Gracilis muscle transposition with electrical stimulation for sphincteric incontinence: a new approach

Gracilis Muscle Interposition to Fill the Perianal Dead Space May Decrease Hospital Length of Stay in Fournier's Gangrene

PURPOSE

The treatment of Fournier's gangrene (FG) includes aggressive debridement of the affected necrotic area, broad-spectrum antibiotic therapy, and reconstructive procedures, respectively. One of the main reasons of unfavorable outcomes in FG surgery is that the dead space occurs in the perianal region because of destruction of fascias and soft tissues. In this study, we aimed to evaluate the results of gracilis muscle flap transposition to fill the FG-associated perianal dead spaces.

METHODS

Patients treated for FG-associated dead spaces in their perianal region between the years 2017 and 2021 were included in the study. The patients who underwent the pedicled gracilis muscle flap surgery were included in group 1, whereas group 2 consisted of the patients with no additional surgical procedure for dead spaces but only the reconstruction of the soft tissue defects. Demographic data (age, sex), comorbid diseases, localization and length of perianal dead space, and management method for the soft tissue defects and complications were noted. The length of hospital stay and discharge day after surgery were also recorded.

RESULTS

In group 1, the mean duration of hospital stay was 23.5 ± 5.0 (range, 14-48) days, whereas the mean period between the surgery and discharge was 5.1 ± 2.2 (range, 3-12) days. These numbers were 31 ± 8.3 (range, 19-58) days and 12.7 ± 6.1 (range, 7-22) days in group 2, respectively. Statistical comparison of the periods between the surgery and discharge was found to be significantly different ( P = 0.022). The duration of hospital stay was also shorter in the patients with gracilis muscle flap ( P = 0.039).

CONCLUSIONS

Perianal dead spaces accompanying many of the patients with FG provide appropriate conditions for bacterial colonization. Filling these pouches by the gracilis muscle flap prevented the progression of infection and enabled the patients to return to their normal life earlier.

Gracilis muscle sling for select incontinent "bladder exstrophy cripples"

PURPOSE

Functional reconstruction of children born with bladder exstrophy results in a successful outcome in the majority. However, failed bladder neck repair, especially after multiple surgical attempts, compromises the quality of the tissues and, thus, limits surgical options. In these cases conventional sphincteroplasty and other continence procedures, such as rectus sheath sling or artificial urinary sphincters, are ill-advised due to ischemia and fibrosis of the bladder neck.

MATERIALS AND METHODS

We transferred the gracilis muscle as a vascularized pedicle flap around the bladder neck in 5 children born with bladder exstrophy, of whom 3 were "exstrophy cripples" with multiple previous failed attempts at reconstruction, and 2 were older with failed prior attempts at bladder closure. In the latter 2 cases a 1-stage repair was performed, which included bladder augmentation, ureteroneocystotomy, epispadias repair and bladder neck wrap with gracilis muscle. The other 3 children underwent gracilis muscle wrap of the compromised bladder neck.

RESULTS

All 5 children were dry between clean intermittent catheterization 2 to 13 years postoperatively. Complications included urinary tract infection in all 5 cases, stomal stenosis in 2, small bowel obstruction in 1 and bladder stones in 2. However, no complication was related to the gracilis muscle transfer.

CONCLUSIONS

Vascularized gracilis muscle flap can be used to wrap around the compromised bladder neck of incontinent patients born with bladder exstrophy. The muscle appears to provide a leak proof, cough competent sling that increases bladder outlet resistance and, thus, provides dry intervals between catheterization. The long-term results of up to 13 years have been satisfactory.

Gracilis muscle sling for select incontinent "bladder exstrophy cripples"

PURPOSE

Functional reconstruction of children born with bladder exstrophy results in a successful outcome in the majority. However, failed bladder neck repair, especially after multiple surgical attempts, compromises the quality of the tissues and, thus, limits surgical options. In these cases conventional sphincteroplasty and other continence procedures, such as rectus sheath sling or artificial urinary sphincters, are ill-advised due to ischemia and fibrosis of the bladder neck.

MATERIALS AND METHODS

We transferred the gracilis muscle as a vascularized pedicle flap around the bladder neck in 5 children born with bladder exstrophy, of whom 3 were "exstrophy cripples" with multiple previous failed attempts at reconstruction, and 2 were older with failed prior attempts at bladder closure. In the latter 2 cases a 1-stage repair was performed, which included bladder augmentation, ureteroneocystotomy, epispadias repair and bladder neck wrap with gracilis muscle. The other 3 children underwent gracilis muscle wrap of the compromised bladder neck.

RESULTS

All 5 children were dry between clean intermittent catheterization 2 to 13 years postoperatively. Complications included urinary tract infection in all 5 cases, stomal stenosis in 2, small bowel obstruction in 1 and bladder stones in 2. However, no complication was related to the gracilis muscle transfer.

CONCLUSIONS

Vascularized gracilis muscle flap can be used to wrap around the compromised bladder neck of incontinent patients born with bladder exstrophy. The muscle appears to provide a leak proof, cough competent sling that increases bladder outlet resistance and, thus, provides dry intervals between catheterization. The long-term results of up to 13 years have been satisfactory.