Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds

doi:10.1016/S0090-4295(02)01823-X

Urology

Volume 60, Issue 3, September 2002, Pages 502-507

https://doi.org/10.1016/S0090-4295(02)01823-X Get rights and content

Abstract

Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.

Section snippets

Case report

A 35-year-old female patient who had been initially treated by conization and succeeding hysterectomy because of cervical carcinoma presented with vesicovaginal and pouch-vaginal fistulas. Because of local recurrence, she had undergone intravaginal local afterloading radiotherapy (40 Gy) four times, causing an extended fistula between the posterior vaginal wall and rectum. Multiple different approaches to close the fistula by direct repair had failed within weeks. She finally underwent

Operative procedure

To close both fistulas, we performed laparotomy, with careful separation of the small bowel loops and revision of the defects using an abdominovaginal approach with the patient in the lithotomy position. A left-sided, inferiorly based, vertical rectus abdominis myocutaneous flap was elevated (Fig. 2A). The hood of the skin paddle of the flap was sutured together to form a dome-like reservoir structure mimicking the vaginal dome (Fig. 2B). The flap was pulled through the pelvis to cover the

Comment

In addition to the obvious psychosocial benefit to the patient and her partner, the incorporation of viable tissue into the pelvic cavity decreases the incidence of infection and small bowel complications. Pelvic and genitoperineal irradiation is an adjunctive or primary option in the treatment of pelvic malignancies. However, it can add to the problems of wound healing, destroy normal anatomy and function, and have a severe effect on the postablative reconstructive process.7 Reconstructive

Conclusions

The outcome for the patient was a satisfactory functional vagina that was technically easy to construct. The operation is straightforward, quick, and safe. The rectus abdominis myocutaneous flap can provide an adequate neovagina with minimal morbidity even when previous surgical incisions exist.

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Cited by (51)

