Flap Interposition Research Articles

ARTROPLASTIA INTERPOSICIONAL PARA TRATAMENTO DE ANQUILOSE DA ARTICULAÇÃO TEMPOROMANDIBULAR

Introduction: Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems in mastication, digestion, speech, appearance, and hygiene. Objective: Report a case of TMJ ankylosis diagnosed in adulthood and discusses the aspects involved in their treatment, and the use of temporal muscle flap in reconstructive surgery of the TMJ. Cases description: 39 year-old female with mouth opening of 4mm, was diagnosed with left TMJ ankylosis and treated by arthroplasty with interpositional temporalis muscle flap, progressing with mouth opening of 20 mm after two months out surgery. Conclusion: Despite the numerous surgical techniques for the treatment of TMJ ankylosis, it is still a great challenge, because of high rates of recurrence, which is associated with several factors including age, time of onset, surgical technique, and postoperative care performed. Therefore, it is necessary not only an interdisciplinary team to establish a complete and adequate treatment, but also to carry out a correct and early diagnosis in order to establish a treatment the prognosis is favorable to the patient.

Inclusion and Exclusion Criteria to Overcome Bias and Reach a Valid Conclusion for Interpositional Flap Coverage in Primary Hypospadias Repair With Tubularized Incised Plate Urethroplasty

There is no general consensus about the best vascularized layer between the neourethra and the skin in tubularized incised plate urethroplasty (TIPU) of Snodgrass. Inclusion of 1 surgeon to repair specific forms of hypospadias by using determined surgical materials and exclusion of definite patients and conditions and definite anomaly parameters may present the needed reliable data about the role of a specific type of interpositional coverage of the neourethra. The 37 patients had been operated by TIPU with a ventral subcutaneous dartos flap covering the neourethra who designed as group A, while 26 patients had been operated by the standard TIPU without urethral coverage who designed as group B. Good cosmetic results were obtained in 93.65% of the patients. In group A, urethral fistulae were encountered in 2 cases of distal hypospadias and 1 case of midpenile hypospadias with a total fistula rate of 8.1%. In group B, urethral fistulae were found in 5 cases of distal hypospadias and 3 cases of midpenile hypospadias with a total fistula rate of 30.7%. Flapless repair should not be tried as long as there is the needed experience to harvest a well-vascularized coverage. Interpositional flap coverage of the neourethra is crucial to decrease the rate of fistula in primary hypospadias TIPU repair. However, before designating a relative study, different forms of the anomaly, surgeon's experience, the potential harvesting complications, complexity degrees of different repairs, and the used surgical materials should be really considered.

Open Surgical Secondary Procedures after Thoracic Endovascular Aortic Repair

Improved outcomes of thoracic endovascular aortic repair (TEVAR) compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. As the number of TEVAR survivors has grown, reports of complications have similarly increased. Although secondary endovascular rescue measures are often undertaken, patients with serious complications are often converted, ultimately, to open repair. The aim of this study was to assess causes and midterm results of open surgical secondary procedures after thoracic endovascular aortic repair. A total of 236 patients underwent TEVAR. Fourteen of these patients required open repair because of six aortobronchial fistulas, four retrograde type A dissections, two aneurysm enlargement without endoleak, one thoracic stent-graft collapse, and one aortoesophageal fistula. Eight (57.1%) patients underwent surgical repair using cardiopulmonary bypass. Six stent-grafts were totally removed, and eight stent-grafts were left in situ. Four patients underwent supracoronary ascending aorta replacement, and one an extensive replacement of the aortic arch through sternotomy. Three patients had descending aortic replacement through left thoracotomy combined with a total esophagectomy in one case. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass and stent-graft explantation. One patient was treated by exclusion bypass of the descending thoracic aorta. Pulmonary resection and large pleural or intercostal muscle flap interposition to wrap the stent-graft left in situ was done in four cases of aortobronchial fistula. All patients survived the surgical procedure. Ten patients (71%) had an uneventful postoperative course. There were two in-hospital deaths (14.3%). Both died from multi-organ failure in the early postoperative course after surgical repair of a stent-graft infection and an aortoesophageal fistula. One patient suffered a definitive paraplegia and a secondary aortoesophageal fistula requiring reoperation for esophageal repair. One patient, treated by pulmonary resection and flap interposition to wrap the stent-graft, underwent stent-graft explantation and in situ descending aortic replacement because of stent-graft reinfection. Actuarial survival was 87.7% after a mean follow-up of 26.3 months (range 9-72 months). Complications or prevention of complications after TEVAR either due to device failure or adverse events may require conversion to open repair or additional open surgical procedure. Open repair can be performed by a team experienced in management of diseases of the thoracic aorta and a low mortality rate achieved despite the precarious preoperative conditions and complex aortic pathologies of patients.

