The management of extensive perineal defects resulting from aggressive tumor resections, such as abdominoperineal resections for advanced pelvic malignancies, can be a complex and demanding process in the treatment journey. The primary options for reconstructing perineal defects are vertical rectus abdominis myocutaneous (VRAM) and anterolateral thigh (ALT) flaps. While both flaps are commonly used in reconstructive surgery, VRAM is often preferred due to several advantages. These include the ability to provide ample tissue to fill large perineal defects, as well as the convenience of harvesting this type of flap through a midline incision. This approach allows for a more cosmetically favorable scar location compared to other techniques. Overall, VRAM is a superior choice for perineal reconstruction due to its versatility and effectiveness in addressing complex defects. In this article, we describe our experience with utilizing a vertical rectus abdominis myocutaneous flap to close a 20 x 10 cm perineal defect that arose after an abdominoperineal resection performed due to extensive rectal melanoma in a 46-year-old male. We found that the vertical rectus abdominis myocutaneous flap was an exceptional choice for covering this substantial defect in our case.

Extralevator Abdominoperineal Excision (ELAPE) and Abdominoperineal Resection create complex perineal defects made more challenging when combined with additional resection of the posterior vaginal wall. This composite defect requires the restoration of a functional vagina, in addi-tion to the obliteration of the large perineal dead space, a need to reduce donor site, and perineal wound morbidity. Previously described fasciocu-taneous and myocutaneous flaps for such defects are associated with long operations requiring intra-operative mobilization and are linked to post-operative complications including herniation, evisceration, flap loss, donor site morbidity and poor cosmetic outcome, amongst other issues. Herein we describe the case of a 60-year-old female patient that underwent com-bined ELAPE and posterior vaginectomy for anal squamous cell carcino-ma. This complex defect was reconstructed using an extended version of the Perineal Turn-Over (PTO) flap based on the Internal Pudendal artery perforator.

Though previous major abdominal surgery and pelvic irradiation may be a significant drawback of subsequent laparoscopic procedure, technological advances such as better visualization and more controlled finer movements of robotic arms allowing better dissection in robotic-assisted laparoscopic surgery may reduce some of these challenges. However, limited data are available on the effect and safety of robotic surgery in these patients. The aim of this case report is to present efficacy and safety of robot assisted radical prostatectomy in a patient who has rectal and concurrent prostate cancer with the history of abdominoperineal resection, pelvic irradiation and adjuvant chemotherapy.

Secondary scrotal tumors originating from viscera are rare and indicate a poor prognosis. We report a patient who underwent abdominoperineal resection due to his rectal cancer. Tumor recurrence at the surgical site led to prostate involvement. About 1 month after the prostatectomy, scrotal skin metastasis presented as bilateral papulonodular lesions. Finally, brain metastasis occurred and caused his death. Also, several ways by which malignancies can metastasize to scrotum have been discussed.

Abdominoperineal resection (APR) along with permanent colostomy is the standard method of low rectal cancer operation and resection. The laparoscopic APR provides better visualization of pelvic structures compared to the open approach. Disadvantages of the laparoscopic approach have been reported as longer operation duration and requirement of expensive equipment Although this issue has been investigated extensively worldwide, data is limited from Iran.. The aim of this study was to compare short-term outcome of Laparoscopic Abdominoperineal Resection (APR) with open APR in patients with low rectal cancer in Shiraz, southern Iran..Patients and This was a non-randomized controlled trial study performed in Shahid Faghihi Hospital affiliated to Shiraz University of Medical Sciences from 2007 to 2012. We included all patients with rectal cancer who underwent laparoscopic or open APR with permanent colostomy. Both groups were evaluated regarding oncology results. Volume of intraoperative bleeding, short-term complications, operation to diet interval and duration of hospitalization were recorded and further compared between the laparoscopy and open APR groups.. Overall, 24 patients were included in this study of whom 11 underwent laparoscopy and 13 underwent open APR. The two study groups were comparable regarding age (P = 0.747), gender (P = 0.605), tumor stage (P = 0.116), tumor histopathology grade (P = 0.421) and distance from the anal verge (P = 0.711). The duration of operation was comparable between the groups (P = 0.336). Those who underwent laparoscopy had significantly lower intraoperative bleeding (485.5 ± 139.8 vs. 658.3 ± 183.2; P = 0.024), shorter operation-diet interval (2.27 ± 0.46 vs. 3.15 ± 0.37; P < 0.001) and shorter duration of hospitalization compared to the open APR group (4.09 ± 0.53 vs. 4.76 ± 0.59; P = 0.008).. Laparoscopic APR is associated with minimal perioperative bleeding, shorter operation-diet interval and shorter durations of hospitalization compared to open approach in patients with low rectal cancer who had not received neoadjuvant chemo radiotherapy. Oncologic results in this operation were comprisable to open procedure because the mesorectal, anus and sphincter complex excision are performed in the same method.. Therefore, laparoscopy could be the method of choice for APR..

