical presentation, evaluation, and
management. Urology. 2015;85(3):684–90.
29. Lazarides AL, Burke ZDC, Gundavda MK, Novak R,
Ghert M, Wilson DA, etal. How do the outcomes of
radiation-associated pelvic and sacral bone sarcomas
compare to primary osteosarcomas following surgical resection? Cancers (Basel). 2022;14(9). Epub
20220427.
30. Gu Q, Wang D, Cui C, Gao Y, Xia G, Cui X.Effects of
radiation on wound healing. J Environ Pathol Toxicol
Oncol. 1998;17(2):117–23.
31. Ogura K, Boland PJ, Fabbri N, Healey JH.Rate and
risk factors for wound complications after internal
hemipelvectomy. Bone Joint J. 2020;102-B(3):280–4.
Pelvic Reconstructive Procedures
JulianPribaz andKristenWhalen
41
Background
Trauma and extensive extirpative gynecologic,
urologic and/or colorectal surgery for malignancy can result in large pelvic defects that
require complex soft tissue reconstruction by
plastic surgeons.
It should be remembered that this is a team
surgery and attention to detail during the extirpative and reconstructive phases are equally important to maximize patient outcomes and prevent
complications. The extirpative surgeon must
strive for complete tumor excision with clear
margins, have minimal blood loss, and avoid
fecal and urinary contamination. This chapter
will focus on optimizing the reconstructive
aspects of this team surgical event.
The goals of female pelvic reconstructive surgery are to provide durable external soft tissue
coverage, obliterate internal dead space, and
restore aesthetics and sexual function when
possible.
Options for pelvic reconstruction are numerous and include primary closure, skin grafts, and
aps. Local and regional pedicled aps such as
the vertical rectus abdominis myocutaneous ap,
J. Pribaz (*) · K. Whalen
Department of Plastic Surgery, University of South
Florida Morsani College of Medicine,
Tampa, FL, USA
e-mail: jpribaz@usf.edu; kswhalen@usf.edu
omental ap, gracilis ap, Singapore ap, other
thigh aps, and gluteal aps are the mainstay of
pelvic reconstruction. Distant free tissue transfer
can be considered when locoregional donor sites
are not available, although this is exceedingly
rare [1, 2].
Flap reconstruction helps decrease complications compared to primary closure and skin grafting because it provides healthy, well-vascularized
tissue (which enables delivery of antibiotics to
this unfavorable milieu), obliterates dead space
and decreases tension on the skin closure [3, 4].
Primary closure following abdominoperineal
resection or pelvic exenteration is more likely to
have delayed wound healing which prolongs
patients’ recovery, negatively affects quality of
life, and delays adjuvant therapy [4].
The choice of ap reconstruction is determined by the location, size and depth of the
defect, the availability of donor tissues, and the
goal of reconstruction [5–7]. Multiple aps may
be necessary for composite reconstruction of
extremely large defects or for vaginal reconstruction [7–9].
There are several inherent challenges in
reconstructing pelvic defects. This unique anatomic area is dependent, exposed to external
pressure and shear forces, and is difcult to keep
clean due to moisture, high bacterial counts, and
contamination from feces and/or urine [6, 9, 10].
Many of these patients have a history of radiation which results in decreased vascularity and
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_41
463
464
J. Pribaz and K. Whalen
pliability of local tissues. Additionally, patients
may be elderly and debilitated, with poor nutritional status and other co-morbidities. These factors all contribute to a poor wound-healing
environment [6].
Complications after pelvic reconstructive sur-
gery are common and include:
• Wound dehiscence and delayed wound
healing.
• Fluid collection (hematoma, seroma).
• Infection.
• Partial or total ap loss.
• Fistula.
Donor site morbidity can occur as well, spe-
cically abdominal bulge or hernia formation
following rectus abdominis aps and cellulitis
and uid collections following thigh aps [1, 11].
In general, the vertical rectus abdominis myocutaneous ap has a lower complication rate over
thigh and gluteal based aps [4, 11]. However,
certain clinical situations including patients with
prior abdominal surgeries, morbid obesity, hernias, or ostomy placement through both rectus
muscles may preclude the use of abdominalbased aps.
The use of perforator aps such as deep infe-
rior epigastric perforator ap, anterolateral thigh
ap, gluteal perforator ap, or perineal perforatorbased island aps that spare muscle have reduced
donor site morbidity [4, 12]. In general, donor
sites should be carefully chosen keeping complication prole and possible future surgical needs
in mind [7].
Overall complication rates after pelvic defect
reconstruction with aps are high, nearing 40%
[13]. This is somewhat attributable to the
increased co-morbidities of patients requiring
extensive pelvic resections and reconstruction.
Preparedness on behalf of the reconstructive surgeon is essential in anticipating and managing
complications in this high-risk patient population. One must recognize settings that predispose
patients to potential complications such as previous failed procedures, trauma, and extensive
radiation damage and adjust the reconstructive
plan accordingly.
While the rst reconstructive option should
have the most reliable and predictable outcome,
some aps will invariably fall short. The surgeon
must critically analyze why a complication
occurred and optimize contributing risk factors.
Lastly, one must have several backup plans, or
lifeboats, and consider these during the initial
operation so as not to burn bridges that may be
needed in the future. This is where surgeon experience and judgment are invaluable.
Prevention
Prevention and mitigation of complications in
this difcult group of patients should be considered during ALL phases of treatment, namely
pre-, intra- and postoperatively.
Preoperative
Thorough preoperative evaluation of patients is
critical in planning the optimal reconstructive
surgery to minimize complications from the outset. A detailed history is performed to ascertain
the patient’s medical and surgical history, as well
as treatment goals including the desire for sexual
function. Modiable patient risk factors, such as
obesity, tobacco use, anemia, diabetes, clotting
disorders, and malnutrition, should be identied
and optimized prior to surgery [2, 8, 11, 14].
When treating high-risk patients, it is important
to counsel them appropriately about outcome
expectations [11].
Patient examination should focus on anatomic
features involved, evidence of radiation damage,
and availability of donor sites including areas of
excess soft tissue, preexisting scars, undermining, ostomies, and hernias. If the vascular integrity of potential donor sites is in question, a
handheld Doppler exam or computed tomography angiography can be performed
preoperatively.
Close communication with the extirpative surgeons regarding the expected extent of resection
and diversion of the urogenital or anorectal system is helpful in developing a reconstructive