Vesicovaginal fistula repair with rectus abdominus myofascial interposition flap

Complex, recurrent vesicovaginal fistulas (VVFs) can be very challenging to repair and often require interposition of nonirradiated, well-vascularized tissue between the urinary system and vagina. We report our experience using a rectus abdominus myofascial (RAM) interposition flap for VVF repair.

A retrospective analysis was performed to identify patients who had undergone VVF repair with RAM interposition. Data were collected focusing on preoperative patient characteristics, etiology of VVF, intraoperative parameters, including surgical techniques, and postoperative patient outcomes.

We used a RAM interposition flap for VVF repair in 5 patients. All VVFs had developed postoperatively; no patient had received radiotherapy. VVF developed after total abdominal hysterectomy (TAH) or radical cystectomy in 3 and 2 cases, respectively. Both cases of VVF after radical cystectomy occurred in conjunction with orthotopic diversion (neobladder-vaginal fistula). In 3 patients with post-TAH VVF, a total of five previous failed repairs were attempted before RAM interposition. In 1 patient with a neobladder-vaginal fistula, who had received adjuvant chemotherapy, RAM interposition failed, and the patient ultimately required cutaneous urinary diversion after two subsequent failed attempts at repair (68 months of follow-up). The remaining 4 patients (80%) had no evidence of recurrent VVF or voiding abnormalities at a mean follow-up of 19 months (range 8 to 32).

Rectus abdominus muscle can be a successful interposition flap during repair of complex, recurrent VVF. In our experience, this has been successful in most cases, particularly in younger patients with nonmalignant processes.