Interposing flaps or grafts in Vesico vaginal fistula seminar 2.pptx

Regarding vvf

1. INTERPOSING FLAPS OR GRAFTS IN VESICO VAGINAL FISTULA ‹#›

2. PRINCIPLES OF VESICOVAGINAL FISTULA REPAIR Adequate and complete exposure Ensuring hemostasis Adequate tissue mobilization Suturing without tension with absorbable sutures Ensuring Watertight closure Good blood supply at the repair site Continuous bladder drainage postoperatively r educing post-operative bladder spasms. ‹#›

3. CONSERVATIVE MANAGEMENT Indwelling catheters VVF diagnosed within first few days of surgery(< 3 weeks)- a transurethral or suprapubic catheter placed and maintained upto 30 days Small fistulas (<0.3 cm) may resolve or decrease No improvement in 30 days- unlikely to resolve spontaneously ‹#›

4. 2. Cystoscopic techniques Electrofulguration of small vvf via a transvaginal and/ or cystoscopic route with continuous bladder drainage for 2 weeks (3.5 mm- 6 mm) Tissue Adhesive interposing layer (fibrin glue/ cyanoacrylate glue) > tissue plugs(plug slowly disappears by fibrinolysis and replaced by connective tissue. (<1cm, suboptimal surgical candidates) Cyanoacrylate: Cystoscopically, 0.5 ml injected followed by 0.5 to 1 ml injected transvaginally into the tract, and catheter kept for 2 weeks Narrow tract are amenable to this treatment Complications: Difficulty removing Foley due to adherence with glue, bladder spasm, dysuria, stone formation at the site of glue instillation ‹#› CONSERVATIVE MANAGEMENT

5. TIMING OF SURGERY Conventionally- Delay >3months to allow resolution of inflammation and sloughing of necrotic tissue EAU states- No minimum delay was recommended from initial diagnosis of fistula to robotic repair, when there is no evidence of active infection or recent irradiation Radiation induced VVF- delayed repair (more than 12 months after radiotherapy) Reattempt Surgery after failure- 3 to 6 months ‹#›

6. PREOPERATIVE REQUIREMENT Urine culture sensitivity- UTI should be fully treated before surgery H/o malignancy- Must undergo fistula tract biopsy Nutritional status assessed and optimized before surgery Unobstructed urinary tract drainage ‹#›

7. PREOPERATIVE COUNSELING General risks of surgery Specific- vaginal approach- vaginal shortening, dyspareunia Continuous bladder drainage- patient should be aware of prolonged catheterization Patient should be aware of possibility of persistent urinary incontinence despite anatomical closure, which may need further evaluation and management. Risk of failure and need for reoperation ‹#›

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9. INTERPOSING TISSUE IN VVF Fistulous tract excision with tissue interposing mainly done for Recurrent VVF Ischemic or obstretic fistulas Poor tissue quality Large fistulas >2cm ‹#›

10. INTERPOSING FLAPS AND GRAFTS Reinforce repairs Fill dead space Improve neovascularization Improvement lymph drainage by importing vital vascular structure to the region ‹#›

11. VAGINAL APPROACH - INTERPOSING FLAP OR GRAFT Labial fibro- fatty Martius pad Gracilis muscle flap Peritoneal flap ‹#›

12. MARTIUS FLAP For mid to distal vvf Fibro-adipose tissue in the labium majus isolated Blood supply Inferiorly via perineal branch of internal pudendal artery Superiorly via deep external pudendal artery (branch of femoral artery) Laterally via obturator artery ‹#›

13. Dissection limits: Medially upto labia minora Laterally labiocrural fold Posteriorly Colle’s fascia covering urogenital diaphragm Flap mobilised on superior or inferior pedicle ‹#›

14. MARTIUS FLAP ‹#›

15. PERITONEAL FLAP Useful in higher VVF ( Eg: vvf lie at or near the vaginal apex) Peritoneum identified just proximal to bladder wall Dissection extended posteriorly beyond bladder wall to expose the peritoneal fold in the cul-de-sac Peritoneal reflection is dissected off the bladder wall- Allow advancement of peritoneal flap over the vvf closure ‹#›

16. ‹#› PERITONEAL FLAP

17. SINGAPORE FLAP Also known as the posterior labial artery flap or pudendal thigh flap Fasciocutaneous flap Blood supply is primarily based on the posterior labial artery , which is a branch of the internal pudendal artery, Anterior division of internal illiac artery The flap is designed to be inferiorly based, just medial to the ischial tuberosity- to preserve this crucial blood supply Sensory innervation: Posterior labial branches of the pudendal nerve and perineal branches of the posterior cutaneous nerve of the thigh ‹#›

18. ‹#› SINGAPORE FLAP

19. GRACILIS MYOCUTANEOUS FLAP Gracilis flap is a Mathes and Nahai Type II . It has one dominant and several minor vascular pedicles arising from the medial femoral circumflex (branch of profunda femoris ) Origin is Broad : pubic symphysis, inferior pubic ramus, ischium. Insertion is Thin: medial condyle of the tibia and medial tibial surface Innervation: Branch of obturator nerve Function: thigh adduction and knee flexion ‹#›

20. ‹#› GRACILIS MYOCUTANEOUS FLAP

21. TRANSABDOMINAL APPROACH- INTERPOSING TISSUES The greater omentum Peritoneum Colonic Epiploic appendages Rectus abdominis myocutaneous flap Other graft materials- dehydrated amniotic membrane, fibrin glue ‹#›

22. GREATER OMENTUM Rich blood supply from both gastroepiploic arteries Allow facile mobilization deep into pelvis- maintaining a robust vascular pedicle Inherent lymphatic properties allow healing and re-epithelialization Paucity of omentum or mobilisation to pelvis difficult –Peritoneum in illiac fossa lateral to bladder harvested Other interposing tissue used - colonic epiploic appendages - readily available, do not require dissection for use ‹#›

23. GREATER OMENTUM FLAP ‹#›

24. This flap is based on the inferior epigastric artery , when used for VVF repair Type III Mathes and Nahai Flap based on the dominant Deep Superior and Inferior Epigastric Arteries DIEA (Inferior): dominant, external iliac artery branch DSEA (Superior): dominant, internal mammary artery branch Origin: anterior costal cartilages VI-VIII and xiphoid process Insertion: pubic symphysis and body Innervation: Intercostal nerves Harvesting is more morbid and technically demanding, hence reserved as last resort option. ‹#› RECTUS ABDOMINIS MYOCUTANEOUS FLAP

25. RECTUS ABDOMINIS MYOCUTANEOUS FLAP ‹#›

26. NOVEL APPROACHES Synthetic tissue interposition: Platelet rich plasma and platelet rich fibrin- injected around the fistula occludes the fistula mechanically, meanwhile, the growth factors derived from platelets stimulate fibrosis and neovascularization Tissue Engineering: Researchers are exploring the use of tissue-engineered scaffolds, potentially seeded with cells, to promote regeneration and prevent fibrosis ‹#›

27. THANK YOU ‹#›