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Management of complex redo and radiated vesicovaginal and urethrovaginal fistulas with an interposition muscle flap.
Jessica DeLong, MD, Sara Lenherr, MD, Jill Buckley, MD, Alex J. Vanni, MD, Leonard Zinman, MD.
The Lahey Clinic, Burlington, MA, USA.

BACKGROUND: Vesicovaginal and urethrovaginal fistulas are rare but devastating complications of pelvic surgery, radiation and obstetric trauma. We review, analyze and describe the management and outcomes of vesicovaginal fistulas and urethrovaginal fistulas (including redo and radiation induced cases) during a consecutive 9-year period utilizing muscle interposition flaps.
METHODS: We performed a retrospective review of patients undergoing vesicovaginal or urethrovaginal fistula repair between September 2003 and October 2011. Patient demographics as well as preoperative, operative and postoperative data were obtained. All fistulas were repaired using a transvaginal approach with a muscle interposition flap.
RESULTS: A total of 13 patients with vesicovaginal and 2 patients with urethrovaginal fistulas underwent repair with a transvaginal approach and muscle interposition flap. Operative details, fistula location, size and anatomic variations were noted. The patients had a collective total of 12 prior failed repairs (range 0-2). Fistula etiology included one trauma (bladder rupture), 3 non-gynecologic iatrogenic, 6 gynecologic iatrogenic, 1 obstetric trauma and 4 radiation induced. Our technique consisted of primary fistula closure with muscle flap interposition into the perineal space and proximal urinary diversion with a suprapubic tube. Four cases required simultaneous Singapore fasciocutaneous flap for vaginal reconstruction (table 1). At a mean follow-up of 9.6 months (range 1-40.2 months), 12 of 15 of fistulas were closed in a single procedure. One urethrovaginal fistula required a second procedure 13 months after the first for recurrent fistula; overall success rate was 87%. Both of the vesicovaginal fistulas that failed were complex, radiated patients requiring Singapore flap at initial closure attempt. Gracilis flap harvest was well tolerated with rare minor sensory loss or slight adductor weakness.
CONCLUSIONS: Closure of complex recurrent and radiation induced vesicovaginal and urethrovaginal fistulas can be achieved with primary fistula closure with muscle interposition muscle flap, thereby avoiding permanent urinary diversion.
Table 1
n
Vesicovaginal fistula13
Urethrovaginal fistula2
Etology
trauma
obstetric trauma
non-gynecologic iatrogenic
gynecologic iatrogenic
radiation induced
-
1
1
3
6
4
Fistula size (cm)0.5-4
Patient age (years, range)63 (21-77)
Muscle flap used (some patients >1)
Gracilis
Singapore
Rectus abdominis
Semitendinosus
Gluteus
-
14
3
2
1
1
Closed in one procedure12 (80%)
Total closed after 2 procedures13 (87%)


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