Interposing Rectus and Gracilis Muscle Flaps for Pelvic Reconstruction in Bladder Exstrophy after Bladder Neck Closure.

IF 3.2 2区医学 Q1 SURGERY Plastic and reconstructive surgery Pub Date : 2024-12-01 Epub Date: 2024-01-30 DOI:10.1097/PRS.0000000000011315

Thomas G W Harris, Chad B Crigger, Visakha Suresh, Ahmad Haffar, Tamir N Sholklapper, Isam W Nasr, John P Gearhart, Robin Yang, Richard J Redett

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Abstract

Background: The exstrophy-epispadias complex is a spectrum of ventral wall malformations including classic bladder exstrophy and cloacal exstrophy (CE). Patients undergo multiple soft-tissue procedures to achieve urinary continence. If unsuccessful bladder neck closure (BNC) is performed, muscle flaps may be used to reinforce BNC or afterward for fistula reconstruction. In this study, patients reconstructed using a rectus abdominis or gracilis muscle flap were reviewed.

Methods: A retrospective cohort study of patients with exstrophy-epispadias complex who underwent BNC and had a muscle flap was performed. Indication for flap use; surgical technique; and risks for BNC failure, including mucosal violations (MVs), were reviewed. MVs were previous bladder mucosa manipulation for exstrophy closure, repeat closures, and bladder neck reconstruction. Success was defined as BNC without fistula development.

Results: Thirty-four patients underwent reconstruction. Indications included fistula prophylaxis during BNC ( n = 13), fistula closure after BNC ( n = 17), fistula prophylaxis after BNC during open cystolithotomy ( n = 1), or fistula closure after open cystolithotomy ( n = 3). A vesicourethral fistula developed most frequently in classic bladder exstrophy (88.9%) and vesicoperineal fistula in CE (87.5%). Thirty-three rectus flaps and 3 gracilis flaps were used, with success achieved in 97.1% and 66.7%, respectively. All 34 patients achieved success, and 2 patients with CE required a second flap.

Conclusions: The rectus flap is preferred as it covers the anteroinferior bladder and pelvic floor to prevent urethral, cutaneous, and perineal fistula formation. The gracilis flap only reaches the pelvic floor to prevent urethral and perineal fistula development. Increased MVs increase the risk of fistula formation and may influence the need for prophylactic flaps.

Clinical question/level of evidence: Therapeutic, IV.

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用于膀胱颈闭合后膀胱萎缩的骨盆重建的直肌和擒拿肌肌瓣间接术

背景：膀胱外翻-尿失禁综合症是一种腹壁畸形，包括典型的膀胱外翻（CBE）和泄殖腔外翻（CE）。患者需要接受多种软组织手术才能实现排尿。如果膀胱颈闭合术（BNC）不成功，可使用肌肉瓣加固BNC或之后进行瘘管重建。本研究回顾了使用腹直肌或腓肠肌肌皮瓣进行重建的患者：方法：对接受过 BNC 并使用肌皮瓣的外瘘-尿失禁综合症患者进行了一项回顾性队列研究。研究回顾了使用皮瓣的指征、手术技巧、BNC失败的风险，包括粘膜侵犯（MVs）。MV指的是之前进行膀胱粘膜操作用于外翻闭合、重复闭合和膀胱颈重建。结果：34名患者接受了重建手术。结果：34 名患者接受了重建手术，适应症包括 BNC 期间（13 人）、BNC 后瘘管闭合（17 人）、开放性膀胱结石切除术期间 BNC 后（1 人）或开放性膀胱结石切除术后瘘管闭合（3 人）。膀胱尿道瘘最常见于CBE（88.9%），膀胱会阴瘘最常见于CE（87.5%）。使用了 33 个直肌皮瓣和 3 个腕骨皮瓣，成功率分别为 97.1% 和 66.7%。所有34例患者均获得成功，2例CE患者需要使用第二个皮瓣：结论：直肌皮瓣覆盖了膀胱前内侧和骨盆底，可防止尿道、皮肤和会阴瘘的形成，因此是首选皮瓣。腓肠肌瓣只覆盖骨盆底，可防止尿道和会阴瘘的形成。中压增加会增加瘘管形成的风险，并可能影响对预防性皮瓣的需求。

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来源期刊

Plastic and reconstructive surgery 医学-外科

CiteScore

5.00

自引率

13.90%

发文量

1436

审稿时长

1.5 months

期刊介绍： For more than 70 years Plastic and Reconstructive Surgery® has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. Plastic and Reconstructive Surgery® , the official journal of the American Society of Plastic Surgeons, is a benefit of Society membership, and is also available on a subscription basis. Plastic and Reconstructive Surgery® brings subscribers up-to-the-minute reports on the latest techniques and follow-up for all areas of plastic and reconstructive surgery, including breast reconstruction, experimental studies, maxillofacial reconstruction, hand and microsurgery, burn repair, cosmetic surgery, as well as news on medicolegal issues. The cosmetic section provides expanded coverage on new procedures and techniques and offers more cosmetic-specific content than any other journal. All subscribers enjoy full access to the Journal''s website, which features broadcast quality videos of reconstructive and cosmetic procedures, podcasts, comprehensive article archives dating to 1946, and additional benefits offered by the newly-redesigned website.