Roberta Fillipo, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/roberta-fillipo-md

Ulrich D antibiotics for stubborn uti buy discount ciplox 500 mg line, Tammaa A infection knee icd 9 code purchase ciplox 500 mg visa, Holbfer S - buy ciplox 500 mg, et al: Ten-year followup after tension-free vaginal tape-obturator procedure for stress urinary incontinence antibiotics before dental work cheap ciplox 500 mg buy on-line, J Urol 196:1201­1206 antibiotics for sinus infection during pregnancy order ciplox online, 2016. Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial, Int Urogynecol J 27:1029­1038, 2016. Vassallo B, Kleeman S, Segal J, et al: Urethral erosion of a tension-free vaginal tape, Obstet Gynecol 101:1055­1058, 2003. Villet R, Ercoli A, Atallah D, et al: Second tension-free vaginal tape procedure and mesh retensioning: two possibilities of treatment of recurrent-persistent genuine stress urinary incontinence after a primary tension-free vaginal tape procedure, Int Urogynecol J 13:377­379, 2002. Wai C, Atnip S, Williams K, et al: Urethral erosion of tension-free vaginal tape presenting as recurrent stress urinary incontinence, Int Urogynecol J Pelvic Floor Dysfunct 15:353­355, 2004. Walsh K, Generao S, White M, et al: the influence of age on quality of life outcome in women following a tension-free vaginal tape procedure, J Urol 171:1185­1188, 2004. Wang W, Zhu L, Lang J: Transobturator tape procedure versus tension-free vaginal tape for treatment of stress urinary incontinence, Int J Gynaecol Obstet 104:113­116, 2009. Zubke W, Becker S, Kramer B, et al: Persistent urinary retention after tension-free vaginal tape: a new surgical solution, Eur J Obstet Gynecol Reprod Biol 115:95­98, 2004. Change in overactive bladder symptoms after surgery for stress urinary incontinence in women, Obstet Gynecol 126:423­430, 2015. Currently there are several class action lawsuits against manufacturers, and lawyers are directly targeting women who have had these procedures via advertising. Because of the risk of litigation, some mesh kit manufacturers have removed their products from the market. The unbalanced depiction of mesh and its use in the media has further frightened patients and has led some surgeons to stop performing these procedures. In spite of these challenges, well-trained urologists should not be dissuaded from using these effective products in the care of their patients. A recent consensus statement from the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction in conjunction with the American Urogynecologic Society (Nager et al. The procedure is safe, effective, and has improved the quality of life for millions of women. Success rates surpass 90% and are maintained at up to 20-year follow-up with low complication rates. In a landmark population-based study of all incontinence procedures performed in Scotland from 1997 to 2016, mesh slings had fewer immediate complications and lower risk of future prolapse surgery than Burch colposuspension (Morling et al. Of course, no surgery is without risks, and surgeons must understand how to appropriately counsel patients before undergoing surgery and to diagnose and treat complications should they occur. Contraction is when the mesh exhibits "shrinkage or reduction in size," and prominence occurs when there are "parts that protrude beyond the surface. Its success at preventing hernia recurrence has led to its use in other body compartments. Unlike the abdominal wall, the vagina has unique properties that may complicate mesh implantation, such as its significant physiologic stretch; proximity to the bladder, urethra, and rectum; and abundant microbiota. Numerous adverse outcomes have been described with vaginal mesh implantation, including mesh infection, chronic pain, dyspareunia, vaginal exposure of the mesh, mesh shrinkage, perforation of mesh into surrounding structures, and lower urinary tract symptoms. However, there are also clear advantages to mesh over native tissue or cadaveric tissue/xenografts, including avoidance of potentially morbid harvests, lack of human or animal products that put the patient at risk for disease transmission, moderate cost, versatility, and durability (Chughtai et al. Several mesh products have been used as mesh slings over the years with varying success and complications. It is one of the stiffest mesh materials with a propensity to wrinkle and a high extrusion rate (Morgan et al. In contrast, polypropylene is a monofilament knitted graft that is softer and more compliant than woven configurations and has larger interstices resulting from the loose knit (1500 vs. Gore-Tex is polytetrafluoroethylene (Teflon) that has been thermomechanically expanded into a microporous mesh with a pore sized 10 µm. It becomes encapsulated in the body, which deters tissue integration, preventing adhesions. Despite success with small patch slings, more than 30% of full-length slings have required excision (Weinberger and Ostergard, 1996). With vaginal use, complications from Mersilene, such as extrusion requiring excision and voiding symptoms, approached 20% (Young et al. The mesh became exposed at the original incision but has continued to become more extruded over time. Note a small central defect in the mesh where it has been trimmed in the office previously. Smaller pore size in woven grafts allows bacteria (1 µm) to enter but restricts entry of host macrophages and lymphocytes (50 µm), impeding immune response. When pores are large, such as with polypropylene type I mesh (approximately 1500 µm), fibrocollagenous tissue ingrowth can occur, which allows the mesh to integrate into the local tissue, providing strength and support (Gomelsky and Dmochowski, 2007). Modifications have been attempted to improve tissue acceptance, such as injection of bovine collagen (ProteGen) or novel welding techniques (Urotype/Obtape), but these have produced unacceptably high rates of exposure and fistula formation (Domingo et al. With long-term use of mesh in the vagina there has been the opportunity to follow women over many years for complications. Mesh has been hypothesized to increase cancer risk because of chronic foreign body response. This theory has been disproved with population-based studies that showed no increase in pelvic or any other cancer diagnoses in women followed