Abdominopelvic isolation-based staged reconstruction for massive perineal defects after extended pelvic exenteration: an exploratory case series

Background: Extended pelvic exenteration with en bloc pelvic floor resection may leave a deep, irradiated composite defect that is contaminated or potentially contaminated and not always suitable for immediate flap reconstruction. We report an initial experience with a staged reconstructive strategy in which abdominopelvic isolation separates the abdominal cavity from the perineal defect, allowing sequential local wound management before delayed flap closure. Methods: We performed a retrospective single-center case series of eight consecutive patients who underwent pelvic exenteration with en bloc pelvic floor resection between December 2024 and June 2025 and were managed using a predefined three-stage protocol. Following reconstruction of the pelvic inlet with a biological mesh, the perineal defect was managed with temporary hemostatic packing, negative-pressure wound therapy (NPWT), and delayed flap reconstruction. Outcomes included protocol completion, duration of each treatment phase, wound-related complications, clinically estimated cavity contraction, flap survival, postoperative length of stay, and durable perineal healing. Results: Median packing duration was 7 days (range, 5–9 days), and median NPWT duration was 38 days (range, 28–45 days). Two patients had focal wound bleeding during dressing changes, requiring local suture ligation and compression. There was one pelvic wound infection during NPWT and one superficial gracilis donor-site infection; both resolved with antibiotics. Healthy granulation developed in all patients, with a clinically estimated 50–65% reduction in cavity volume before closure. Delayed reconstruction used five gluteus maximus and three gracilis myocutaneous flaps; all survived. Median postoperative hospital stay was 56.5 days (range, 47–62 days). At a median follow-up of 12 months (range, 9–15 months), all patients had durable perineal healing without chronic sinus formation. Conclusions: In selected patients with massive perineal defects after extended pelvic exenteration, this staged reconstructive pathway was feasible and was associated with durable perineal healing in this small series. It may provide a practical option when the wound bed is not suitable for reliable immediate flap inset, although comparative studies are required to define its role relative to immediate reconstruction.