V2-12: Vesicovaginal Fistula repair in orthotopic neobladder with pedicled island skin flap
51 y/o female patient with history of bladder cancer and subsequent orthotropic neobladder vesicovaginal fistula. She failed two attempts at closure due to necrosis of the vaginal wall. She was averse to using muscle flaps and was considering conversion to urinary diversion. A martius flap with a skin island was used to correct the defect on the anterior vaginal wall.
An inverted U incision was made on the vaginal wall. The intestinal mucosa was carefully separated from the anterior vaginal wall. The neobladder defect was closed in an interrupted fashion with 3-0 polyglactin sutures. A 3 x 1.5 centimeter skin island was isolated from the labia and the underlying fibrofatty tissue was mobilized. The anterior portion of the graft is ligated leaving the fibrofatty graft supplied by the posterior labial artery from the internal pudendal artery. A tunnel is developed from the vaginal incision to the labia and the graft is transferred through the tunnel to cover the vaginal wall defect. The skin island was secured to the vaginal defect with interrupted 3-0 polyglactin sutures. An indwelling foley catheter and a suprapubic tube were left in place.
8 weeks postoperatively the patients graft had excellent uptake. Cystoscopy was performed and there was no evidence of the neobladder defect. The neobladder was filled with methylene blue and there was no leakage to suggest persistence of the fistulous tract. 12 weeks post operatively the patient did not have recurrence of fistulous tract.
Transvaginal correction of orthotropic neobladder vesicovaginal wall fistula with martius flap and a skin island is a viable alternative for repair of large complex defects.