Management of temporomandibular joint ankylosis in children with arthroplasty and distraction osteogenesis in the same surgical time

Temporomandibular joint (TMJ) ankylosis in children is a challenging problem for the maxillofacial surgeon since the surgical technique is difficult and the recurrence rate is high. It is characterized by a hipomobility, breathing, eating problems,and facial asymmetry. There is a vertical and sagittal mandibular deficiency. Numerous treatment approaches have been proposed in the literature. The surgical excision of the ankylotic mass is mandatory; gap arthroplasty and interpositional flaps have been discussed.

A Novel Use of the Gracilis Muscle as a “Walking” Flap for Repair of a Rectovaginal Fistula

INTRODUCTION: Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained.1–2 Case Report: We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed, but failed. The right gracilis flap was then re-used successfully as a “walking” flap. The medial femoral circumflex vessels were ligated and the proximal muscle was released and wrapped in a tubed piece of acellular dermal matrix (Figure 1). One week later, the fistula was divided and primary closure of the rectum and vagina was obtained. Subsequently, the proximal muscle was tunneled between the rectum and vagina and tacked 3 cm above the suture lines of both the rectal and vaginal defects and down to the opening of the perineal wound (Figure 2). At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later.Figure 1: Ligation of medial femoral circumflex vessels and release of the proximal gracilis muscle followed by wrapping in a tubed piece of acellular dermal matrix (ADM).Figure 2: Inset of the delayed gracilis flap between the rectum and the vagina - saggital view (green color = proximal end of the muscle, yellow color = distal end of the muscle).CONCLUSION: To our knowledge, this is the first report of the use of a gracilis muscle as a “walking” flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Titanium Plate Fixation for Sternal Dehiscence in Major Cardiac Surgery

BackgroundSternal dehiscence is one of the most troublesome complications following cardiac surgery. Treatment failure and consequent lethal outcomes are very common. The aim of this study was to evaluate titanium plate fixation as a treatment for sternal dehiscence following major cardiac surgery.Materials and MethodsBetween 2010 and 2012, 17 patients underwent sternal reconstruction using horizontal titanium plating for the treatment of post-cardiac-surgery sternal dehiscence. The plates were cut and shaped, and then were fixed to corresponding costal segments using 2-3 titanium screws per each side.ResultsThe median age of our patients was 66 years (range, 50 to 78 years) and 9 were female. Indications for sternal reconstruction included aseptic sternal dehiscence in 3 patients and osteomyelitis in 14 patients including 6 patients who were diagnosed with mediastinitis. During the operation, sternal resection and autologous flap interposition were combined in 11 patients. One patient died due to sepsis. Two patients required additional soft tissue wound revisions. Another patient presented with a tuberculous wound infection which was resolved using anti-tuberculosis medications. The postoperative course was uncomplicated in the other 13 patients.ConclusionTitanium plate fixation that combines appropriate debridement and flap interposition is very effective for the treatment of sternal dehiscence following major cardiac surgery.

Robotic repair of vesico-vaginal fistula with perisigmoid fat flap interposition: state of the art for a challenging case?

Since its introduction, robotic-assisted operations have established themselves in an increasingly wide range of procedures. We applied this approach as a viable surgical alternative for the management of a complex vesicovaginal fistula. We present the case of a patient with total urinary incontinence due to the formation of a vesicovaginal fistula, following total abdominal hysterectomy. The fistula was located at the vaginal vault and at approximately one cm from the right ureteric orifice. For this specific scenario a robotic approach was chosen over the vaginal-, laparotomic- and laparoscopic repair, as in our view it offered the best possibility to specifically treat the target anatomy with a reduced risk for involvement of the surrounding structures, while maintaining a low morbidity and a quick postoperative recovery.In our video we show how the vesicovaginal fistula can be repaired by interposition of a vascularized flap of perisigmoid fat, in order to reduce the risk of recurrences [Ezzat et al., Repair of giant vesicovaginal fistulas, 181(3):1184-1188, 2009].The postoperative course was uneventful; on postoperative day 1 the patient reported pain of 2/10 on a VAS scale (0 = no pain; 10 = unbearable pain) and was mobilized. She was discharged on postoperative day two with bladder catheter in situ. The successful repair of the fistulous tract was confirmed via retrograde cystogram on postoperative day 10 and the patient was continent immediately after catheter removal. At the six month follow up visit the patient had no complaints.