for 6 years after implant (Chughtai et al. Similarly mesh implantation has not been associated with the development of autoimmune diseases over long-term follow-up (Chughtai et al. There is, however, moderate vaginal tissue fibrosis in more than half of patients, and almost all have giant cell reaction that occurs after vaginal mesh placement. Interestingly, those patients with extrusion or pain have less inflammation noted on histopathology than patients with voiding dysfunction, but overall mild inflammation predominates (Hill et al. This 2008 statement advised care providers that mesh has the potential for complications. In a Medicare population the use of mesh in prolapse repair was only 2% in 2005 and increased to 35% in 2008. With the 2008 warning mesh use plateaued and then started to decrease in 2011 (Wang et al. Given the medicolegal controversy surrounding mesh, before any mesh excision it is advisable to have a standard consent form for mesh removal as well as an institutional policy for the handling of mesh being returned to patients if they desire it. It is important to keep in mind that mesh removal is not without its own complications and the more mesh removed the greater the risks. It has been shown that more mesh removal leads to an increase in recurrent prolapse (Marcus-Braun and Theobald, 2010) and incontinence as well as excess bleeding (Pickett et al. Mesh becomes embedded in tissue and does require significant dissection to remove. Removal of all the mesh is rarely required, and removing asymptomatic mesh is never indicated. The patient had severe pelvic pain with voiding and wanted the entire abdominal mesh removed. Both are strongly related to obesity, smoking, childbearing, and advancing age, and their prevalence appears to be increasing. Stress incontinence can be treated conservatively with pelvic floor physical therapy, vaginal inserts, or a pessary, but if these are not effective, a surgical approach is the next step. In regard to single-incision, or "mini-slings," "physicians may offer single-incision slings to index patients undergoing midurethral sling surgery with the patient informed as to the immaturity of evidence regarding their efficacy and safety" (Kobashi et al. There are clear contraindications to mesh implantation in the vagina, including women who are having a simultaneous urethrovaginal fistula, mesh urethral perforation, or urethral diverticulum repaired given the extensive urethral dissection in these procedures (Kobashi et al. Other less well-defined risk factors for mesh exposure or extrusion include prior (not concurrent) urethral fistula repair, prior diverticula surgery, pelvic radiation or the presence of significant scarring, and poor tissue quality. Other potential patient risk factors include extremes of age, smoking, obesity, and low estrogenization of the vagina. If the patient is improving, short-term voiding dysfunction can be managed expectantly for up to 6 weeks. However, if the patient is in retention, intervention should be much sooner because it is unlikely to resolve (Committee Opinion 694, 2017). If done within the first week, the sling can be loosened by opening the vaginal incision, placing an instrument around the mesh, and tugging. If the sling is embedded in the tissue and does not loosen, then the sling can simply be divided. Before division of the sling, the amount of urethral mobility can be assessed by pulling on the catheter; after division, this should be appreciably improved. Women with increased medical comorbidities (Charlson comorbidity index 1) are also at greater risk of failing their initial voiding trial (Ripperda et al. Blood loss for all sling procedures is typically less than 50 mL; however, major vessel injury can occur with the retropubic approach (<1/1000) and may be life threatening (Ford et al. In addition, symptomatic pelvic hematomas occur more often in retropubic slings (1. This is in contrast to the mesh used in vaginal prolapse repair, in which the rate is much higher at 10% to 12% (Abed et al. Voiding dysfunction resulting from obstruction is more common after retropubic slings (0. De novo symptoms of overactive bladder occur in 0 to 7% of cases and may be related to obstruction, which should be ruled out (Ford et al. Rarer complications include bowel perforation, nerve injury, and obturator/vaginal abscess (all <1%). A thorough history including review of prior operative reports (from mesh implantation and attempts at excision) as well as a good speculum pelvic examination are required in all cases of suspected mesh complication. Cystoscopy can be performed if there is any suspicion of mesh perforation into the bladder. The time elapsed from surgery does not exclude the possibility of a complication: patients who had slings placed decades ago can still have new mesh exposures (Khanuengkitkong et al. Vaginal Mesh Exposure and Extrusion Mesh exposure and extrusion likely occur as a result of a delayed infection of the incision or mesh, a vaginal hematoma that leads to separation of the incision, excess tension on the graft, or inadvertent injury to the vagina with mesh placed too superficially within the vaginal wall (Chermansky and Winters, 2012). Small exposures can sometimes spontaneously reepithelialize, especially in the early postsurgical period, and this can be facilitated with short-term topical estrogen (Committee Opinion 694, 2017). Different approaches have been reported, such as laparoscopic mesh removal (Rouprêt et al. If the mesh is not appreciated on exam, an inverted U-shaped incision offers maximal exposure to explore for the mesh and allows the flap to be extended proximally as needed. Before incision, hydrodissection with 1% lidocaine with epinephrine facilitates flap creation by maximizing epithelial thickness over the mesh. The surgeon should not accidentally divide the mesh while making the vaginal incision because this makes mesh localization difficult. If the mesh is not easily palpated, a metal instrument can be used to sound over the dissected space because mesh can be "felt" as a scratching over the area. Alternatively, intraoperative translabial ultrasound can localize mesh very accurately (Staack et al. It can be found as distal as the urethral meatus and can migrate proximally past the bladder neck. Once the