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Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction

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  • SCC vulva
  • F. l. flap
  • Transcript

    • 1. Vaginal & Genitourinary Reconstruction Sanjay Sharma, M.D. Jeffrey Friedman, M.D. Rahul Nath, M.D. Tue Dinh, M.D.
    • 2. Outline
      • Embryology
      • Vaginal Reconstruction
        • Congenital defects
        • Acquired defects
      • Penile/Scrotal Reconstruction
        • Cavernous nerve reconstruction
      • Other entities of GU reconstruction
    • 3. Anatomy/Embryology
    • 4. Anatomy/Embryology
      • Genital and urinary tracts intimately associated in development
      • All 3 germ layers involved
        • Mesoderm
          • Nephrotic system, Wolffian Ducts, Mullerian Ducts, Gonads
        • Endoderm
          • Cloaca, Cloacal membrane
        • Ectoderm
          • External Genitalia
    • 5. Anatomy/Embryology
      • Male
        • Wolffian Ducts
          • Epididymis
          • Vas deferens
          • Seminal vesicles
          • Mullerian ducts regress
    • 6. Anatomy/Embryology
      • Female
        • Mullerian Ducts differentiate into
        • Fallopian tubes
        • Uterus
        • Upper portion of vagina
        • Wolffian tubes degenerate
    • 7.
      • 2 pairs genital ducts Males - mesonephric (Wolffian) Females - paramesonephric (Mullerian)
    • 8. External Genitalia
      • 11 th week
      • Genital tubercle
      • Labioscrotal swellings
      • Urethral folds
      • Male- fuse proximal-distal (central raphe)
    • 9. Congenital Defects
      • Vaginal Agenesis
        • Mayer-Rokitansky Syndrome
      • Ambiguous Genitalia
        • Congenital Adrenal Hyperplasia
        • Mixed Gonadal Dysgenesis
        • Male pseudohermaphroditism
    • 10. Ambiguous Genitalia
    • 11. Bladder Exstrophy
      • Absence of a portion of lower abdominal wall and anterior vesical wall
      • Thought to be cleft of lower trunk, pubic diastasis
      • Failure of cloacal membrane to allow ingrowth of mesoderm—leads to rupture
      • Incidence: 1:25,000 to 1:40,000 live births
      • Severe genitourinary defect
    • 12. Bladder Exstrophy
      • Surgical Correction
        • Diversion of urinary stream
        • Closure of exstrophied bladder
        • Reconstruction of external genitalia
          • Epispadias, release of chordee
          • Cleft clitoris
          • Diastasis of labia minora
          • Mons pubis
    • 13. Rokitansky Syndrome
      • Congenital absence of the Vagina
      • 1:4000
      • Defect mullerian duct development
      • Partial or complete vaginal agenesis with renal abnormalities
      • Usually normal external genitalia
    • 14. Rokitansky Syndrome
      • 46 XY karyotype
      • Usually present 14-16
      • 1 ° amenorrhea
      • Rudimentary uterus, normal ovaries
      • Baseline IVP for preop evaluation
    • 15. Reconstruction
      • Frank Method
      • Bowel Flaps
      • McIndoe Procedure
      • Vulvovaginoplasty
      • Musculocutaneous flaps
    • 16. Preoperative Evaluation
      • Mature individual, post puberty
      • Compliance of patient/family—stents
      • History & Physical
        • Rectal examination
        • C-spine
        • Buccal smear
      • Baseline U/S, IVP
    • 17. Frank Method
      • Serial progressive dilatation & pressure
      • Rigid dilator slowly expanded into rudimentary vagina
      • Placed between rectum and urethra
      • painful
      • 12-24 months
      • High failure due to non-compliance
    • 18. Bowel Flaps
      • Small bowel or colon
      • Laparotomy and associated complications
      • Large amount of mucous
      • Malodorous discharge
      • Fissures, bleeding, stenosis frequent
      • 1-2% mortality rate
    • 19. Local Flaps
      • Vulvovaginoplasy
        • Williams: labia majora infolded
        • Hwang: labia minora flaps
      • Tissue expansion
      • Musculocutanous flaps
        • Gracilis
        • Rectus
        • Posterior thigh fasciacutaeous
        • TFL
    • 20. McIndoe Technique