Editorial Comment

Tenets of fistula repair are a good tension-free closure with healthy tissue and especially for “complex” fistulas, an interposition flap. A peritoneal or omental flap is relatively easily attained abdominally, but not so easy vaginally where a peritoneal flap can be found if you are fortunate or a Martius flap can be used if the fistula is distal. Is Tissue Interposition Always Necessary in Transvaginal Repair of Benign, Recurrent Vesicovaginal Fistulae?UrologyVol. 82Issue 3PreviewTo evaluate and compare the outcomes of transvaginal repair of benign, primary, and recurrent vesicovaginal fistulas (VVFs) treated without tissue interposition because, historically, tissue interposition with a vascularized flap has been advocated in both transabdominal and transvaginal repairs of recurrent VVFs. Full-Text PDF

A Systematic Review of the Literature on the Outcomes of Treatment for Recurrent and Persistent Carpal Tunnel Syndrome

Recurrent and persistent carpal tunnel syndrome is an uncommon but potentially difficult surgical dilemma. Many surgical treatment options have been described in the literature without comparative data on outcome. A systematic review on recurrent carpal tunnel syndrome was performed for all articles from 1946 to 2012 in MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists from all identified articles. Twenty-three articles were screened and identified from the time period 1972 to 2012, representing two general treatment groups: decompression with flap interposition and repeated open decompression. A meta-analysis was then performed, generating forest and funnel plots of the data. In total, 294 patients from 14 studies in the flap arm of the meta-analysis had a weighted success rate of 86 percent (95 percent CI, 0.75 to 0.96), and 364 patients from nine studies in the nonflap arm had a weighted 75 percent success rate (95 percent CI, 0.66 to 0.84). Heterogeneity was statistically analyzed and revealed low heterogeneity with the I statistic. Forest plots were created and analyzed between subgroups, and chi-square analysis revealed a highly statistically significant difference (p = 0.001). The odds ratio of success in the nonflap group was 0.50 (95 percent CI, 0.33 to 0.75). Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression. The relevance of these data is pertinent to all hand surgeons, as they could have an impact on treatment guidelines for this relatively uncommon but problematic condition, but further prospective study is needed. Therapeutic, III.

Multidisciplinary Approaches to the Management of Breast-Cancer-Related Lymphedema

Breast-cancer-related lymphedema is a significant morbidity mostly observed following primary treatments for breast cancer (surgery, radiation, and chemotherapy) (1). Multiple complications might accompany lymphedema including cosmetic deformity, psychological disorders, consistent pain, and consequently decreased quality of life. Treatment mostly focuses on reducing edema and its subsequent pain; however, no definite treatment has been hitherto introduced (2). Surgical approaches in the management of lymphedema are efficient including physiologic methods (e.g. flap interposition, lymph transfer, and lymphatic bypass) and reductive techniques (e.g. liposuction) (3). While the former mostly targets at reducing lymphedema through restoring lymphatic drainage, the latter aims at removing fibrofatty tissues which contribute to lymph stasis. Microsurgical variation of lymphatic bypass has gained popularity, in which the accumulated lymph in the lymphedematous limb is redirected. Non-surgical approaches are also practiced in most cases. Comprehensive decongestive therapy, consisting of skin care, exercise, special bandaging and massage, is the most frequently used non-surgical approach efficacy of which could be enhanced in combination with self-management strategies (4). Recently newer techniques have been introduced to tackle lymphedema and its associated pain. Manual lymph drainage, stellate ganglion block, acupuncture, deep oscillation, and pneumatic compression have been efficiently used in several studies. Moreover, significant short-term progress has been reported following other modalities such as low-level laser therapy (5). The complexity of breast-cancer-related lymphedema and its complications necessitates a multidisciplinary approach with the primary goal of easing the burden of the disease on the breast cancer patients. In addition, developing special guidelines encompassing these multidisciplinary approaches and providing educational and training programs for both the patients and their families seems to be pivotal.

The Posttraumatic Proximal Cross-union of the Forearm in Childhood: What is Recommended?

The posttraumatic proximal cross-union of the forearm in childhood is a rare complication after radial head, neck or proximal forearm fractures and elbow dislocations. There is no standardized treatment. Several surgical procedures with or without interposition techniques are described in the literature. The aim of this study was to analyze all children with cross-unions who underwent surgery over the last 15 years. From 1998 to 2013, 8 children with a posttraumatic proximal cross-union of the forearm (Type 3 according to Vince and Miller) received surgical treatment with resection of the cross-union or radial head. Mean age at the time of initial trauma was 9.0±2.56 years (range 6-14 years), age at the time of surgery was 11.9±3.09 years (range 7-16 years). Mean time of resection of the crossunion was 23.2 months. Follow-up time was 10.6 months (range 1-36 months). Five patients had a resection of the cross-union without any interposition techniques, in 2 cases with an additional arthrolysis of the elbow. One patient had an interposition of a local fascia flap. In 2 cases, a primary excision of the radial head, six and seven years, respectively, after trauma, was performed. All patients, except one, had non-steroidal antiinflammatory drugs therapy after surgery. A post-operative irradiation was performed in 3 cases. The mean postoperative range of motion for pronation/supination was 36/0/53°. Controversy remains about the best procedure to adopt for posttraumatic cross-union in childhood. After analysis of our data and the literature, we recommend the resection of the crossunion within 6-24 months of occurrence without necessarily using any interposition techniques. All patients reported an improvement with regard to ordinary activities. In cases of long-term cross-union for several years with ankylosis of the elbow and bony deformities of the proximal radius, an excision of the radial head as salvage procedure is recommended.

The Urachal Flap

Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31-88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.

563 TRANSLABIAL ULTRASOUND (TLUS) DETECTION IN URETHRAL MESH SLING REVISION: FACTORS ASSOCIATED WITH THE NEED FOR INTERPOSITIONAL TISSUE FLAP OR URETHRAL RECONSTRUCTION

You have accessJournal of UrologyUrodynmaics/Incontinence/Female Urology: Incontinence, Evaluation & Therapy (I)1 Apr 2013563 TRANSLABIAL ULTRASOUND (TLUS) DETECTION IN URETHRAL MESH SLING REVISION: FACTORS ASSOCIATED WITH THE NEED FOR INTERPOSITIONAL TISSUE FLAP OR URETHRAL RECONSTRUCTION Forrest Jellison, Leah Nakamura, Lisa Rogo-Gupta, Denise Chow, Chad Baxter, Ja-Hong Kim, Larissa Rodriguez, and Shlomo Raz Forrest JellisonForrest Jellison Los Angeles, CA More articles by this author , Leah NakamuraLeah Nakamura Los Angeles, CA More articles by this author , Lisa Rogo-GuptaLisa Rogo-Gupta Los Angeles, CA More articles by this author , Denise ChowDenise Chow Los Angeles, CA More articles by this author , Chad BaxterChad Baxter Los Angeles, CA More articles by this author , Ja-Hong KimJa-Hong Kim Los Angeles, CA More articles by this author , Larissa RodriguezLarissa Rodriguez Los Angeles, CA More articles by this author , and Shlomo RazShlomo Raz Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1959AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The objective of this study is to detect and localize urethral sling mesh by TLUS and to determine preoperative factors predictive of an interpostional tissue flap or urethral construction (UC). METHODS Patients who underwent excision of transvaginal mesh between 7/2005 to 7/2012 were retrospectively reviewed. Women that had only urethral mesh sling revision and pre-operative TLUS were included for analysis. Demographics, pre-operative, TLUS findings, and operative findings were compared. RESULTS A total of 43 (mean age 58 +/− 17, BMI 26 +/− 3.58, postmenopausal 32%) women underwent urethral mesh sling revision and pre-operative TLUS. UC or interpositional flap of tissue was performed in 44% (19) with a local flap (periurethral fascia, perivesical fat) in 68%, and a martius flap in 32%. TLUS was able to detect mesh in all patients. TLUS sensitivity and specificity was (74%, 100%) for reconstruction when mesh was within 1 mm of the lumen of bladder or urethra. TLUS findings of mesh within 1 mm of the urethral or bladder was predictive of urethral or bladder flap during reconstruction in 93% and was significant compared to those not requiring reconstruction, p<0.01. 63% (12) of patients requiring reconstruction were not identified on pre-operative cystoscopy of which 66% (8) were found to be within 1 mm of the urethra or the bladder lumen on ultrasound. TLUS findings of mesh folding or mesh location (proximal to distal) were not predictive of reconstruction. There was a higher rate of pre-operative stress and mixed incontinence (66% vs 48%, p=0.01) and subsequent surgical procedures for stress incontinence (63% vs 43%, p=0.03) in the reconstructive group. Significant risks for urethral reconstruction was age greater than 65 (p<0.01), BMI >25 (p<0.01), and parity > 3 (p.02).There was no significant difference in reconstruction operative times (105 +/− 25 vs 82 +/− 17, p=0.08), EBL (165 +/− 70 vs 177 +/− 171, p=74), or complications (5% vs 4%) compared to those who did not undergo reconstruction. CONCLUSIONS TLUS was able to detect and localize urethral sling mesh and may predict those who would need an interpositional flap or UC at the time of surgery. This technique may allow the surgeon to pre-operatively identify and council the patient about the need for reconstruction. This information needs to be applied prospectively to determine if indeed sling location within 1 mm of urethral lumen predicts need for UC or interpositional tissue flap. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e231 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Forrest Jellison Los Angeles, CA More articles by this author Leah Nakamura Los Angeles, CA More articles by this author Lisa Rogo-Gupta Los Angeles, CA More articles by this author Denise Chow Los Angeles, CA More articles by this author Chad Baxter Los Angeles, CA More articles by this author Ja-Hong Kim Los Angeles, CA More articles by this author Larissa Rodriguez Los Angeles, CA More articles by this author Shlomo Raz Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of Prior Radiotherapy and Ablative Therapy on Surgical Outcomes for the Treatment of Rectourethral Fistulas