The worldwide age-standardized incidence and mortality rates of rectal cancer are estimated to be 7.6 and 3.3 per 100,000, respectively (1). Previous literature suggests that low anterior resection (LAR) may be superior to abdominoperineal resection (APR) for rectal cancer, with better 5-year survival, local recurrence rate, oncological outcomes, and prognosis (2). However, it is reported that around 41% of patients who underwent LAR experience major low anterior resection syndrome (LARS) one year after surgery. LARS is characterized by fecal and gas incontinence, diarrhea, urgency or frequency of stools, sensation of incomplete emptying, and clustering of bowel motions (3) . These symptoms are reported to persist over time and influence health related quality of life (4), functional bowel symptoms may also occur after sigmoid resection (5) . Despite assessing the effects of several therapeutic strategies in reducing the LARS symptoms, its treatment is still challenging (6) .Perturbation of the gut microbiome has been linked to numerous chronic diseases, such as obesity, endocrine disorders, gastrointestinal diseases, cancer, cardiovascular diseases, etc.(7).

 Diffuse cavernous haemangioma of rectum (DCHR) is rare in clinical practice. Rarely, DCHR may be associated with Klippel-Trenaunay syndrome and are commonly misdiagnosed, and treated as hemorrhoids. The usual presentation is with painless bleeding per rectum. Despite many diagnostic modalities available today, the correct diagnosis is difficult to arrive at. Although the management of these cases has evolved over years, it still remains a challenge for the surgeons because of the nature and extent of involvement and risk of bleeding during the surgery. The advocated surgical interventions vary from abdomino-perineal resection (APR) to sphincter preserving surgery. Recently, transarterial embolization (TAE) has been found to be useful as a nonsurgical method of treatment in select cases of DCHR. DCHR with extension upto dentate line in young patients can be managed by sphincter preserving surgery with the advent of modern staplers, avoiding the abdominoperineal resection and a permanent stoma. We present two cases of this rare entity, DCHR, managed in our department by ultralow anterior resection with stapled anastomosis, with a review of the literature emphasizing on management.

Vaginal metastasis from colorectal adenocarcinoma can occur months after the resection of the primary tumor. Most of the time, bleeding is the bothersome symptom. The optimal treatment involves surgical excision followed by reconstruction to prevent the lymphatic networks in the rectovaginal septum serving as a potential route of spread. There have been a number of successful vaginal reconstructive options reported. We describe a 32-year-old woman who had previously undergone an abdominoperineal resection for rectal cancer and was now suffering with rectal adenocarcinoma vaginal metastases. An inferior gluteus perforator flap (IGAP) repair was carried out following posterior vaginectomy after a comprehensive multidisciplinary examination. This flap can be used to address perineal dead space as well as to reconstruct the neovaginal area, eliminating the need for a second flap and significantly reducing donor morbidity. The lesson from this case is that vaginal metastases can still develop even after the primary colorectal tumor has been removed. One-step surgical excision and perineal repair can result in an enhanced quality of life and a good prognosis.

Currently, neoadjuvant chemoradiation followed by total mesorectal excision through a low anterior- or abdominoperineal resection (APR) is considered the standard treatment approach in the vast majority of patients with locally advanced rectal cancer. Even though LAR allows for anatomic rectal preservation, APR led to significant morbidity and compromised quality of life in rectal cancer patients. Approximately 10-40% of patients achieve clinical complete response (CCR) following neoadjuvant chemoradiation. Meanwhile, the rate of pathologic complete response (PCR) is usually less than CCR rate. Complete response rate may be improved by escalating radiation dose and optimizing (total) neoadjuvant chemotherapy. Therefore, at least one-fifth of patients will have the chance of rectal preservation using the watch-and-wait strategy. In this therapeutic strategy, patients should be followed up by an active surveillance protocol to detect early tumor regrowth and salvage radical surgery and will, therefore, provide comparable oncologic outcomes to those achieved in patients who undergo initial radical surgery. This review aimed to present the largest reports and highlight the most recent evidence and guidelines for watch-and-wait therapeutic strategy in patients with rectal cancer.

With the advances of neoadjuvant chemoradiotherapy, the identification of complete tumor responses, and the reduction of local recurrence even with the adoption of expectant approaches aimed at sphincter preservation, several authors have published results analyzing these aspects with conflicting results, which require further investigation. This study aims to evaluate the anatomopathological changes in surgical specimens of rectal resection due to adenocarcinoma in patients undergoing neoadjuvant therapy, including the complete response rate, in addition to estimating the sensitivity and specificity indexes of the imaging methods used in the preoperative period. This was an observational, retrospective, cross-sectional study in which 44 medical records of patients with cancer of the middle and lower rectum who underwent neoadjuvant chemoradiotherapy and subsequently underwent oncological surgical resections over 10 years were studied. Demographic data, CT scans, colonoscopies, anatomopathological reports and surgical reports were analyzed. Abdominoperineal resection of the rectum (APR) was performed in 16 cases (36.4%), and abdominal rectosigmoidectomy (AR) was performed in 28 cases (63.6%). Preoperative computerized tomography (CT) showed a sensitivity of 75% and specificity of 77.8% for the detection of lymph node metastases. The complete pathological response to neoadjuvant chemoradiotherapy was found in 11.36% of cases. The local recurrence was detected in 23.9% cases and distant metastasis in 15.2% of the patients on the follow-up period, additionally, there was a 77.7% 5-years disease-free survival and the overall survival was 73.9%. The rate of complete pathological response to neoadjuvant therapy was 11.36%. Locally advanced disease and angiolymphatic embolization were associated with a higher frequency of lymph node involvement. CT obtained high rates of sensitivity and specificity for comparison with anatomopathological results.