Case 47 Perineal Reconstruction
47.1 Description
Wide resection of perineal contents including mons pubis, vulva, and clitoris
Resection area extends to urethral and vaginal orifices
47.2 Work-Up
47.2.1 History
Personal history of cancer and prior related treatments or surgeries
Family history of cancer
Prior radiation treatment or exposure
Prior urinary or fecal incontinence
47.2.2 Physical Examination
Evaluate surgical defect and classify as partial (anterior, lateral, posterior, upper two-thirds) or circumferential/total loss of vagina
Examine abdomen and lower extremities to assess possible reconstructive options
Evaluate for dead space, hernias, fistulae, prolapse, infection, devascularized tissue, and regional lymphadenopathy
Assess radiation effects to surrounding tissues
Evaluate need for ostomy after resection
47.2.3 Pertinent Imaging or Diagnostic Studies
Assess nutritional status: Transferrin, albumin, and prealbumin levels
Computed tomography (CT) scan to evaluate nodal spread in the pelvis
Positron emission tomography (PET) scan has improved sensitivity to detect small nodal metastases
47.3 Consultations
Oncologic surgeon: Wide local excision with pelvic lymph node dissection, as indicated
Radiation oncologist: Evaluation for postoperative or intraoperative radiation therapy, including possible placement of brachytherapy catheters at time of tumor resection
Medical oncologist: Consider need for neoadjuvant or postoperative chemotherapy
May consider involvement of psychiatrist or sex therapist
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