      • Neovagina lined with skin graft
      • Surgically created space between bladder and rectum
      • Relatively easy procedure
      • Obviates need for laparotomy
      • Gynecology assistance
    • 21. McIndoe Procedure
    • 22. McIndoe Technique
      • Patient Selection
        • Mature, 16-18 years old
        • Approaching sexual activity
        • Mature and compliant
      • Pre-operative considerations
        • Full bowel prep
        • Ememas
        • Foley catheter
        • DVT prohylaxis
    • 23. Procedure
      • STSG harvest
      • Suprapubic region
      • Tumescence
      • Alternative sites: lateral thigh, buttock
      • Single sheet, depth 0.015 " -0.018"
    • 24. STSG Donor Sites Tumescence for uniform Surface skin graft
    • 25. Procedure
      • Perineal Phase
      • Rectovesicular space between bladder and rectum
      • Avoid straight line incisions at introitus
      • Vaginal stent used to guide depth of space
      • ABSOLUTE HEMOSTASIS
    • 26. Procedure
      • Graft Fixation:
      • Dermal side out
      • Affix to mold, non linear suture line
      • Use of Tisseel or similar fibrin glue
      • Suture labia together
      • Keep in hospital 1 week
    • 27.  
    • 28.  
    • 29. Graft Fixation , dermal side out
    • 30.
      • Spiral Suture Line
    • 31.  
    • 32. Avoid straight line incisions at introitus
    • 33.  
    • 34. Rectovesical Space Peritoneal reflection (15 cm)
    • 35. Meticulous hemostasis is essential
    • 36.  
    • 37.  
    • 38. Suture labia together, prevents extrusion
    • 39.  
    • 40. Procedure
      • Post-operative care
      • Strict bedrest
      • Foley catheter
      • Anti-motility agent—lomotil
      • Return to OR 1 week for stent removal
      • Assessment of graft take, re-graft if necessary
      • Replace stent
    • 41. Check graft at POD #7 Regraft if >2 cm necrosis
    • 42. Post-operative care
      • Continue mold 3-6 months
      • Sexual activity resume in 6 weeks
      • Mucosalization/sensitivity
      • Yearly followup
      • Functional success ~90%
      • Complications: fistula, stenosis, dyspareunia, graft failure, SCC (15 years)
    • 43. Acquired Defects of GU System
    • 44. Acquired Defects of GU System
      • Extensiveness
        • Defects of vulvoperineal surface
        • Defects of scrotal skin
        • Defects of vaginal vault
        • Defects of penis
        • Combined perineum and pelvic support structures
        • Other—pelvic brim, urethra, sphinter mech
    • 45. Preoperative Evaluation
      • Define goals of reconstruction
        • Wound healing
        • Functional restoration
        • Individualize for each patient—70 yo vs 20 yo
      • Condition of surrounding tissue
        • Need for adjuvent radiotherapy
        • Previous pelvic surgery
      • Physical examination
        • Groin pulses
        • Other incisions around planned flaps
    • 46. Assessment of Defect
      • Post oncologic
        • Evaluation of size, missing tissue, donor vessels
        • Planning of routes of flap transfer
        • Intrapelvic—width of pelvis, height
        • Body habitus—thick, bulky flaps
      • Trauma
        • Zone of injury
        • Local-regional tissues
    • 47. Vulvoperineal Surface
      • Cancer resections
        • Skinning vulvectomy
        • Wide local excision
        • Loss of skin, subcutaneous tissue
    • 48. Vulvoperineal Surface
      • Skin grafts
        • Appropriate for unsure margins, high recurrence
        • Best in non-irradiated beds
        • Non-meshed sheet STSG vs FTSG
      • Donor site
        • Suprapubic area, injectable saline
        • Lateral thigh, gluteal area
    • 49.  
    • 50.  
    • 51.  
    • 52. Vulvoperineal Surface
      • Local Flaps
        • Irradiated tissue
    • 53. Vulvoperineal Surface
      • Laxity posterior, lateral regions
        • Small to medium defects: local rotation flaps, rhomboid
        • Larger defects: fasciocutaneous flaps, posterior thigh
      • Limit pressure in area
        • DVT prophylaxis
        • Sexual activity 6 weeks
    • 54.  
