Rectal flap advancement – a simple and effective approach for the treatment of rectourethral fistula

Objective Rectourethral fistula is a rare complication of prostatic surgery and other pelvic procedures. We report our experience of surgical repair of using a rectal advancement flap. Patients Three patients with rectourethral fistula following prostatic surgery were treated. Two patients had an anterior partial thickness of rectal flap advancement via a trans‐anal approach without urinary or faecal diversion. In one patient a rectal flap repair was performed through a posterior transsphincteric approach following urinary and faecal diversion. Results No significant postoperative complications occured. Healing was successful in each patient and faecal and urinary continence was normal. Conclusion Transanal rectal advancement flap is a simple and effective technique for the treatment of a rectourethral fistula with no need for urinary or faecal diversion.     

Martius advancement flap for low rectovaginal fistula: short‐ and long‐term results

Aim Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short‐ and long‐term results of the Martius flap procedure. Method Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF‐12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined. Results Crohn’s disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn’s disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2–31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right‐sided flap was associated with a higher success rate (P = 0.0442). Conclusion The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.     

Required length of follow-up after transanal advancement flap repair of high transsphincteric fistulas

Objective  Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow-up needed to assess the healing rate after TAFR of high transsphincteric fistulas.
Method  Between 1992 and 2000 a consecutive series of 80 patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Medical records of all patients were studied. The initial healing rate and the median healing time were assessed. The initial outcome was successful in 54 patients. The medical records revealed that only one of these patients presented with a recurrent fistula after 28 months. The other 53 patients were sent a questionnaire in 2006 aimed to determine whether they had any complaints or signs of a recurrent fistula.
Results  The initial healing rate was 68%. The median healing time was 3.6 months. The completed questionnaire was returned by 48 patients. None of these patients reported any complaints or signs of a recurrent fistula. Median duration of follow-up in these patients was 92 months.
Conclusion  At a median time interval of 3.6 months fistula healing was observed in 54 patients (68%). Only one patient (2%) encountered a recurrence. The length of follow-up can be restricted to the healing time.     

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair

Aim Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. Method Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn’s disease with proctitis, malignant or radiation‐related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure‐of‐eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. Results Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28–78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn’s disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow‐up of 14 (2–67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre‐ and postoperatively were 1.3 (0–15) and 0.6 (0–6), respectively. Conclusion The success rate was promising with no deterioration of anal continence.     

Anal fistula plug vs mucosa advancement flap in complex fistula-in-ano: A meta-analysis

AIM: To investigate the efficacy of the anal fistula plug (AFP) compared to the mucosa advancement flap (MAF), considered the best procedure for patients with a complex anal fistula.METHODS: The literature search included PubMed, EMBASE, Cochrane Library and OVID original studies on the topic of AFP compared to MAF for complex fistula-in-ano that had a deadline for publication by April 2011. Randomized controlled trials, controlled clinical trials and prospective cohort studies were included in the review. After information collection, a meta-analysis was performed using data on overall success rates as well as incidence of incontinence and morbidity. The quality of postoperative life was also included with the clinical results.RESULTS: Six studies involving 408 patients (AFP = 167, MAF = 241) were included in the meta-analysis. The differences in the overall success rates and incidence of fistula recurrence were not statistically significant between the AFP and MAF [risk difference (RD) = -0.12, 95%CI: -0.39 - 0.14; RD = 0.13; 95%CI: -0.18 - 0.43, respectively]. However, for the AFP, the risk of postoperative impaired continence was lower (RD = -0.08, 95%CI: -0.15 - -0.02) as was the incidence of other complications (RD = -0.06, 95%CI: -0.11 - -0.00). The postoperative quality of life, for patients treated using the AFP was superior to that of the MAF patients. Patients treated with the AFP had less persistent pain of a shorter duration and the healing time of the fistula and hospital stay were also reduced.CONCLUSION: The AFP is an effective procedure for patients with a complex anal fistula; it has the same success rate but a lower risk of complications than the MAF and may also be associated with an improved postoperative quality of life. Additional evidence is needed to confirm these findings.     