mesh is found, careful blunt and sharp dissection is performed to expose the full width of the sling lateral to the urethra. This careful exposure allows easy passage of an instrument behind the sling, avoiding injury to the urethra. Each arm can be dissected laterally to the lateral sulcus of the vagina and with tension divided as far as the surgeon can safely pass the scissors. Care must also be taken not to injure the urethra when passing the instrument behind the sling. If the urethra is injured, it should be repaired in layers and a catheter left in place. Patients can have their catheters removed before discharge, unless bladder or urethral injury is noted. Also women with new obstructive urinary symptoms such as straining, double voiding, slow stream, or the need to assume unusual positions such as crouching to void are obvious and often do not require urodynamics to diagnose. Women with prior difficulty emptying may have underlying pathology such as detrusor underactivity or diabetes, but in women who voided well before sling placement the cause is most likely the sling. Women without overt retention often take longer to diagnose (on average 6 months) (Crescenze et al. This is a rapidly expanding vulvar hematoma after vaginal removal of an obturator sling. Patient required open evacuation via the vaginal incision, and the bleeding resolved with suture ligation of bleeding and vaginal packing. Preoperative risk factors for the development of pain after a sling include younger age, pain conditions such as fibromyalgia, or preexisting pelvic pain (Geller et al. Pain has been proposed to be caused by mesh shrinkage, excess tension on surrounding structures, obturator neuralgia, or muscle hypertonia from mesh being placed through pelvic floor muscles (Rigaud et al. Pain that is severe and occurs acutely after a sling placement in the absence of other complications should be evaluated immediately. Many chronic mesh pain patients describe their pain as occurring immediately postprocedure. Although this is untested, it would seem legitimate to consider rapidly removing a mesh sling in the case of severe postoperative pain because mesh removal procedures are straightforward before tissue ingrowth (Rigaud et al. Before proceeding with mesh removal, the urologist should obtain crosssectional imaging to rule out hematomas, because they are a common cause of discomfort and will likely resolve over time. Diffuse pelvic floor hypertonicity or unilateral levator hypertonicity will benefit from oral analgesia and pelvic floor physical therapy or trigger point injections as a first step. Dyspareunia can also be the result of vaginal atrophy and lack of lubrication rather than the sling, and a trial of vaginal estrogen should be considered in postmenopausal women.

Zipper injuries to the penis more often happen to impatient boys or intoxicated men antibiotic 9 letters buy ciplox from india. Multiple maneuvers are available to free the entrapped skin and to remove the mechanism antibiotics for sinus infection not penicillin cheap ciplox 500 mg buy line. After a penile block virus under microscope 500 mg ciplox free shipping, the zipper slider and adjacent skin can be lubricated with mineral oil bacteria yeast and blood slide purchase generic ciplox from india, followed by a single attempt to unzip and untangle the skin (Kanegaye and Schonfeld bacterial conjugation generic ciplox 500 mg buy, 1993; Mydlo, 2000). The cloth material connected to the zipper can be incised with perpendicular cuts in between each zipper tooth to release the lateral support of the zipper, allowing the device to fall apart and release the trapped skin (Oosterlinck, 1981). A bone cutter or similar tool can be used to cut the median bar (diamond-shaped connection) of the slider. This maneuver allows separation of the upper and lower shields of the slider, and the entire zipper falls apart (Flowerdew et al. Alternatively, a screwdriver may be placed between the upper and lower shields of the slider, and a twisting action separates the two shields from the median bar and unravels the zipper (Raveenthiran, 2007). Another technique involves cutting the anterior shield with a wire cutter (Maurice and Cherullo, 2013). Some children may require more than local anesthesia or sedation; circumcision or an elliptical skin excision can be performed in the operating room under anesthesia (Mydlo, 2000; Yip et al. Accidental injuries with thread, hair, or rubber bands occur in children, but child abuse must be considered in such cases. Any child with unexplained penile swelling, erythema, or difficulty voiding should be examined closely for a hidden strangulating hair or string. Adults may place objects around the shaft as a means of sexual pleasure or to prolong an erection. The constricting device can reduce blood flow, cause edema, and induce ischemia; gangrene and urethral injury may develop in delayed presentations. Emergent treatment requires decompression of the constricted penis to allow blood flow and micturition. Initial attempts to remove a solid constricting device causing penile strangulation involve lubrication of the shaft and foreign body and attempted direct removal. A string or latex tourniquet can be wrapped around the distal shaft to decrease swelling and to improve the odds of removing the device with lubrication. If the constricting object cannot be severed or removed, a string technique should be considered (Browning and Reed, 1969; Vahasarja et al. A thick silk suture or umbilical tape is passed proximally under the strangulation object and wound tightly around the penis distally toward the glans. The tag of suture or tape proximal to the ring is grasped; unwinding from the proximal end pushes the object distally. Glanular puncture with a needle or blade allows escape of dark trapped blood and improves the odds of removing the object with the string method (Browning and Reed, 1969; Noh et al. Plastic constricting devices can be incised with a scalpel or an oscillating cast saw (Pannek and Martin, 2003), but metal objects present a more difficult challenge. Readily available hospital equipment (ring cutters, bolt cutters, dental drills, commercially available rotary tools, orthopedic and neurosurgical operative drills) may be inadequate to cut through heavy iron or