Previous Unsuccessful Repair Research Articles

Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases

PurposeComplex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies.MethodsA retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef’s Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula.ResultsA total of 60 patients (44 women, 16 men; mean age 50 years, range 24–82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1–15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1–187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1).ConclusionBased on the authors’ experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.

Outcome of urethral reconstruction among vesico-vaginal fistula patients: a cross-sectional study

BackgroundObstetric fistula (OF) complicated by urethral loss (UL) poses a challenge to both the fistula surgeon and obstetric fistula patient. The involvement of the urethra and urethral closure mechanism in OF is an important determinant of successful closure of fistula and restoration of urinary continence. OF with UL is often associated with unsuccessful repair outcome. We describe urethral reconstruction in genital tract fistula patients with UL and the outcomes of the repair.MethodsAim To review the clinical characteristics and outcome of vesico-vaginal fistula associated urethral loss following urethral reconstruction.This was a descriptive cross-sectional study conducted at the University College Hospital, Ibadan, Nigeria. A 5-year prospective data of all vesico-vaginal fistula patients with urethral loss (2011–2016) were reviewed and analysed. Data collected include socio-demographic and obstetric characteristics; cause of the fistula; and fistula characteristics—type of fistula, number of previous repairs, urethral loss, outcome of repair and follow-up. Data were entered and analysed using IBM SPSS version 20.ResultsUrethral loss occurred in 23 (15.3%) out of 150 women with OF; these women had urethral reconstruction surgery. The commonest type of urethral loss encountered in this cohort was proximal urethral loss which was seen in 12 (52.2%) patients. The most common types of fistula seen with urethral loss were large vesico-vaginal fistula (34.8%) and mid-vaginal fistula (26.1%). More than half of the women (56.6%) had previous unsuccessful repair at other facilities before presentation. The fistula closure rate was high (82.6%) regardless of type of urethral loss. Among the women with successful closure of OF with UL, about 36.8% had urinary stress incontinence post-fistula repair.ConclusionUrethral loss appears to be a rare complication of obstetric fistula. Successful closure with stress incontinence was seen in a sizeable number of women with OF with UL. Preoperative assessment for determinant of post-repair incontinence and surgical repair by experienced surgeons will improve successful outcome of repair in women with obstetric fistula with UL.

EVALUATION OF ONE STAGE MODIFIED MATHIEU’S URETHROPLASTY FOR DISTAL PENILE HYPOSPADIAS IN BIHAR POPULATION

With an incidence of 1:300, hypospadias is one of the most common genital anomalies in male newborns. Hence the present study was planned to evaluate the one stage Flip- flap procedure to repair Distal Penile Hypospadias. Mathieu’s technique (peri-meatal based flap) makes use of the urethral plate in the repair of anterior hypospadias, thereby creating an almost natural neo-urethra. In a circumcised baby or after previous unsuccessful repair, Mathieu’s flap may be one of the few options left to repair anterior hypospadias.
 A total of fourteen patients were included in this study. Their age ranged from 1-13 years, mean age was 4.9 years. Construction of neourethra is generally recommended to be completed before the school going age. The 14 cases of hypospadias are primary repaired by modified Mathieu’s Flap technique to achieve both cosmetic and functional normality. An overall success rate of 87.5% was achieved and In the remaining 14% of the cases, success was achieved with only one additional procedure.
 The protocol followed the recommended guidelines of surgery. The present study was planned in the Department of Plastic Surgery, Pulse Emergency Hospital, Patna, Bihar. Total surgeries done from Oct 2016 to Nov 2017 were included in the present study.
 The present study concludes that in a developing country like India with rural patients having poor access to good healthcare facilities. One stage Repair is beneficial in many ways. The follow-up compliance of poor rural patients is extremely poor because they need to come to the urban cities for treatment. The authors have seen multiple cases where the patients have gone for the Chordee Correction (first stage of a two-stage repair) in childhood and then reported after a decade.
 Keywords: Hypospadias, MAGPI, Mathieu flap, Single-stage repair, etc.

