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Smith A, Burton L, Mama S. Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion. Int Urogynecol J 2024:10.1007/s00192-024-05787-3. [PMID: 38733381 DOI: 10.1007/s00192-024-05787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/27/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION AND HYPOTHESIS This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS The surgery was accomplished without complications. CONCLUSIONS To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.
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Affiliation(s)
- Alicia Smith
- Department of Obstetrics and Gynecology, Jefferson Einstein Hospital, Philadelphia, PA, USA.
| | - Lauren Burton
- Department of Obstetrics and Gynecology, Division of Urogynecology, Cooper University Healthcare, Camden, NJ, USA
| | - Saifuddin Mama
- Department of Obstetrics and Gynecology, Division of Urogynecology, Cooper University Healthcare, Camden, NJ, USA
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Capozzi VA, Rotondella I, De Finis A, Scarpelli E, Ghi T, Berretta R. Rectovaginal fistula repair by Martius flap after exclusive chemoradiation in a patient with advanced cervical cancer. Int J Gynecol Cancer 2023; 33:1473-1474. [PMID: 36958754 DOI: 10.1136/ijgc-2023-004365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Affiliation(s)
- Vito Andrea Capozzi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Isabella Rotondella
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alessandra De Finis
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Elisa Scarpelli
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
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Toia B, Unterberg S, Sihra N, Pakzad M, Hamid R, Ockrim JL, Greenwell TJ. Functional outcomes of vaginal surgery for urethral extrusion of mid-urethral tape in women. Int Urogynecol J 2021; 33:2251-2256. [PMID: 33822257 DOI: 10.1007/s00192-021-04774-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 03/21/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We aim to determine the presentation of and immediate and longer-term outcomes of vaginal surgical excision of urethral extrusion of mid-urethral tape (MUT). METHODS We performed a retrospective analysis of all patients with urethral extrusion of MUT having vaginal surgical excision between 2007 and 2018. The MUT was removed either partially (via vaginal approach) or completely (via combined vaginal and laparoscopic approach). Functional outcomes and any re-interventions are described. RESULTS Thirty-four patients of median age 53 (range 34-82) years were identified. Preoperative symptomatic recurrent/persistent urinary incontinence was present in 29/34(85%) with 24/34(71%) women having recurrent/persistent stress urinary incontinence (SUI) or stress predominant mixed urinary incontinence (s-MUI) on urodynamics. Vaginal surgical excision was performed alone in 33/34(97%) women and in combination with laparoscopic removal of abdominopelvic MUT in 1/34(3%) woman. In the longer term vaginal/urethral pain resolved or improved in all 15/15(100%) patients presenting with this complaint whilst patient reported poor flow resolved in 8/9 (89%) women. Twenty-eight of 34 women (82%) had persistent/recurrent SUI or s-MUI following MUT excision. Twenty-four of 34 women (71%) had further SUI surgery with cure or improvement of SUI in 20/24 (83%) patients. CONCLUSIONS The outcome of vaginal surgical excision of the MUT was cure or improvement of pain in 100% and resolution of poor flow in 89% women. Recurrent/persistent SUI or s-MUI was present in 82% following removal as compared to 71% women prior to removal. Of the 71% of women electing to have further surgery for recurrent/persistent SUI/s-MUI, 83% were dry or improved afterwards.
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Affiliation(s)
- Bogdan Toia
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK.
| | - Stephen Unterberg
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
| | - Neha Sihra
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
| | - Mahreen Pakzad
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
| | - Rizwan Hamid
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
| | - Jeremy L Ockrim
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
| | - Tamsin J Greenwell
- Department of Urology, University College London Hospital, Westmoreland Street, London, UK
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Marina T, Lago V, Padilla P, Matute L, Domingo S. Vesicovaginal Fistula Repair by Modified Martius Flap: A Step-by-Step Surgical Technique Video. Ann Surg Oncol 2020; 28:1002-1006. [PMID: 32797377 DOI: 10.1245/s10434-020-09020-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/25/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fistula repair in the perineal region represents a major challenge for surgeons. It is important for the medical community to facilitate and disclose these techniques. OBJECTIVE The aim of this article was to show a stepwise approach for a direct repair and use of a Martius flap for a vesicovaginal fistula. METHODS We show a single case performed in a patient who presented with a vesicovaginal fistula diagnosed after surgery, which did not respond to conservative management. The procedure consists of the following steps: intraoperative cystoscopy, anatomical direct repair of the fistulous tract between the bladder and vagina, and modified Martius flap. CONCLUSIONS Martius flap is a repair technique used for complex fistula in the perineal region. It is a simple, safe, and reproducible procedure with good long-term functional and esthetic results.
