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A Systematic Review of Pressure Injuries Associated with Urethrocutaneous Fistula
Serge Zogheib1, Nour Khalil, Georges Mjaess
1At Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon, Serge Zogheib, MD, is Plastic Surgeon, Department of Plastic, Reconstructive, and Cranio-Maxillo-Facial Surgery, and Nour Khalil, MD, MSc, is Urology Resident, Department of Urology. Georges Mjaess, MD, is Urology Resident, Department of Urology, Université Libre de Bruxelles, Brussels, Belgium. Also in the Department of Plastic, Reconstructive and Cranio-Maxillo-Facial Surgery, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Charbel Feghaly, MD; Bechara Daou, MD, and Cyril Hanna, MD, are Urology Residents, and Marwan Nasr, MD, is Plastic Surgeon. The authors have disclosed no financial relationships related to this article. Submitted August 2, 2022; accepted in revised form December 1, 2022.
Insights
Surgical management is crucial for pressure injuries (PIs) with urethral fistulas. Combining urinary diversion with reconstructive surgery, especially using musculocutaneous flaps, significantly improves outcomes for these complex wounds.
Area of Science:
- Urology
- Plastic Surgery
- Wound Management
Background:
- Pressure injuries (PIs) with urethral fistulas present complex management challenges.
- These injuries often occur in patients with spinal cord injuries and pre-existing voiding dysfunction.
Conclusions:
- While prevention and wound care are vital, surgical intervention is necessary for PIs with urethral fistulas.
- Urinary diversion is a critical prerequisite for any ulcer reconstruction.
- Urethral reconstruction, particularly when augmented with musculocutaneous flaps, yields favorable outcomes.
Objective:
To review the literature about combined urologic and reconstructive management of pressure injuries (PIs) with urethral fistulas.
Data Sources:
Authors searched the PubMed, MEDLINE, EMBASE, and Cochrane databases using the following keywords: "Perineum" or "Perineal" and "Pressure Ulcers" or '' Pressure Injury'' and "Urethral Fistula."
Study Selection:
The search yielded a total of 95 articles. Study selection followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement, and the study was designed according to the PICOS (Population, Intervention, Comparison, Outcomes, Study) guidelines. Congress abstracts, letters to the editor, and editorial comments were excluded. After screening, a total of 9 studies (30 patients) were included in the review.
Data Extraction:
Included patients received treatment for a perineal or ischial PI associated with a urinary fistula. The outcomes were recovery, complications, treatment failure, recurrence, and illness-related death.
Data Synthesis:
Pressure injuries were mainly ischiatic (50%) and perineal (43%). Forty-six percent of patients had spinal cord injuries, and at least 40% reported voiding dysfunction. Sixteen percent had previous ischiectomy. Flaps such as posterior thigh flap, biceps femoris flap, and inferiorly based transverse rectus abdominal muscle flap had 88% to 100% success rates when used with urinary diversion techniques. Suprapubic cystostomy, the simplest method of urinary diversion, was successful in 47% of cases when performed alone and in 100% when combined with a pedicled omental flap or a transverse rectus abdominal muscle flap.
Conclusions:
Prevention and wound care are essential for PI management, but when combined with a urinary fistula, surgical management is unavoidable. Urinary diversion is essential before undergoing any type of ulcer reconstruction. Urethral reconstruction showed favorable results, further strengthened when combined with a musculocutaneous flap.
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