    • 55.  
    • 56.  
    • 57.  
    • 58.  
    • 59. Vaginal Vault
      • Advantages of immediate reconstruction
        • Primary healing of perineal defect
        • Decreased fluid loss
        • Reduced infection rate
        • Emotional/psychological well-being
        • Early rehabilitation
        • Future radiotherapy
    • 60. Vaginal Vault
      • Considerations
        • Patient Selection
          • Wound coverage vs functional reconstruction
        • Defect Analysis
          • Oncologic
          • Trauma
          • Entire vagina vs anterior or posterior wall
    • 61. Vaginal Vault
      • Goals of Reconstruction
      • Neovagina of sufficient depth
      • Durability, pliability
      • Provide closure of peritoneal cavity, separate bowel from pelvis
      • Minimal morbidity
    • 62. Vaginal Vault
      • Gracilis
      • Small dead space
      • Relatively thin patient
      • No associated laparotomy
      • Previous workhorse flap
    • 63. Vaginal Vault
      • Gracilis
      • Originates pubic symphysis, inserts on medial tibial condyle
      • Raised distal to proximal off adductor group
      • Medial circumflex femoral artery (Type II)
        • 8-10 cm below origin
      • Lithotomy position
    • 64. Vaginal Vault
      • Gracilis Limitations
        • Distal skin island less reliable
        • Rotation of flap dependent on pedicle
        • Thus, limits depth of vault
      • Bilateral gracilis for complete vault recon
      • Donor site issues
        • Bulge, unsightly scars
      8X15 cm skin island
    • 65. Vaginal Vault
      • Rectus Abdominus
      • Total or partial defects
      • Ease of elevation, obliterates dead space
      • Robust blood supply, resists radiation
      • Contraindications
        • Previous abdominoplasty, stoma through muscle, incisions across DIEA
    • 66. Vaginal Vault
      • Rectus Abdominus
      • Originates on pubis, inserts on ribs 5-7
      • Superior and inferior epigastric arteries (type III)
      • Harvested as inferiorly based musculo-cutaneous flap (TRAM or VRAM)
    • 67. Vaginal Vault
      • Reconstruction
        • Skin paddle designed high over line of Douglas to decrease herniation
        • Can curve superior aspect of skin paddle onto ribs for increased length in total reconstruction
        • Fold cutaneous paddle on itself or suture to vaginal wall remnant
        • Extend flap to edge of introitus to limit stricture
    • 68.  
    • 69.  
    • 70.  
    • 71.  
    • 72.  
    • 73.  
    • 74.  
    • 75. Vaginal Vault
      • Posterior Thigh Flap
        • Fasciocutaneous flap
        • Descending branch of inferior gluteal vessel
        • Great for large skin loss, total vaginal reconstructions
        • Lack of rectus abdominus
        • Sensory innervation by posterior femoral cutaneous n.
        • Bilateral harvest in lithotomy position
    • 76. Vaginal Vault Posterior Thigh Flap
    • 77. Vaginal Vault Reconstuction
    • 78. Vaginal Vault Reconstuction
    • 79. Vaginal Vault Reconstuction
    • 80. Vaginal Vault Reconstuction
    • 81. Vaginal Vault Reconstuction
    • 82. Vaginal Vault
      • Other flaps
        • Omentum with skin graft
        • Obese patients, small pelvis
        • Left gastroepiploic artery, pedicle flap
        • STSG with stent as in McIndoe
        • TFL
        • Hemivaginal or perineal defects
        • Shorter reach, donor site morbidity
    • 83. Penis and Scrotum
    • 84. Penile-Scrotal Reconstruction
      • Congenital
        • Hypospadias
        • Epispadias
      • Acquired
        • Avulsions
        • Amputations
        • Burns
        • Infections
    • 85. Penile-Scrotal Defects
      • Goals
      • acceptable appearance
      • normal micturition
      • normal sexual activity
      • Translates to a penis with adequate length, tactile sensation, sufficient rigidity
    • 86. Avulsions
      • Penis
        • Caused by deceleration injury
        • Gently clean any pedicled soft tissue and replace
        • STSG—0.020 inch