A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach

Aim Despite advances in the treatment of Crohn’s disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD. Method Medical databases from January 1983 to August 2008 were consulted for potentially relevant publications. All studies dealing with the RV fistula repair in CD with RAF or VAF were included. Two researchers worked independently on the study selection, quality assessment, data extraction and analysis phases of the study. Analyses were performed with Review Manager 2.0 software. Results Eleven observational studies were included with a total of 219 flap procedures for RV fistula. The primary fistula closure pooled rate was 54.2% (range 33.3–100%) after RAF and 69.4% (range 0–92.9%) after VAF (P = 0.13). Four studies were eligible for direct comparison between the two procedures. No clearly significant difference between RAF compared with VAF in terms of primary fistula closure rate, nor in terms of overall fistula closure rate, was apparent. The risk of recurrence after RAF compared with VAF seemed similar; in this case, only two studies were taken into consideration. Conclusions Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.     

Results of combined medical and surgical treatment of recto‐vaginal fistula in Crohn’s disease

Aim Surgical repair of recto‐vaginal fistula (RVF) in Crohn’s disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. Method A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. Results Fifty‐one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. Conclusion RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.     

Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap

Abstract A 47-year-old man was admitted with the chief complaint of a urethral defect. An approximately 17-cm defect of the urethra seemed to have been occurred by the infection of implanted foreign bodies in the penile skin. Reconstruction of the urethra and the ventral skin was performed with a free radial forearm flap. A fistula formed at the proximal anastomosis after the operation, but was controlled conservatively. Urethral stricture at the proximal anastomosis subsequently developed. A urethral stent made of shape memory alloy was placed with the preservation of voiding function.     

A very late onset urethral fistula coexisting with skin bridge after neonatal circumcision: a case report

Complications of neonatal circumcision are generally minor and occur early; a few reports exist on the late or serious kind. The authors describe a case of urethrocutaneous fistula occurring 13 years postcircumcision. The patient also had a skin bridge, another late complication of circumcision. The authors suggest erections in puberty as the triggering factor for onset of fistula. To our knowledge, neither such a late occurrence of fistula nor coexistence of these complications have been reported.     

Autologous platelet‐derived growth factors (platelet‐rich plasma) as an adjunct to mucosal advancement flap in high cryptoglandular perianal fistulae: a pilot study

Aim The aim of this study was to explore autologous platelet‐rich plasma as an adjunct to the staged mucosal advancement flap in the treatment of perianal fistulae. Method Between February 2006 and May 2007, 10 patients with fistula tracts transversing from the middle‐third or upper part of the anal sphincter were treated for at least 3 months with noncutting setons prior to definitive closure by autologous platelet‐rich plasma as an adjunct to a mucosal advancement flap. Five patients smoked tobacco. Results The study group consisted of six women and four men with a median age of 44 (range 30–75) years and a median follow up of 26 (range 17–32) months. One (10%) patient had a recurrent fistula. No new continence disorders developed after definitive treatment in both groups. Conclusion Platelet‐rich plasma as an adjunct to a staged mucosal advancement flap for the treatment of perianal cryptoglandular fistulae is a promising treatment modality and seems to establish a high healing rate.     

Double breasting repair of urethral fistula in a patient with perineal abscess secondary to a large urethral stone

We report here a case of urethral fistula managed successfully following incision and drainage for the urethral abscess secondary to a large urethral stone leading to a large diverticulum (another rare condition) by using the technique of double breasting, where we used the redundant urethra and overlying skin.     

Management of an acquired tracheoesophageal fistula with a fascial free flap

BACKGROUND: Failure in the primary repair of a benign acquired tracheoesophageal fistula limits the operative options available at revision. Use of a fascial free flap to treat this condition has not been previously reported. METHODS: We review the case of a patient who had a tracheoesophageal fistula develop after percutaneous tracheostomy, who had failed previous primary repair with strap muscle interposition. RESULTS: A radial forearm fascial free flap was used at revision and resulted in resolution of the fistula. CONCLUSION: Use of a fascial free flap to address a persistent acquired tracheoesophageal fistula, when an accompanying stenotic segment is not present, is a viable treatment option.