We evaluate the impact of pelvic radiation and ablative therapy on the surgical repair of rectourethral fistula. A total of 45 patients with rectourethral fistulas were identified from a prospective database. From 1998 to 2010 a total of 49 surgical reconstructive procedures were performed. Fistula formation was secondary to radiation (brachytherapy, external beam radiation) and ablative therapy (cryotherapy or high intensity focused ultrasound) in 29 patients. The approach for surgical repair and clinical outcomes were analyzed to identify the impact of radiation and ablative therapy on successful fistula repair. Median patient age was 68 years and mean followup was 42 months (IQR 7, 71). A primary repair was more frequently attempted (15 of 16 [94%] vs 6 of 29 [21%], p <0.0001) and successful in nonradiation/ablation cases (13 of 15 [87%] vs 1 of 6 [17%], p = 0.003). Patients with prior radiation/ablation were significantly more likely to require permanent colostomy (25 of 29 [86%] vs 0%, p <0.0001) and permanent urinary diversion as part of fistula management (27 of 29 [93%] vs 1 of 16 [6%], p <0.0001). Of the 6 patients with radiation/ablation induced fistula who underwent primary repair, 4 subsequently required urinary diversion for fistula recurrence, 1 is symptomatic with recurrence and 1 (who presented with a 0.5 cm fistula) has had no evidence of fistula recurrence. Unlike the repair of a rectourethral fistula after surgical intervention, which is typically amenable to primary repair, most patients with severe radiation and ablation induced fistula will require urinary diversion with or without permanent colostomy. Thus, permanent urinary diversion should be considered early in the surgical management of these cases.

Use of gracilis muscle as a “walking” flap for repair of a rectovaginal fistula

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Continent cutaneous diversion for bladder exstrophy in adults

ObjectivesBladder exstrophy is a rare and devastating congenital anomaly. These patients are usually seen immediately after birth where correction can be attempted. Presentation in adulthood where bony fusion has occurred and bladder capacity is very low presents a major surgical challenge. Such patients require urinary diversion. This is a review of our initial experience with continent cutaneous urinary diversion in patient with classic bladder exstrophy who presented in adulthood. Patients and methodsWe reviewed the social and clinical characteristics, operative reports, and postoperative course of two female and five male patients who have been living with bladder exstrophy since birth. They underwent augmentation cystoplasty or simple cystectomy, bladder neck transection, repair of epispadias followed by a continent cutaneous diversion. The continent catheterizable outlet was constructed using the serous lined extramural tunnel technique as a continence mechanism. Postoperative continence, renal function, and changes in social life were documented. ResultsFollow-up has ranged from 17 months to 5 years in these initial patients. Thus far, all these patients have achieved complete daytime and night time continence, Complications consisted of pouch cutaneous fistula which was successfully repaired with interposition of a rectus abdominis flap and one case of urosepsis. All upper urinary tract imaging studies have shown stable function. All the patients are doing well with improved social interaction. ConclusionBladder neck closure in conjunction with continent cutaneous diversion is a reliable and safe method for achieving continence in adults presenting with bladder exstrophy. Total continence can be achieved without resorting to multiple complex and expensive surgeries.