        • Lymphedematous changes arise in skin proximal to corona, therefore, remove
    • 87. Scrotal avulsions
      • Small defects
        • Debridement and direct approx
        • Highly elastic and compliant
      • Complete scrotal avulsions
        • Moist dressings over exposed testicles
        • Testes and cords buried in subcutaneous thigh pockets
        • Reconstruct scrotum by 4 weeks due to increased temp and injury to spermatogenesis
    • 88. Scrotal avulsions
      • Reconstruction
        • STSG 0.014-0.018 in
        • Flaps
          • Superolateral thigh
          • TFL
          • Rectus abdominus
          • Gracilis
          • posterior thigh
    • 89. Scrotal Defects
    • 90. Scrotal Defects
    • 91. Scrotal Defect Gracilis myocutaneous flap
    • 92. Scrotal Defect
    • 93. Coverage with Gracilis
    • 94. Algorithm
      • Penis
      • Partial Total
      • 1 ° closure STSG Meshed Thick
              • (thick) STSG STSG
              • or FTSG
    • 95. Algorithm
      • Scrotum
      • Partial Total
      • 1 ° closure Testes in pouches
      • Meshed STSG Thigh Flaps
    • 96. Penis Amputations
      • Primary reattachment
        • Bux and coworkers
        • 14 cases, no vascular anastomosis
        • Corpus spongiosum approximated
        • Corpus cavernosa sutured through tunica albuginea
        • Aspiration of corpora cavernosa 2X day
        • Survival, but shaft skin slough  STSG
    • 97. Amputations
      • Microvascular repair
        • Artery x2, vein, nerves
        • Urethra repair with urology svc
        • Approximate corpora spongiosa
        • Better outcome
    • 98. Penis Replantation
    • 99. Penis Replantation
    • 100. Penis Replantation
    • 101.  
    • 102.  
    • 103. Penis Replantation
    • 104. Penis Reconstruction
    • 105. Penile Reconstruction
      • Previous attempts multistage
        • Tubed abdominal flaps
        • Scrotal skin flaps
        • Muscle pedicle flaps
      • All generally overly bulky or lack of length
      • Best reconstructions one stage microvascular transfer
    • 106. Phallus Reconstruction
      • Goals:
        • Urinary conduit
        • Rigidity
        • Errogenous and protective sensation
        • Appearance
    • 107. Penile Reconstruction
      • Radial Forearm Free Flap
        • Tube-within-tube
        • Innervation via antebrachial cutaneous nerves to pudendal nerve
        • Limited hair
        • Vascularized urethra
        • Return of tactile, errogenous sensation
        • Rigidity via rib bone graft or prosthesis
    • 108. Radial Forearm Flap
    • 109. Radial Forearm
      • Nondominant arm
      • Allen’s test/duplex doppler
      • Do not shave arm
        • Urethral stones
      • 15 x 17 cm
      • Suprapubic catheter
    • 110.  
    • 111. Radial Forearm
      • Saphenous vein loop- temp A-V fistula
      • LAC to dorsal penile branches (Pudendal Nerve)
    • 112. Radial Forearm
      • Tactile sensation 4-6 mo
      • Prosthesis 6-9 mo
      • Achieve orgasm
      • Complications
        • Urethral stones
        • Sinuses, fistulae
        • Strictures
        • Hypopigmentation
        • Implant exposure
    • 113. Penile Reconstruction
      • Fibula sensate free flap
        • Lateral sural nerve
        • Osteocutaneous free flap
        • Concealed donor site
        • Fistula prone
        • hirsute
    • 114. Phallus Reconstruction
      • Other descriptions:
        • Ulnar forearm free flap
        • Lateral Arm flap
          • Pre-fabricated
        • “ Cricket-bat” Flap
    • 115. Gender Reassignment
      • Psychological issues
      • Physical issues
      • Multispecialty approach
      • Male to female
        • Breast aug
        • Genitalia
      • Female to male
        • Mastectomy
        • Genitalia, partial transformation
        • More difficult
    • 116. Male Potency
      • Radical prostatectomy
      • Cavernous nerves mediate erectile function
      • Sacrifice unilateral or bilateral depending on extent of tumor