steel items. The use of industrial drills, steel saws, hacksaws, saber saws, and high-speed electric drills is often required (Perabo et al. Occasionally, fire department and emergency medical services equipment may be required to cut through iron and steel rings. The phallus should be protected from thermal injury, sparks, and the cutting blade by use of tongue depressors, sponges, or malleable retractors; continuous saline irrigation may be used for cooling (Video 133. Such elaborate undertakings are best accomplished in the operating room under anesthesia. If decompression is delayed and the patient is distended and unable to void, a suprapubic bladder catheter should be placed. Outcomes are generally favorable with device removal alone, although the surgeon should be prepared to consider reconstructive techniques such as skin grafting if the strangulation injury causes skin necrosis (Gaspar et al. Testis Etiology Although the testis is relatively protected by the mobility of the scrotum, reflexive cremasteric muscle contraction, and the tough fibrous tunica albuginea, blunt injury (usually the result of assault, sports-related events, and motor vehicle accidents) can result in rupture of the tunica albuginea, contusion, hematoma, dislocation, or torsion of the testis. Testicular injury results from blunt trauma in about 75% of cases (Cass and Luxenberg, 1991; McAninch et al. Similar to penetrating urethral injuries, penetrating scrotal trauma (roughly 80%) usually involves neighboring structures, including the thigh, penis, perineum, bladder, urethra, or femoral vessels (Cline et al. In contemporary military conflicts, genital wounds account for a larger percentage of urologic injuries because of the powerful explosive weapons involved and absence of protective body armor over the genitalia (Janak et al. Blast injuries are typically associated with extensive scrotal skin loss, multiple projectile injuries of both testes, and concomitant extensive destruction of the lower extremities and abdomen. Diagnosis Rupture of the testis must be considered in all cases of blunt scrotal trauma. Swelling and ecchymosis are variable, and the degree of hematoma may not correlate with the severity of testicular injury; absence does not entirely rule out testicular rupture, and contusion without fracture can manifest as significant bleeding. Scrotal hemorrhage and hematocele along with tenderness to palpation often limit a complete physical examination. Differential diagnosis of testicular fracture includes hematocele without rupture, torsion of the testis or an appendage, reactive hydrocele, hematoma of the epididymis or spermatic cord, and intratesticular hematoma. A nonpalpable testis in a trauma patient should raise the possibility of dislocation outside the scrotum. This entity usually occurs after motorcycle crashes when extreme forces on the scrotum expel the testis into surrounding tissues such as the superficial inguinal pouch (50%) or to a pubic, penile, pelvic, abdominal, or perineal location (Bromberg et al. Finally, approximately 5% of spermatic cord torsions are thought to be precipitated by trauma; torsion should be considered in all cases of significant scrotal pain without signs or symptoms of major scrotal trauma (Elsaharty et al. Penetrating injuries mandate careful examination of surrounding structures, especially the femoral vessels. Ultrasonography can be helpful to assess the integrity and vascularity of the testis in equivocal cases. Because it may be operator dependent, false-positive and false-negative studies range from 56% to 94% (Corrales et al. Although ultrasonography may assist in detection of testicular fracture or hematoma (Guichard et al. Minor scrotal injuries without testicular damage can be managed with ice, elevation, analgesics, and irrigation and closure in some circumstances. The objectives of surgical exploration and repair are testicular salvage, prevention of infection, control of bleeding, and reduced convalescence. Either transverse or vertical scrotal incisions can be performed for successful exploration. The tunica albuginea should be closed with small absorbable sutures after removal of necrotic and extruded seminiferous tubules. Even small defects in the tunica albuginea should be closed primarily because progressive swelling and any rise in intratesticular pressure can continue to extrude seminiferous tubules over time. Loss of capsule tissue may require removal of additional parenchyma to allow closure of the remaining tunica albuginea. Ultrasound examination demonstrates hypoechoic intratesticular areas (arrow) consistent with testicular rupture sustained by blunt trauma. Significant intratesticular hematomas should be explored and drained, even in the absence of testicular rupture to prevent progressive pressure necrosis and atrophy, delayed exploration (40%), and orchiectomy (15%) (Cass and Luxenberg, 1988). Significant hematoceles should also be explored, regardless of imaging studies, because up to 80% are caused by testicular rupture (Buckley and McAninch, 2006; Vaccaro et al. Penetrating scrotal injuries should be surgically explored to inspect for vascular and vasal injury; the same principles of salvage, hemostasis, and reconstruction apply as in blunt trauma. The injured vas should be ligated with nonabsorbable suture, and delayed reconstruction should be performed if necessary. Depending on the mechanism and trajectory of the projectile, scrotal exploration of the contralateral testis should be considered (Simhan et al. Genital and Lower Urinary Tract Trauma 3053 Outcome and Complications Nonoperative management of testicular rupture is frequently complicated by infection, atrophy, necrosis, chronic unrelenting pain, and delayed orchiectomy. Testicular salvage rates exceed 90% with exploration and repair within 3 days of injury (Cass and Luxenberg, 1991; Del Villar et al. Indicative of the benefits of early intervention, testicular salvage rates with conservative management approach only 33%, with delayed orchiectomy rates between 21% and 55% (Cass and Luxenberg, 1991; McAleer and Kaplan, 1995; Schuster, 1982). Timely surgical intervention for testis injury is also probably warranted as roughly one-half of patients initially managed conservatively fail and will ultimately undergo surgical