Management of urosymphyseal fistula and pubic bone osteomyelitis: Description of a new surgical technique by cystectomy, urinary diversion and pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap
2024, French Journal of Urology
Pubic bone osteomyelitis is a rare infection, mostly related to urinary fistula. The published data about the medical or surgical management of this type of infection is relatively poor. In this case study of three patients, we describe our surgical technique for the management of urosymphyseal fistula complicated with pubic bone infection using pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap. The first patient had the pelvic space filled with omentum flap. Unfortunately, the patient presented, postoperatively, an enteric fistula resulting from intestine incarceration on the resected bone. Considering this failure, the next two cases, have benefited from a Taylor flap to protect the peritoneal cavity by covering the residual pubic bone. Early complications were pyelonephritis and anemia (Clavien-Dindo 2), but no repeat surgery was required afterwards. The hospital stay for both cases were 26- and 12-days contrary to the first case who was hospitalized for 180-days. In conclusion, despite our limited experience in managing complicated urosymphyseal fistula, Taylor's flap, mainly used for gynecological or rectal surgery, might be a good reproducible solution for the surgical management of this kind of fistula with pubic debridement. It allows to protect the peritoneal cavity with fewer postoperative complications.
L’ostéomyélite de la symphyse pubienne est une infection rare, le plus souvent liée à une fistule urinaire. Les données publiées sur la prise en charge médicale ou chirurgicale de ce type d’infection sont relativement pauvres. Dans cette étude de cas portant sur trois patients, nous décrivons une technique chirurgicale pour le traitement d’une fistule urinaire compliquée d’une infection de l’os pubien en utilisant un lambeau de comblement par lambeau musculocutané unilatéral pédiculé du muscle grand droit de l’abdomen. Lors de la chirurgie du premier patient le pelvis avait été comblé en tapissant avec le grand omentum.Celui-ci a présenté, en postopératoire, une fistule digestive résultant de l’incarcération de l’intestin grêle sur l’os réséqué. Compte tenu de cet échec, les deux cas suivants ont bénéficié d’un lambeau de Taylor en recouvrant l’os pubien résiduel afin de limiter les complications digestives. Les complications précoces ont été une pyélonéphrite et une anémie (Clavien-Dindo 2), mais aucune reprise chirurgicale n’a été nécessaire dans les suites. La durée d’hospitalisation pour les deux cas a été de 26 et 12 jours, contrairement au premier cas qui a été hospitalisé pendant 180 jours. En conclusion, malgré notre expérience limitée dans la prise en charge des fistules urinaires compliquées de symphysite pubienne, le lambeau de Taylor, principalement utilisé en chirurgie gynécologique ou rectale, pourrait être une bonne alternative, reproductible, pour la prise en charge chirurgicale de ce type de fistule avec résection de l’os pubien. Il permet de combler le pelvis et de protéger la cavité péritonéale avec une diminution du risque de complications postopératoires.
Free fillet lower leg flap for coverage after hemipelvectomy or hip disarticulation
2019, Revue de Chirurgie Orthopedique et Traumatologique
La résection carcinologique est le traitement de référence des sarcomes des tissus mous et osseux. Au bassin, cet impératif peut nécessiter une hémipelvectomie pouvant compromettre la fermeture cutanée de première intention. L’utilisation de lambeaux est indispensable, mais la vascularisation des potentiels lambeaux pédiculés peut avoir été réséquée lors de l’exérèse. Le recours aux tissus sains du membre amputé comme lambeau libre peut constituer une excellente solution de couverture.
Le lambeau libre de jambe banque est une technique de couverture simple et fiable après hémipelvectomie ou désarticulation de hanche.
Sept patients ont été opérés dans 3 centres de références : six désarticulations inter-ilio-abdominales et une désarticulation coxo-fémorale. Le lambeau était constitué dans trois cas de la loge postérieure superficielle du mollet et pour les autres cas de toutes les loges de la jambe avec la fibula non dépériostée. Les différentes complications ont été analysées.
Pour tous les patients, les marges étaient saines (R0). Le recul moyen lors de la dernière évaluation était de 13 mois (de 6,5 à 21 mois). Au total, six patients ont une complication sur le lambeau avec une seule perte du lambeau. Quatre patients ont pu être appareillés.
Le lambeau libre de jambe banque est une technique fiable (86 %) pour la couverture après hémipelvectomie ou désarticulation de hanche. Dans la littérature, aucun échec de cicatrisation n’est décrit pour les 16 cas rapportés. Les lambeaux locaux sont souvent trop fragiles et avec un matelassage musculaire insatisfaisant. Ce lambeau libre est à privilégier en première intention car il permet d’économiser les autres lambeaux libres potentiels en cas de faillite sans augmenter la morbidité d’un geste déjà important. Cette technique doit faire partie des solutions de couverture après hémipelvectomie.
IV, étude rétrospective.
Free fillet lower leg flap for coverage after hemipelvectomy or hip disarticulation
2019, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Complications have been reported in 37.5% to 67% of cases [19,30,39]. While the vertical rectus abdominis myocutaneous (VRAM) flap [11,20,21,40–42] is a potential coverage option, donor site morbidity is very high. It requires that the abdominal wall be reconstructed with synthetic material.
Tumor resection is the gold standard treatment for soft tissue and bone sarcomas. In the pelvis, this may require a hemipelvectomy that can compromise primary skin closure. Flaps are essential in this context; however the vascularization of potential pedicled flaps may have been removed during tumor excision. Using healthy tissue from the amputated limb as a free flap is an excellent coverage option.
The free fillet flap from an amputated lower limb is a simple and reliable coverage technique after hemipelvectomy or hip disarticulation.
Seven patients were operated on at three specialty centers: six transpelvic amputations (external hemipelvectomy) and one hip disarticulation. In three cases, the flap consisted of the superficial posterior compartment of the calf area and in the three other cases, the lower leg compartments with the fibula and its intact periosteum. Complications were documented.
Clear resection margins were achieved in all patients. The mean follow-up at the final visit was 13 months (range, 6.5 to 21 months). Six patients had complications but only one resulted in loss of the flap. Four patients were able to be fitted with a hip prosthesis.
The free fillet flap from an amputated lower limb is a reliable coverage technique (86%) after hemipelvectomy or hip disarticulation. In the 16 cases previously reported in the literature, there were no wound-healing failures. Local flaps are often too fragile with insufficient muscular padding. This free flap is the preferred first-line technique as it spares other potential free flaps in case of failure without increasing the morbidity of a procedure that is already extensive. This coverage technique should be one the options considered after external hemipelvectomy.
IV, retrospective study.
Buccal mucosal graft interposition in the treatment of recurrent vesicovaginal fistula: A report on two cases
2015, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
Various tissue grafts can be used in both vaginal (labial fat pad and gracilis muscle) and abdominal repair (peritoneum, omentum, and myocutaneous muscle flaps). These grafts improve local vascularity, absorb urinary extravasate, and prevent leakage of urine from the bladder [5]. However, 5–10% of VVFs recur after the primary repair.
To present the use of autologous buccal mucosa graft (BMG) in the treatment of recurrent vesicovaginal fistula (VVF).
In 2011, two women, aged 45 years and 56 years, were admitted due to recurrent VVF. Both women had previously undergone abdominal hysterectomies for benign conditions and, subsequently, vaginal VVF repair due to vaginal urine leakage. On admission, the younger woman had a round fistula, with a diameter of 1.5 cm, located on the left side, supratrigonally; the other woman had an ellipsoidal fistula measuring 2.5 cm × 1.5 cm, located medially and supratrigonally. Both women underwent suturing of the VVF with the interposition of BMG. After the last treatment, both women were cured.
Treatment of recurrent VVF with the interposition of BMG is a good alternative to the use of other tissue grafts. Larger series are needed to confirm the advantages of this method.
A modified surgical technique for treatment of radiation-induced vesicovaginal fistulas
2012, Urology
To present a modified surgical technique in the management of radiation-induced vesicovaginal fistulas. Radiation-induced vesicovaginal fistulas pose a great challenge to the treating surgeon owing to the fibrotic, poorly vascularized tissue in the area. Various techniques have been used to promote healing and prevent fistula recurrence, but most centers still recommend urinary diversion or more individualized management.
We used the left rectus abdominis muscle based on the deep inferior epigastric vessels as an interposition flap in 3 patients presenting with vesicovaginal fistulas 19, 28, and 34 years after radiotherapy for cervical cancer. The fistulas were isolated using an abdominal approach, and the distal half of the left rectus abdominis muscle was mobilized. Without closure of the 2 defects, the muscle was then interposed between the bladder and vagina, where it was fixed using single sutures around the edges of the 2 defects. The operations were performed by a team that included both a urologist and a plastic surgeon.
All 3 patients underwent successful treatment. With a follow-up of 5-8 years, there has been no recurrence of symptoms.
This modified surgical technique offers well-vascularized, nonirradiated tissue to be used as an interposition flap based on the inferior epigastric vessels in the management of radiation-induced vesicovaginal fistulas. The technique allows obstruction of the fistula without the need for closure of the mucosal defects in the bladder and vagina.
Vesicovaginal Fistula: Open Approach
2023, Urinary Fistula

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Surgeon’s workshopBilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds

Abstract

Section snippets

Case report

Operative procedure

Comment

Conclusions

J Urol

J Urol

Clin Plast Surg

Urology

Gynecol Oncol

Gynecol Oncol

The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration

Obstet Gynecol

Surgeon’s workshop
Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds