Oncology Patients With
Cylinders for Intracavitary
of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy
Injection of Chromic Phosphate
Omental Pedicle "J"
With Bilateral Inguinal
Lymph Node Dissection
Vulva With Gracilis Myocutaneous Flaps
Flap and Vertical Rectus
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina
"J" Pouch Rectal
Omental "J" Flap
Continent Urostomy (Miami Pouch)
Gracilis Dynamic Anal
System Versus Skin Grafting
Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina
of Hemorrhage in Gynecologic Surgery
of the Punctured
of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery
Suspension of the Vagina
Not to Do in Case of Pelvic Hemorrhage
Associated With Abdominal Pregnancy
Pelvic High-Dose Afterloader
If, at the time of total pelvic exenteration, tumor margins are close
to the pelvic wall or if microscopic tumor remains on the pelvic wall
in the area of radical excision of the pelvic wall, it is recommended
that the tumor bed be irradiated even if the patient has already received
total pelvic irradiation and intracavitary radiation therapy.
Physiologic Changes. After total pelvic
irradiation at 5000 cGy plus intracavitary radiation sources, either
intracavitary radiation therapy with tandem and ovoid or high-dose
afterloader techniques, the tumor on the pelvic wall frequently has
not received enough irradiation to destroy it. In fact, the pelvic
wall frequently receives no more than 5600 cGy in most techniques.
Thus after total pelvic exenteration, there may be additional microscopic
tumor present. It would be extremely difficult and dangerous to give
more external beam therapy to the pelvic wall, and because of the inverse
square law, there would be no method of giving standard tandem and
ovoid therapy in the vagina that would significantly reach the pelvic
Therefore, if, following total pelvic exenteration,
microscopic tumor remained on the pelvic wall, the high-dose afterloader
technique could be used through a standard support frame device to
give an additional cytoreductive dose of radiation to the tumor.
Points of Caution. The destructive effect of radiation
on the external iliac artery and vein and the possibility of radiation
osteomyelitis to the ischial bones of the pelvis must be considered.
In addition, the radiation should be covered by omental flaps or a
rectus abdominal flap to give greater distance from the high-dose afterloader
tubes in order not to damage adjacent intestine and allow neoangiogenesis
to revascularize the pelvic wall.
A total pelvic exenteration has been performed.
Microscopic tumor remains on the pelvic side wall. One notes
the stump of the rectum, the vagina, and the urethral meatus.
The ureters have been cut at the pelvic brim.
The high-dose afterloader tubes for delivery
of the radioactive material are seen placed into the slots of
the frames that have been designed to deliver an even isodose
curve of irradiation to the tumor. The high-dose afterloader
frames manufactured out of a modified polygalactide L-lactide
material that will undergo hydrolysis when left in the pelvis
do not require removal.
The omental flap plus a rectus
abdominis muscle flap ("VARM" flap) is moved over the frames
and the radiation tubes to protect the adjacent intestine by
at least 4 cm and allow neoangiogenesis to revascularize the
The radiation tubes are exteriorized
through the right flank or right lower quadrant and attached
to the high-dose afterloader device. At the completion of the
radiation treatment, the tubes can be surgically removed. The
frames, made of polygalactide L-lactide, will dissolve.