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Affiliation(s)
- Tiermes Marina
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain.
| | - Víctor Lago
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | - Pablo Padilla
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | - Luis Matute
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
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Martius labial fat pad graft (use in rectovaginal fistula repair). Int Urogynecol J 2020; 31:2427-2429. [PMID: 32377801 DOI: 10.1007/s00192-020-04315-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective is to demonstrate the utility of the Martius labial fat pad graft in pelvic fistula repair. METHODS An incision is made over the labium majus from the level of the clitoral hood superiorly and extending inferiorly to the level of the labiocrural fold. The fibrofatty graft is then mobilized from the adjacent labium majus. The flap can be divided either at its anterior or at its posterior pedicle. A subepithelial defect is created through which the flap will be passed. The flap is sewn into place by attaching it to the underlying rectovaginal fascia without associated tensioning. Next, the posterior vaginal wall is closed over the graft with a series of everting subepithelial mattress sutures followed by a reinforcing layer of interrupted #1 Vicryl through the vaginal epithelium. CONCLUSIONS The advantages of the Martius flap in fistula repair include low morbidity, lack of a cosmetic defect, and the need for only a single surgical field. Its prominent fibrous component makes it a stronger graft than adipose tissue from other areas and its abundant blood supply promotes rapid neovascularization and lends itself well to many surgical modifications that can be utilized in even the most difficult of fistula repairs.
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Terry M, Ng MK, Ma T, Stein SL. Rectoperineal Fistula Repair Through Perineal Approach, Martius Flap, and House Advancement Flap. Cureus 2020; 12:e7001. [PMID: 32206465 PMCID: PMC7077134 DOI: 10.7759/cureus.7001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A rectoperineal fistula (RPF) is a relatively rare, non-life-threatening form of anorectal malformation that nevertheless causes significant physical discomfort, and remains technically challenging for surgeons to treat. We present a case of a 72-year-old female with a history of a recurrent perianal fistula with multiple approaches including endorectal advancement flap previously attempted. Our procedure involved laparoscopic loop ileostomy with transversus abdominis plane (TAP) block, and RPF repair through the perineal approach with primary repair involving Martius flap and house advancement flaps. The patient tolerated the procedure well with no known peri-operative complications and resolution of stool incontinence at subsequent post-operative visits, the first within a month of the procedure. This case was used to demonstrate and highlight the surgical technique of the RPF repair by Martius flap. Informed consent was obtained from the patient for video recording for educational purposes.
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Affiliation(s)
- Morgan Terry
- Surgery, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Mitchell K Ng
- Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Truong Ma
- Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Sharon L Stein
- Surgery: Colorectal Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
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Use of Cadaveric Pericardial Tissue in the Surgical Treatment of Neurogenic Bladder. Case Rep Urol 2019; 2019:6182397. [PMID: 31392069 PMCID: PMC6662501 DOI: 10.1155/2019/6182397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/04/2019] [Indexed: 12/05/2022] Open
Abstract
The surgical treatments for neurogenic bladder are extremely variable. The lack of specific treatment guidelines makes this disease process even more challenging to treat. We present a case of a 55-year-old female with neurogenic bladder secondary to spinal cord injury (SCI). Her incontinence was conservatively managed with indwelling Foley drainage. Despite continued upsizing of the Foley catheters, the patient continued to have urinary leakage. The patient subsequently underwent a transvaginal bladder neck closure (BNC) with suprapubic bladder neck diversion (SPC). The urethra was successfully closed and uniquely supported with the use of cadaveric pericardial tissue (CPT). This surgical approach of neurogenic bladder provides durable continence with short operative times, minimal patient morbidity, decreased hospital length, and low risk of progressive renal dysfunction. BNC with SPC can provide an excellent management solution for neurogenic bladder from spinal cord injury refractory to conservative management.
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Waterloos M, Verla W. Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6715257. [PMID: 30906779 PMCID: PMC6398057 DOI: 10.1155/2019/6715257] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/05/2019] [Indexed: 11/18/2022]
Abstract
Female urethral strictures are rare. Guidelines on how to diagnose and treat these strictures are lacking. At present, only expert opinion is available to guide clinical practice. Once the diagnosis is suspected based on obstructive voiding symptoms and uroflowmetry, most clinicians will use in addition video-urodynamics (including urethrography), urethral calibration and cystourethroscopy for confirmation of the diagnosis. Clinical inspection and gynaecological examination are also important. Urethral dilation is usually the first-line treatment despite the lack of long-term success. Female urethroplasty is associated with higher success rates. A multitude of techniques are described but not one technique has shown superiority above another. This narrative review aims to provide a clinical guide for diagnosis and treatment to the urologist motivated to perform female urethroplasty.
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Affiliation(s)
- Marjan Waterloos
- Department of Urology, Algemeen Ziekenhuis Maria Middelares, Ghent, Belgium
| | - Wesley Verla
- Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium
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A Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue. Case Rep Urol 2018; 2018:6183618. [PMID: 30519496 PMCID: PMC6241371 DOI: 10.1155/2018/6183618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/04/2018] [Accepted: 09/24/2018] [Indexed: 11/17/2022] Open
Abstract
A urethral diverticulum is a relatively uncommon finding. The estimated prevalence is approximately 1-5% in the general population. While the definitive treatment is surgical correction, there are limited studies guiding the best approach to repair. This is the case of a 48-year-old female who initially presented with vaginal discharge, dysuria, and dyspareunia. MRI revealed the diagnosis of suspected urethral diverticulum. The patient was treated with surgical correction with the aid of needle localization prior to the procedure. After the diverticulum was excised, the resulting defect in the urethra was successfully closed with cadaveric pericardial tissue. A urethral diverticulum should be considered in the differential diagnosis when a patient presents with symptoms such as recurrent urinary tract infections (UTIs) vaginal mass, dysuria, dyspareunia, or vaginal discharge. The use of cadaveric tissue augments the surgical technique for repair.
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