exploration for pain, infection, and persistent hematoma (Cass and Luxenberg, 1991; Del Villar et al. Convalescence and time of return to normal activities are significantly reduced after early surgical repair. In contrast with blunt testis rupture, for which salvage rates are very high, penetrating testicular trauma has historically been associated with gonad salvage in only 32% to 65% of cases in historic cohorts (Bickel et al. However, likely secondary to heightened provider awareness, improved salvage rates as high as 86% have been reported in more recent civilian series (Bjurlin et al. Most surgical patients have adequate preservation of hormonal and fertility function (Kukadia et al. Sperm production has been documented in men with appropriately repaired bilateral testis rupture and bilateral penetrating injuries (Brandes et al. Urologists may be consulted for opinion and guidance with regard to boys with a solitary testis who play a contact sport. Testicular injuries are exceedingly rare in boys involved in individual or team contact sports and recreational activities (McAleer et al. Parents should be appropriately counseled, and a protective cup device should be recommended, but it also must be made clear that the benefits of continued physical activity far outweigh any concerns for potential complications (Diokno and Rowe, 2010). Further, the American Academy of Pediatrics Committee on Sports Medicine and Fitness has definitively recommended that children with a solitary testicle be allowed to participate universally in noncontact and full-contact sports (Rice, et al. Penile skin loss can result from traction by mechanical devices, such as farm or industrial machinery, or by suction devices, such as vacuum cleaners. Because the superficial penile tissue is loose areolar tissue, it is often torn free without damage to the underlying structures. Penile burns, although rare, are often full-thickness burns because the penile skin is so thin (Horton and Dean, 1990). Constricting bands placed on the penis can result in significant skin loss, although a more common injury involves direct pressure necrosis under the band, which usually heals well with device removal alone. Diagnosis and Initial Management Although both cellulitis and Fournier gangrene are commonly associated with significant genital edema and erythema, skin ischemia with crepitus is the hallmark of Fournier gangrene. Wounds are treated with frequent wet-to-dry dressing changes or with vacuum-assisted closure therapy (Czymek et al. Early suprapubic urinary diversion should be strongly considered for extensive injuries to simplify wound care and to prevent urethral complications related to prolonged catheterization. Hyperbaric oxygen treatment has been advocated as an adjunctive measure to promote wound healing, although we do not recommend this because of the considerable increased expense and logistical complexity in the absence of proven benefit (Mindrup et al. Negative-pressure wound care therapy can also be utilized in complex cases of Fournier gangrene with large wound surface areas to reduce mortality and theoretically promote wound granulation (Czymek et al. Genital Skin Loss Etiology Necrotizing gangrene secondary to polymicrobial infection in the genital area, or Fournier gangrene, is the most common cause of extensive genital skin loss (McAninch et al. Skin loss is iatrogenic, caused by the necessity for acute debridement of necrotic genital skin and optimization of infection control. Genital burns are largely treated similarly to other burns, with early resection of burn eschar and coverage with split-thickness skin grafts when possible. Partial-thickness skin loss or genital burns may be treated with silver sulfadiazine cream. For deep penile electrical burns, a conservative approach is warranted because the ultimate outcome usually is autopenectomy and/or death as a result of extensive concurrent injuries (Medendorp et al. Penile Reconstruction In selected uncircumcised patients, mobilization of redundant foreskin may allow primary closure of middle to distal penile skin loss (Horton and Dean, 1990). Scrotal rotation flaps can also be used for more proximal defects if skin loss is limited, but the hair-bearing nature of scrotal skin risks an unacceptable cosmetic result (Zhao et al. Local flaps, such as from the abdomen and thigh, can be used but are cosmetically inferior to split-thickness skin grafts. Skin coverage with avulsed skin should be avoided because it often becomes necrotic. Meshed grafts can be used but have a tendency to contract and are cosmetically inferior to unmeshed grafts. If grafts are to be used, care must be taken to remove any subcoronal skin remaining after debridement. Lymphatic obstruction of this distal foreskin, if it is not excised, results in circumferential lymphedema (McDougal, 2003). Graft stabilization in the immediate postoperative period may be achieved with either a tie-over-bolster technique or with a circumferential vacuum dressing (Senchenkov et al. Skin grafts placed on the penile shaft never regain normal sensation (Horton and Dean, 1990), although sexual function is often preserved because of intact sensation in the glans and maintenance of corporal anatomy without alteration of blood flow. In addition to providing an excellent cosmetic result, meshing allows exudate to escape from the interstices, improving graft take. The spermatic cords and testes are sewn together in multiple areas before grafting to prevent a bifid neoscrotum (Tan et al. The neoscrotum may appear unnaturally tight initially, but after 6 to 12 months the testes eventually occupy a more natural dependent position. Thigh flaps can be used to reconstruct the scrotum when the testes have been buried in the thighs after traumatic or surgical scrotal removal (Morey and McAninch, 1999). Fibrin sealant has proven useful as a tissue glue to promote healing and to reduce drainage during complex genital reconstruction cases (Morris et al. Most blunt bladder injuries are the result of rapid-deceleration motor vehicle collisions, but many also occur with falls, crush injuries, assault, and blows to the lower abdomen. Disruption of the bony pelvis tends to tear the Scrotal Reconstruction Scrotal skin loss defects of up to 50% can often be closed directly.