Management of temporomandibular joint ankylosis with temporalis fascia flap and fat graft

AimTemporomandibular joint (TMJ) ankylosis is a serious problem that restricts jaw mobility and causes disturbances in facial and mandibular growth. The purpose of this paper is to present an easy and versatile method for the treatment of TMJ ankylosis to decrease postoperative complications such as re-ankylosis. Material and methodEleven patients who presented with ankylosis of the TMJ underwent surgical release. After performing gap arthroplasty through a preauricular approach, the temporalis fascia flap was transposed to the gap. An autogenous fat graft was then obtained from the abdomen and used as interpositional material. The follow-up time was 3–5 years. ResultsRe-ankylosis did not occur in any of the patients, and all had satisfactory mouth opening. ConclusionSurgical treatment of TMJ ankylosis with gap arthroplasty, interposition of the temporalis fascia flap and fat grafting is an effective and easily procedure for preventing of re-ankylosis. The autogenous nature and close proximity to the joint are the main advantages of the temporalis fascia flap when compared with other interpositional materials, and the fat graft provides additional support by reducing pressure.

Acquired Rectourethral Fistulas in Adults

Rectourethral fistulas are uncommon. Retrospective studies and case reports have highlighted various approaches for surgical repair. Because clinical presentations and technical expertise vary widely, no single procedure has been universally adopted. We sought to qualitatively analyze studies describing surgical techniques and outcomes in adult acquired rectourethral fistulas to outline universal approaches for evaluation and management. MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms rectourethral fistulas, recto-urethral fistulas, urethrorectal fistulas, and prostatourethral-rectal fistulas. All studies were retrospective, in English, and reported at least 4 cases. Any series with >50% congenital cases or <50% adults (19+ years) was excluded. Of the 569 records identified, 26 articles were included. The intervention was surgical repair of rectourethral fistula. The main outcome measures were successful fistula closure, fistula recurrence or persistence, and permanent fecal and/or urinary diversion. Four hundred sixteen patients were identified, including 169 (40%) who had previous pelvic irradiation and/or ablation. Most patients (90%) underwent 1 of 4 categories of repair: transanal (5.9%), transabdominal (12.5%), transsphincteric (15.7%), and transperineal (65.9%). Tissue interposition flaps, predominantly gracilis muscle, were used in 72% of repairs. The fistula was successfully closed in 87.5%. Overall permanent fecal and/or urinary diversion rates were 10.6% and 8.3%. Most high-volume centers (≥25 patients) performed transperineal repairs with tissue flaps in 100% of cases. This review was limited by the heterogeneity of repairs and bias toward preferred surgical approaches in single-center studies. Regardless of complexity, rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems.

Index

Urethro-vaginal fistulae (UVF) occur usually as infrequent complications of a variety of gynecological surgical procedures. The aim of this study was to present an interesting case of a complicated UVF diagnosed after gynaecological surgery. A 61-year-old gravida-2, para-2, post-menopausal woman was referred with a complaint of urine loss through the vagina. She had undergone anterior and posterior vaginal wall repair due to cystocele and stress urinary incontinence (SUI). Transvaginal repair was performed 20 weeks after primary surgery. However, a second transvaginal reconstructive surgery using Martius-flap originating from the bulbocavernosus muscle was necessary due to persistent urine leakage in the vagina. Thirty-two months after successful urethro-vaginal treatment, the patient self-referred for persistent SUI. Burch colposuspension was performed and at 16 months follow-up the patient remains continent. Surgical repair of complicated UVF seems to be more successful with Martius flap interposition than with no interposition.

Traumatic rectourethral fistula repair: A potential application of porcine small intestinal submucosa

Rectourethral fistula is an uncommon but devastating condition. Traumatic rectourethral fistula is still uncommon and repair of traumatic rectourethral fistula involves a complex procedure. Most of the urologists would prefer to repair the fistula through perineal route especially when urethral reconstruction is also required. The repaired ends of the fistula are separated with various interposition flaps and grafts in order to prevent recurrence. Gracilis interposition muscle flap is commonly used. We describe the first case of traumatic rectourethral fistula repair in a 45-year-old man using interposition of a porcine small intestinal submucosal (Biodesign™ (Surgisis®) graft.