Modified Manchester and Gracilis Flap Reconstruction of Postradiation Rectovaginal Fistula and Prolapse

INTRODUCTION: Along with obstetrical trauma, malignancy, radiation, prior surgery, and infection are risk factors for vaginal fistulas. The gracilis muscle is one of 5 hip adductors and the proximity of its vascular pedicle to the groin makes it an ideal flap for vaginal wall reconstruction. Structurally, it provides an adequate length that, once dissected, mobilized and interposed, the distal end of the muscle can reach the proximal posterior vagina without tension. Functionally, the gracilis is fairly expendable. OBJECTIVE: We present the case of a 58-year-old female with history of stage III squamous cell carcinoma of the anus status post radiation and abdominoperineal resection with surgical removal of distal colon, rectum, and anal sphincter complex, with an end colostomy. Postoperatively, she suffered from poor wound healing of her perineum and presented to urogynecology reporting poor quality of life in setting of sexual dysfunction and low self-image. Her preoperative pelvic exam noted an essentially absent posterior vaginal wall proximal to the perineal bridge, and an elongated cervix prolapsing through the defect and protruding through abdominoperineal resection wound defect at the site of her prior anus. When reduced to the vaginal canal, the leading edge of the elongated cervix extended to 2 cm beyond the hymen with Valsalva. The anterior vaginal wall was otherwise decently supported. METHODS: An interdisciplinary preoperative discussion was conducted between urogynecology, plastic surgery, and colorectal surgery for surgical planning. Taken into account were the patient’s intraabdominal surgical history, compromised integrity of postradiation tissue, apical prolapse predominantly of an elongated cervix, and importantly the patient’s primary goal of reconstructing vaginal canal for self-image and sexual function. Thus, we planned for extraperitoneal colpopexy with trachelectomy, and gracilis muscle interposition for vaginal wall reconstruction. RESULTS: At 6 months postop, she reported the highest level of improvement on the PGI-I questionnaire for sexual function. The flap mucosalized with intact sensation, and was essentially indistinguishable from the surrounding vaginal canal. Her gracilis donor site was well healed, and her pelvic exam noted good apical support. CONCLUSIONS: Long-term follow-up studies have found overall high success rates for the gracilis flap in reconstruction of rectovaginal fistulas. Risk factors for failure include chronic inflammatory conditions such as Crohn’s disease, insufficient mobilization causing dehiscence and ischemia of the gracilis, and history of radiation and multiple prior surgeries. Postoperative success may be optimized with fecal diversion, as already done in this case with end colostomy, adequate mobilization to allow tension-free inset, meticulous hemostasis to avoid hematoma, and early utilization of the gracilis flap in patients with history of radiotherapy.