The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex.

OBJECTIVE: To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition. METHODS: A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas. RESULTS: In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716). CONCLUSION: Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.

Use of rectus abdominis muscle flap as adjunct to bladder neck closure in patients with neurogenic incontinence: preliminary experience.

PURPOSE: Vesicoureteral fistula is a well-known potential complication following bladder neck closure for neurogenic incontinence. Various maneuvers, including omental interposition, have been described to prevent this problem. Unfortunately omentum is not always available or feasible for use. We describe the surgical anatomy and use of a rectus abdominis muscle flap as an adjunctive maneuver during bladder neck closure to correct or prevent development of bladder neck fistula. MATERIALS AND METHODS: We performed a retrospective chart review of all patients at our institution undergoing rectus abdominis muscle flap by a single surgeon (EAS). Patient demographics, indications for surgery, intraoperative and postoperative complications, and long-term efficacy were assessed. Cadaveric dissection was also performed to gain a greater understanding of the surgical anatomy relevant to this procedure. RESULTS: In 6 patients with neurogenic bladder dysfunction a rectus abdominis muscle flap was interposed between the bladder neck and urethral stump at bladder neck closure. There were no intraoperative or postoperative complications associated with this procedure. At a mean followup of 45.5 months (range 18 to 120) all 6 patients were continent of urine. There have been no urinary fistulas related to use of the rectus abdominis muscle flap. Cadaveric dissections confirmed the inferior epigastric artery to be the dominant and readily mobile blood supply of the rectus abdominis muscle flap. CONCLUSIONS: The rectus abdominis muscle flap is easily harvested without significant risk of morbidity and offers a well vascularized tissue for coverage of a bladder neck closure when an omental flap is not available.

Genital fistula--our experience.

Genital fistulas cause immense physical and psychosocial problem in women's life. The present study was conducted to note the varieties of genital fistula as well as their causative factors and the results of the operative corrections. Altogether 42 patients with different varieties of genital fistula were enrolled in the study. The causative factors of the genital fistulas, specially, that of vesicovaginal fistulas were thoroughly enquired. After confirming the diagnosis, the operative corrections were undertaken. Among the varieties of genital fistula, 76.19% were vesicovaginal fistula, 11.90% were rectovaginal fistula and 4.76%, 4.76% and 2.38% cases of ureterovaginal, urethrovaginal and vesicocervical fistulas respectively. The primipara women were the major sufferers of genital fistulas due to obstetric grounds. Regarding aetiologies of vesicovaginal fistulas, 71.87% patients had obstetric reasons, after prolonged labour, instrumental delivery and after caesarean section due to obstructed labour. Abdominal hysterectomy (44.44%) topped the list of the gynaecological causes of vesicovaginal fistulas. The cases of ureterovaginal fistulas were after abdominal hysterectomy. One case of urethrovaginal fistula was due to some chemical application for correction of genital prolapses. The rectovaginal fistulas were mostly due to obstetric reasons. The success rate after the first attempt of repair of vesicovaginal fistula was 82.75% and overall failure was 10.34%. The other varieties of fistulas were repaired with 100% success rate. The incidence of genital fistulas can be reduced by vigilant obstetric care and meticulous surgery.