Bladder Outlet Obstruction as a Cause for Late Total Flap Failure in Pelvic Reconstruction with a VRAM

Abstract

Background A 67-year-old man presented with abrupt failure of a pedicled vertical rectus abdominus myocutaneous (VRAM) flap 13 days postoperatively.

Methods The patient underwent pelvic reconstruction with a pedicled VRAM flap following sacral chordoma and abdominoperineal resection. The flap remained well perfused and viable until postoperative day 13, at which point the patient was noted to become systemically unwell with fever, chills, and abdominal pain. This clinically coincided with prompt arterial and venous insufficiency of the VRAM flap.

Results Computed tomography of the abdomen was ordered to rule out a pelvic collection and revealed an inflated Foley catheter in the bulbar urethra. This was associated with marked distention of the bladder and bilateral hydronephrosis. Direct compression of the deep inferior epigastric pedicle by the bladder neck was noted.

Conclusion The case highlights the importance of considering bladder outlet obstruction and subsequent distention as a cause of pedicle compression and VRAM flap failure following pelvic reconstruction.

Keywords

pelvic reconstruction - perineal reconstruction - pelvic exenteration - VRAM - abdominoperineal resection - flap failure

• References

• 1 Touran T, Frost DB, O’Connell TX. Sacral resection. Operative technique and outcome. Arch Surg 1990; 125 (07) 911-913
• 2 McAllister E, Wells K, Chaet M, Norman J, Cruse W. Perineal reconstruction after surgical extirpation of pelvic malignancies using the transpelvic transverse rectus abdominal myocutaneous flap. Ann Surg Oncol 1994; 1 (02) 164-168
• 3 Khoo AK, Skibber JM, Nabawi AS. , et al. Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery. Surgery 2001; 130 (03) 463-469
• 4 Mathes SJ, Feng LJ, Hunt TK. Coverage of the infected wound. Ann Surg 1983; 198 (04) 420-429
• 5 Baird WL, Hester TR, Nahai F, Bostwick III J. Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Arch Surg 1990; 125 (11) 1486-1489
• 6 Anthony JP, Mathes SJ. The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure. Arch Surg 1990; 125 (10) 1371-1376
• 7 Devulapalli C, Jia Wei AT, DiBiagio JR. , et al. Primary versus flap closure of perineal defects following oncologic resection: a systematic review and meta-analysis. Plast Reconstr Surg 2016; 137 (05) 1602-1613
• 8 Ferenschild FT, Vermaas M, Hofer SO, Verhoef C, Eggermont AM, de Wilt JH. Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. World J Surg 2005; 29 (11) 1452-1457
• 9 Galandiuk S, Jorden J, Mahid S, McCafferty MH, Tobin G. The use of tissue flaps as an adjunct to pelvic surgery. Am J Surg 2005; 190 (02) 186-190
• 10 Jeon H, Yoon ES, You HJ, Kim HS, Lee BI, Park SH. Comparison of the complications in vertical rectus abdominis musculocutaneous flap with non-reconstructed cases after pelvic exenteration. Arch Plast Surg 2014; 41 (06) 722-727
• 11 Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate VRAM flap reconstruction of irradiated abdominoperineal resection defects. J Am Coll Surg 2008; 206: 694-703
• 12 Radice E, Nelson H, Mercill S, Farouk R, Petty P, Gunderson L. Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies. Br J Surg 1999; 86 (03) 349-354
• 13 Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg 2004; 52 (01) 22-26
• 14 Bakx R, van Lanschot JJ, Zoetmulder FA. Inferiorly based rectus abdominis myocutaneous flaps in surgical oncology: indications, technique, and experience in 37 patients. J Surg Oncol 2004; 85 (02) 93-97
• 15 Horch RE, Hohenberger W, Eweida A. , et al. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis 2014; 29 (07) 813-823
• 16 Chessin DB, Hartley J, Cohen AM. , et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005; 12 (02) 104-110
• 17 Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009; 16 (01) 68-77