Urogenital fistula in the UK: a personal case series managed over 25 years

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Whilst several very large series of obstetric fistulae from the developing world have been published, data on fistulae as seen in the developed world are relatively few. Most fistulae in the UK are known to follow hysterectomy, and several risk factors are recognised. We have confirmed the common association with pelvic surgery, and in particular hysterectomy, but also show the broad range of other associated operations, including so called 'minimally invasive' procedures. High rates of both anatomical fistula closure and continence are shown, when a consistent approach to assessment, selection of surgical procedure, and postoperative care are applied. Successful closure is seen more often in women who have not undergone previous attempts at repair before referral, and as a result a pattern of surpra-regional management is proposed. Whilst overall the number of urogenital fistulae seen in the UK appears to be decreasing, there is a suggestion from these data that the rate of fistula formation following hysterectomy may be increasing; we are currently investigating this possibility through detailed interrogation of a national dataset. To review demography, aetiology, surgery and outcomes of women with urogenital fistula seen in one unit over the last 25 years; to provide data for comparison with a parallel study based on Hospital Episode Statistics. This is a prospective case series from a tertiary urogynaecology centre providing a de facto supra-regional fistula service. The women included had confirmed urogenital fistula referred between January 1986 and December 2010. Index cases were identified from a surgical database; data were entered prospectively and updated as appropriate; statistics are largely descriptive. The primary outcome is the patient's report of absence of urinary leakage. Secondary outcomes include operative or postoperative complications, anatomical closure of the fistula, other residual or new urinary symptoms, and the need for further intervention. In all, 348 women with urogenital fistula were referred; two-thirds were of surgical aetiology, with almost half following hysterectomy. Although 11% followed childbirth, most of these followed operative obstetric interventions. Spontaneous closure occurred in 6.9% of women and 291 underwent surgical treatment. The anatomical closure rate at first operation was 95.7%, although 2.2% reported residual urinary incontinence. The success rates were similar regardless of aetiology, although successful fistula closure was significantly more likely in women who had not had attempts at closure before referral (98.2 vs 88.2%; Fisher's exact test; P= 0.003). High rates of fistula closure are reported regardless of aetiology, although previous unsuccessful repair militates against successful outcome; this emphasises the appropriateness of centralisation of the management of this increasingly rare condition in UK practice.

Retrospective analysis of Mathieu’s urethroplasty for anterior hypospadias repair in circumcised children: A single center experience

Mathieu’s technique (peri-meatal based flap) makes use of the urethral plate in the repair of anterior hypospadias, thereby creating an almost natural neo-urethra. In a circumcised baby or after previous unsuccessful repair, Mathieu’s flap may be one of the few options left to repair anterior hypospadias. To evaluate the result of Mathieu’s flap repair for anterior hypospadias in a resource poor setting. This is a retrospective review of post-circumcision anterior hypospadias managed by Mathieu’s flap repair between January 1996 and December 2006 in the paediatric surgical unit of the Obafemi Awolowo University Teaching Hospital, a tertiary hospital in the South Western Nigeria. Mathieu’s flap repair was performed in 16 patients with isolated anterior hypospadias; 15 (93.8%) were circumcised before presentation. The complications were urethrocutaneous fistula in 3 (18.8%), wound infection in 2 (12.5%) and flap necrosis in 1 patient (6.3%). Final outcome was satisfactory in all patients. Mathieu’s flap remains a viable option in the repair of anterior hypospadias even after circumcision.

Complex anal fistulas: plug or flap?

Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.

CR21P COMPLEX ANAL FISTULAS: PLUG OR FLAP?

Purpose: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair.Methodology: A retrospective review of all complex anal fistulas treated, by either a RMAF or a FP, at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of MRI.Results: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. 21 patients (30%) had had at least 1 previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch‐vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. 48 RMAF's (69% of total) were performed with 16 successful repairs (33%). 22 FP's (31% of total) were performed with 7 successful repairs (32%, p = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months vs. FP 4.1 months, p = 0.62). MRI was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%.Conclusion: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.

The Use of Unilateral Pericranial Flaps for the Closure of Difficult Medial Orbital and Upper Lateral Nasal Defects

We present 3 cases in which a unilateral pericranial flap was used to repair defects in the medial orbital and upper lateral nasal areas. All three patients had undergone previous excision of malignant tumors from the upper septum and ethmoid areas. Postoperatively, they all received radiation and then developed wound breakdown with fistula formation, particularly in the area of the incisional site. All 3 patients had undergone previous unsuccessful repair of the fistula. Closure of such fistulas requires well-vascularized nonradiated tissue, which can be provided by a unilateral pericranial flap. This flap is flexible, thin, and well suited to the sinonasal area. Use of this flap avoids the need for a paramedian forehead or other musculocutaneous flap. Cosmetic results were excellent, and there have been no flap breakdowns or complications to date.

Angioplasty of Acute Occlusion of the Popliteal Artery After Unsuccessful Surgical Repair: A Case Report

In the following case, percutaneous transluminal angioplasty was used to treat acute occlusion of the popliteal artery in a 28-year-old accident victim who had undergone previous unsuccessful repair. Although transluminal angioplasty has proved valuable in treating peripheral vascular lesions, we are not aware of any other case in which this technique has been used to treat postoperative vascular occlusion.