Extralevator Abdominoperineal Resection (APR) for Recurrent Anal Cancer With an En Bloc Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy and Total Vaginectomy With Permanent Colostomy Formation and Pelvic Floor Reconstruction Using a Right Rectus Abdominis Flap
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This video provides a step-by-step, detailed demonstration of this extensive surgical procedure performed on a 53-year-old female patient with recurrent anal cancer after initial chemoradiotherapy. The surgical technique is thoroughly illustrated, emphasizing the importance of proper anatomical planes, multidisciplinary coordination, and reconstructive considerations.
Anal cancer is a relatively rare malignancy, accounting for approximately 2% of all digestive system cancers, with an annual incidence rate of 1–2 cases per 100,000 population.1 Primary treatment involves chemoradiation rather than surgery.2 While primary treatment with chemoradiotherapy (CRT) achieves favorable outcomes in 70–80% of cases, persistent disease and local recurrence remains a significant challenge, occurring in 20–30% of patients following primary treatment.3–6 Surgery is usually preserved for patients with persistent or locally recurrent disease. The management of persistent disease despite chemoradiation or locally recurrent anal cancer presents a complex therapeutic challenge, particularly when extensive local invasion into adjacent organs is observed.
In patients in whom gynecologic involvement is present, an en bloc resection incorporating total abdominal hysterectomy, bilateral salpingo-oophorectomy, and total radical vaginectomy may be required to achieve adequate resection margins and often an extra elevator abdominoperineal resection.
The complexity of such extensive resections necessitates careful preoperative planning and a multidisciplinary approach. The subsequent large pelvic defect created by such radical surgery presents significant reconstructive challenges. Various techniques for pelvic floor reconstruction have been described, with the rectus abdominis myocutaneous flap being one of the options for perineal reconstruction.7,8
The patient referred to in this video has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
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- NCCN Guidelines, Anal Carcinoma Version 2.2025 — January 17, 2025.
- Shakir R, Adams R, Cooper R, et al. Patterns and predictors of relapse following radical chemoradiation therapy delivered using intensity modulated radiation therapy with a simultaneous integrated boost in anal squamous cell carcinoma. Int J Radiat Oncol Biol Phys. 2020;106(2). doi:10.1016/j.ijrobp.2019.10.016.
- Melcher AA, Sebag-Montefiore D. Concurrent chemoradiotherapy for squamous cell carcinoma of the anus using a shrinking field radiotherapy technique without a boost. Br J Cancer. 2003;88(9). doi:10.1038/sj.bjc.6600913.
- Di Santo S, Trignani M, Neri M, et al. Radiochemotherapy in anal cancer: CCR, clinical outcomes and quality of life using two different treatment schedules. Rep Pract Oncol Radiother. 2015;20(2). doi:10.1016/j.rpor.2014.11.001.
- Hagemans JAW. ASO author reflections: salvage surgery for anal cancer. Ann Surg Oncol. 2018;25. doi:10.1245/s10434-018-7025-1.
- Zhang Y, Wang D, Zhu L, et al. Standard versus extralevator abdominoperineal excision and oncologic outcomes for patients with distal rectal cancer. Med (US). 2017;96(52). doi:10.1097/MD.0000000000009150.
- McMenamin DM, Clements D, Edwards TJ, Fitton AR, Douie WJP. Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience. Ann R Coll Surg Engl. 2011;93(5). doi:10.1308/003588411X572268.
Cite this article
Garoufalia Z, Wexner SD. Extralevator abdominoperineal resection (APR) for recurrent anal cancer with an en bloc total abdominal hysterectomy and bilateral salpingo-oophorectomy and total vaginectomy with permanent colostomy formation and pelvic floor reconstruction using a right rectus abdominis flap. J Med Insight. 2025;2025(472). doi:10.24296/jomi/472.