      • Erectile function diminished to degree of nerve sacrifice
    • 117. Cavernous Nerve Grafting
      • Cavernous nerve grafting
        • Sural nerve harvest
        • Loupe magnification
        • Large instruments operating in a hole
        • Clips and microsuture to hold grafts
        • Epineural repair
        • Results can be enhanced with Viagra
    • 118. Unilateral Cavernous Nerve resection with Sural Nerve graft
    • 119. Nerve graft Silastic tubing Metal clip microsuture Melted end of suture Cavernous nerve repair with Sural nerve grafts Nerve graft
    • 120. Results 0% 60% Bilateral nerve grafts 21% 75% Unilateral nerve grafts Percentage of successful inter-course WITHOUT nerve grafting Percentage of successful inter-course WITH nerve grafting 200 cases to date
    • 121. Inguinal Region
      • Infected Vascular Grafts
      • Presentation
        • Local signs
        • Fever
        • Sepsis
        • Pseudoaneurysm
        • Thrombosis
        • Bleeding
    • 122. Inguinal Region
      • Vascular grafts
      • Common Flaps
      • Sartorius
      • Gracilis
      • Rectus Abdominus
      • Rectus Femoris
      • TFL
      • Vastus Lateralis
    • 123. Vascular Graft Coverage
    • 124. Gracilis Rotation Coverage
    • 125. Gracilis Rotation Flap
    • 126. Sartorius Flap
    • 127. Exposed Vascular Graft
    • 128. Sartorius Rotation Coverage
    • 129. Infections
      • Necrotizing infections
      • Fournier’s Gangrene—1882
      • Penetrates Colles fascia
      • Spreads in subDartos space, involves superficial tissues
      • Sx: pain, fever, crepitus
      • Pathophys: thrombosis of small vessels
    • 130. Fournier’ Gangrene
      • Treatment
        • Radical debridement, repeat usually necessary
        • Cultures, broad spectrum antibiotics
          • Mixed aerobic/anaerobic organisms
        • Hydrotherapy
        • Skin grafting of defect, testes coverage
    • 131. Genital Burns
      • Children more often than adults
      • Involve CPS for suspicious burns
      • Usually 1 st and 2 nd degree burns
      • Local wound care
        • Serial debridement, dressing care with Bacitracin
        • Hydrotherapy
      • 3 rd degree—excision and grafting
    • 132. Pelvic Exenteration
      • Through-and-through defects
      • Skin defect
      • Space filler to prevent bowel descent
      • Flap choice—bulky, robust blood supply
        • Posterior thigh
        • Rectus abdominus
        • Omentum—filler only, clear infection
        • Gracilis—small lower pelvis/perineum
    • 133. Pelvic Exenteration
      • Importance of vascularized flaps
        • Radiation
        • Clear infection—pelvic abscess
        • Durable tissue for sitting
        • Prevents herniation of bowel
    • 134. Pelvic/Perineum Defect
    • 135. VRAM Reconstruction
    • 136. VRAM to Pelvic Defect
    • 137. Pelvic Defects
      • Pelvic Bone defects
      • Ensure continuity of pelvic ring
        • Heavy, large non-absorbable mesh
      • Support herniation of bowel
        • Local flaps
        • TFL
        • Rectus
        • omentum
    • 138. Pelvic/Perineal Defects
    • 139.  
    • 140. Pelvic/Perineal Defects
    • 141. Final Result
    • 142. Anal Sphincter Reconstruction
      • Restoration of fecal continence
      • Rotational gracilis
      • Free gracilis with implantable stimulator
      • Inferior gluteus maximus
    • 143. Gracilis Sphincter Reconstruction
      • Pickrell 1956
        • Rt gracilis, clockwise 1 wrap
        • N=6 all continent
      • Song 1982
        • 2 wraps counterclockwise
      • Inferior Gluteus- procedure of choice
    • 144. Summary
      • Form follows function
      • Analyze the defect
        • Vaginial—partial or total
        • Penis/Scrotum—skin grafting, free tissue transfer
        • Pelvis/inguinal defects
      • Primary flaps
        • Rectus, gracilis, posterior thigh
    • 145. THANKS TO: Jeff Friedman, M.D. Rahul Nath, M.D Tue Dinh, M.D.

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