OMENTAL INTERPOSITION FOR REPAIR OF A VESICO-ACETABULAR FISTULA

Abstract

An 84-year-old woman underwent revision of a previous right total hip replacement for degenerative joint disease. Shortly after surgery the metallic hip prosthesis became infected and required removal. The acetabular space was preserved using polymethyl-methacrylate cement. Persistent cellulitis and drainage of clear yellow fluid from the hip incision led to suspicion of a vesico-acetabular fistula. Urethral catheter bladder drainage for 4 weeks was unsuccessful and, subsequently, the patient was referred to our facility. A computerized tomography cystogram confirmed the diagnosis of vesico-acetabular (fig. 1, A). Cystoscopy revealed a solitary fistulous tract between the right lateral bladder wall and acetabular hemispheric shell which was cannulated using a 5Fr ureteral catheter (fig. 2). Through an infraumbilical extraperitoneal incision, the right lateral aspect of the bladder was mobilized off of the adhesed pelvic sidewall and the fistula was identified. A longitudinal cystotomy was made at the dome allowing bladder exploration and precise excision of the cannulated fistulous tract. The most challenging aspect of this procedure involved dissection and excision of the fistulous tract in its entirety as it coursed towards the acetabulum. After dissection to well vascularized tissue, a multilayered tension-free bladder closure was performed. To secure the repair, omentum was mobilized through a small peritoneotomy and interposed between the right pelvic sidewall and bladder. A cystogram (Fig. 1) after 3 weeks of continuous uninterrupted bladder drainage revealed successful closure of the vesico-acetabular (fig. 1, B).