500 mg ciplox with visa. Antimicrobial Resistance Could End Modern Medicine – Dr. Margaret Chan.

They noted that the long-term results were acceptable with minimal adverse effects antibiotics for uti cephalexin purchase cheap ciplox line. Blood loss was minimal antibiotic resistance is ancient purchase ciplox with mastercard, and no transfusions were needed antibiotic resistance penicillin order ciplox 500 mg on-line, but mild postoperative buttock pain was noted that resolved by 3 months antimicrobial 3-methyleneflavanones order ciplox online now. In 21 of 24 patients there was no recurrence of prolapse at the apex antibiotic resistance cdc buy ciplox 500 mg on line, but one patient underwent repeat operation for a significant cystocele. With a unilateral suspension, the vagina is deflected to the right side and caudally. The anterior compartment has been reported as a particularly vulnerable site for developing a defect after sacrospinous vaginal vault suspension. This is noted not only postoperatively but also intraoperatively, although many who develop anterior defects remain asymptomatic and do not undergo subsequent surgery to correct the anterior compartment defect (Paraiso et al. The Pelvic Floor Network Dyfunction Network evaluated anatomic anterior compartment prolapse recurrence and the effect of concomitant repair after vaginal apical procedures. Some of the theoretic advantages of the anterior approach include improved ability of the vagina to withstand increased intraabdominal pressures (Pohl and Frattarelli, 1997), and less likelihood of rectal injury (Sauer and Klutke, 1995). Again, a low incidence of anterior compartment recurrence was noted at 7% (Cespedes, 2000). Those who showed absence of any compartment defect at the 6-week follow-up had only a 3% likelihood of requiring additional reconstructive surgery within 2 to 5 years. Generally, this pain has shown spontaneous resolution within 2 to 3 months when delayed absorbable sutures were used (Maher et al. Postoperative mild to moderate neuropathic pain can be managed with observation, and patients should be counseled that duration may be as long as 3 months (Sauer and Klutke, 1995). Injection of the nerve with local anesthetic has been used for treatment (Lantzsch et al. In patients with severe or persistent radicular neuropathic type pain, suture removal may be considered. When a perforation was recognized at the time of surgery and repaired primarily, no sequelae were observed (Richter and Albrich, 1981; Sauer and Klutke, 1995). In addition, injury to the pudendal nerve and internal pudendal vessels may occur with sutures placed too near the ischial spine. As the fatty tissue is dissected free, the anterior surface of the sacral promontory is visualized, usually by identification of the anterior longitudinal ligament. Two to three interrupted, nonabsorbable monofilament sutures are placed in the anterior longitudinal ligament with care to avoid perforation of the midline sacral vessels. Generally, sutures are placed under the vessels and tied down over the top of the vessels. Alternatively, if vessels overlie the ligament, bipolar energy can be used on the vessels to prevent bleeding before placing the sutures. Alternatively, commercially available tacking devices may be used for securing the graft to the sacral promontory, although minimal data exist to confirm comparable efficacy. After placing an end-to-end anastomosis sizer or commercially available vaginal stent in the vagina, the surgeon identifies the enterocele sac, if present, and secures it with an Allis clamp. If the enterocele is large, a Halban culdoplasty can be performed by placing linear permanent or delayed absorbable sutures through the posterior peritoneum and on the outer surface of rectum up to the vaginal cuff (Geomini et al. Alternatively, if an aggressive posterior vaginal dissection to the perineum is to be performed (see later) for placement of an extended piece of posterior mesh with subsequent retroperitonealization of the mesh, the culdoplasty is usually not needed. Some pelvic surgeons perform minimal dissection of the peritoneum and bladder off the vagina, enough to fix the mesh for 4 to 5 cm on each side, whereas other techniques describe a more extensive dissection that involves lifting the posterior bladder wall and trigone off the underlying vagina, as well as dissecting all the way to the perineal body. With the advent of robotic techniques, it seems that more extensive dissections are being carried out with longer mesh segments attached to the bladder, although there are no controlled studies to identify the optimal technique of graft placement to the vagina. Care is taken to identify the border of the bladder to avoid suturing the graft to the bladder and to secure the lateralmost portions of the mesh to prevent folding. An obturator in the vagina is useful to facilitate suture placement and secure the mesh to the vagina. The graft is secured to the vagina by folding over the cuff of the vagina and allowing the long end of the graft to exit posteriorly and extend to the sacrum. The short arm of the this placed on the top of the vagina, and the long arm of the this secured to the lower end of the vagina. The posterior segment of the mesh is then attached to the posterior vaginal wall with 6 to 8 interrupted monofilament delayed absorbable or nonabsorbable sutures. At this step, the central sutures from the culdoplasty are placed through the long arm of the mesh if desired. Placing the obturator all the way into the vagina but not pushing the vagina upward establishes the proper length for the graft. The graft is placed along the right lateral aspect of the rectum in the space previously developed by extending the opening of the peritoneum from the sacrum. With this technique, the vaginal vault is attached to the fascia of the iliococcygeus muscle as the anchoring site in contrast to the uterosacral or sacrospinous ligaments. The fascia of the iliococcygeus muscle is identified lateral to the rectum and distal the ischial spine (Shull et al. It is recommended that bilateral suture fixation be performed to achieve optimal results. Special needle drivers and lighted retraction are useful to facilitate suture placement. In cases using permanent suture a pulley-stitch technique is applied, tying the knot internally. Eight patients experienced pelvic support loss postoperatively, 3 in the middle (apical) compartment, 2 in the posterior compartment, and 4 in the anterior compartment. Intraoperative complications included rectal and bladder laceration and hemorrhage requiring transfusion. Postoperative complications included vaginal cuff abscess, fever, and transient femoral neuropathy. Abdominal Sacrocolpopexy Abdominal sacrocolpopexy should be considered a treatment option in the following clinical scenarios: failed previous vaginal repair, isolated uterine prolapse and/or enterocele, younger women, women with a highly active lifestyle, women who are sexually active, and women who desire one of the consistently most durable repairs at the expense of a potentially more invasive approach. As discussed earlier, other pelvic floor defects and stress urinary incontinence can be addressed at the same time. In addition to open surgery, robotic-assisted laparoscopic and pure laparoscopic approaches have been described and are commonly used today (Daneshgari et al. The critical elements of the operation include the use of permanent mesh (polypropylene) or autologous fascia as graft material and secure fixation of the graft to the sacral promontory and vaginal cuff. The patient is positioned in the low lithotomy position, providing transvaginal and transabdominal access. Upon surgical entry into the peritoneal cavity, it is important to achieve exposure of true pelvis by careful packing of the small intestine and sigmoid colon. This is accomplished by releasing all adhesions in the pelvis and packing the bowel above the level of the sacral promontory and displacing the sigmoid to the left, exposing the sacral promontory and posterior peritoneum. An incision is made in the posterior peritoneum over the sacral promontory, extending inferiorly along the right lateral aspect of the rectum towards the cul-de-sac. Electrocautery is used when dividing the fatty tissue over the promontory to minimize bleeding and improve visualization. Abdominal sacrocolpopexy Synthetic graft material is sutured securely to vaginal cuff using multiple interrupted permanent sutures. The peritoneal cul-de-sac is closed using linearly placed sutures to obliterate this potential space. Tensioning in this fashion is not feasible with a robotic or laparoscopic approach. It requires a visual cue of the mesh attachment while extending the vagina cephalad with an end-to-end anastomotic sizer to its maximal length without actively stretching it. Last, the graft is positioned in the retroperitoneal space by closing the posterior peritoneum over the graft and covering the graft on the vagina with the superior edge of the anterior peritoneum and bladder flap. The patient is then examined to determine if any ancillary transvaginal prolapse repairs are needed. Sacrocolpopexy may be performed with a minimally invasive technique using laparoscopy or robotic surgery. The basic steps of the procedure are the same whether performed abdominally, robotically, or laparoscopically and differ mainly by the method of abdominal entry, trocar placement, docking the robotic patient cart, and method of suture fixation. After administration of general anesthesia, the patient is properly positioned in Allen stirrups in a low lithotomy position, the arms are properly tucked to the side, and all bony prominences are padded. A pelvic exam is performed, the abdomen and vagina are surgically prepared, a Foley catheter is inserted into the bladder, and nasal/ oral gastric tube is placed. Laparoscopic entry can be performed with an open or closed technique; although the umbilicus is the most frequent site of entry, other sites include the left upper quadrant or subxiphoid and less commonly, transuterine and transvaginal. However, meta-analyses have not shown that any of the techniques are superior to the others (Ahmad et al. Typically starting at the umbilicus, the surgeon makes an incision at the base of the umbilicus and an 8. B, From Scarpero H, Cespedes R, Winters J: Abdominal approach to the repair of vaginal vault prolapse. The typical robotic instruments used are the robotic monopolar scissors, robotic Maryland bipolar instrument, and a robotic bowel grasper. After any necessary adhesiolysis, the bowel is gently swept out of the pelvis and above the pelvic brim. Next the ureters are identified along the pelvic side walls, especially the right ureter, which is close to the area of dissection. Careful dissection in this area is essential to avoid shearing of presacral veins because severe bleeding may occur. It is equally important to avoid the left common iliac vein, which is not infrequently located more medial than the artery and can be injured during exposure of the promontory (Good et al. The middle sacral vessel traverses over the promontory and should also be avoided. The peritoneum incision is extended along the right pelvic side wall into the Douglas cu-de-sac. The upper vagina and vaginal apex must be elevated and distended with a vaginal stent. This permits adequate dissection and visualization of the fibromuscular layers of the vaginal wall and aids in graft placement. The vagina is elevated via the vaginal stent, and the peritoneum covering the vagina is incised transversely. Dissection should progress just above the fibromuscular layer in the loose areolar tissue of the vaginal wall. Dissecting in the appropriate plane decreases the risk of accidental entry into the vagina. Unintentional entry into the vaginal lumen increases the risk of future graft exposure especially when using synthetic mesh. If the vaginal wall is opened, it should be irrigated copiously followed by a two-layer closure with 2-0 or 3-0 delayed absorbable suture. Vaginal apex is redirected anteriorly, and the peritoneum covering the posterior wall is open. If a sacrocolpoperineopexy is planned, dissection continues beyond the rectal reflection to the level of the perineal body (Reddy et al. The selection of the sacrocolpopexy graft is a preference of the surgeon, in general if using synthetic mesh it should be lightweight, flexible, and porous (Brown et al. Once the initial dissection has been performed, the robotic instruments are switched to robotic needle drivers with the addition of a bowel-safe grasper. The suture is placed in full-thickness fashion without entering the vaginal lumen. Studies have shown equivalent long-term outcomes with the use of absorbable suture compared with permanent suture for sacrocolpopexy mesh fixation (Shepherd et al. The vaginal stent is then directed posteriorly toward the promontory and maximally extended cephalad. Tension on the stent is then released, allowing the apex to lie in a normal apical position with the prolapse reduced. Excessive tension should be avoided because it can result in pain or de novo stress urinary incontinence (Nygaard et al. The apical suspension should reduce the prolapse of the apex as well as the segments of the anterior and posterior vaginal walls. The tail of the graft is sutured to the anterior longitudinal ligament at the level selected by the surgeon. Traditionally sutures are placed at the S1 vertebral body or at the level of the sacral promontory (Nygaard et al. Suture placement at S3 or S4 vertebral body increases the risk of injury to the presacral venous plexus, whereas placement sutures at the upper portion of the sacral promontory risks laceration of the middle sacral vessel or the left common iliac vein (Wieslander et al. However, at the level of S1 the middle sacral vessels are readily visible and can be easily isolated and avoided; two to three monofilament permanent sutures are used to fixate the graft to the anterior longitudinal ligament. Cystoscopy is performed to rule out injury to the bladder, intravesical suture, or mesh perforation and to confirm ureteral patency. As stated earlier, sacrocolpopexy may be performed with a minimally invasive technique using laparoscopy or robotic surgery. After administration of general anesthesia, the patient is properly positioned in Allen stirrups in low lithotomy position, the arms are properly tucked to the side, and all bony prominences are padded, a pelvic exam is performed, the abdomen and vagina are surgically prepared, and a Foley catheter is inserted into the bladder. A 0-degree laparoscope is inserted through the umbilical trocar and careful inspection of the peritoneal cavity is performed, delineating all the pertinent anatomy to performing the sacrocolpopexy. Depending on the anatomy and whether adhesiolysis is necessary, trocar placement can be performed.

The peak incidence of vesicoenteric fistula occurs at 55 to 65 years of age bacteria resistant to penicillin ciplox 500 mg order on-line, although fistulae from Crohn disease manifest much earlier (Badlani et al antibiotics for dogs petsmart discount ciplox 500 mg with mastercard. In a multi-institutional retrospective review of 400 patients with Crohn disease over a 10-year period viruses ciplox 500 mg purchase on-line, 8 patients (2%) were found to have enterovesical fistulae common antibiotics used for sinus infection purchase ciplox 500 mg with visa, 7 had ileovesical going off antibiotics for acne 500 mg ciplox otc, and 1 had colovesical fistulae (Gruner et al. Intestinal fistulae in Crohn disease most typically involve the small bowel, although communication with urinary tract and large bowel are also found; involvement of the bladder was reported in 27% and of the colon in 14% in one series (Glass et al. Three large series examining the urologic complications in association with Crohn disease reported that although a majority of patients were female, the most serious complications were seen in males; most significantly, 30 of 31 or 93% of the ileovesical fistulae described in these series were in men (Ben-Ami et al. Although clearly diverticular disease involves the large bowel primarily in all cases, diverticular fistulae have been reported to communicate with the bladder in 65% of cases, the vagina or uterus in 28%, and small bowel in 7% (Woods et al. Diverticular disease is the most common cause of colovesical fistula in most reports, accounting for up to 75% of cases (Ferguson et al. Previous hysterectomy appears to be a significant factor in the incidence of fistula associated with diverticular disease (Bahadursingh and Longo, 2003). In a national case-controlled study from Sweden involving a total of 783,245 women over a 30-year period, the risk of undergoing fistula surgery increased 4-fold in hysterectomized women without diverticulitis, 7-fold in women with diverticulitis without hysterectomy, and 25-fold in hysterectomized women with diverticulitis (Altman et al. In the early stages, symptoms are nonspecific and relate to lower urinary tract dysfunction. Pneumaturia is considered the most common presenting symptom noted in 50% to 70% of cases (Morse and Dretler, 1974; Solem et al. The classic presentation of vesicoenteric fistula is described as Gouverneur syndrome and consists of suprapubic pain, urinary frequency, dysuria, and tenesmus (Chebli et al. Although it is rare for enterovesical fistulae to have sepsis as the presenting sign (Woods et al. Chronic inflammatory disease, such as xanthogranulomatous pyelonephritis or other infectious diseases involving the kidney or bowel, historically has been the most common cause of this condition (Hui Wu et al. Unlike the majority of these fistulae, there is minimal inflammation around the fistula tract. Penetrating external trauma, malignancy, ulcer disease, ingested foreign bodies, and complex calculous disease may also result in pyeloenteric fistulae (Atalla et al. Right-sided pyeloenteric fistulae most often involve the duodenum because of their close anatomic relationship, whereas left-sided pyeloenteric fistulae most commonly involve the descending colon. Diagnosis Many studies exist for the diagnosis of enterovesical fistulae; however, there are significant problems with false negatives and false positives among the diagnostic modalities, and thus the diagnosis is often made on clinical grounds. However, the findings on cystoscopy are often nonspecific and include localized erythema, papillary, or bullous change; a definitive diagnosis using cystoscopy can be made in only 35% to 46% of cases (Pontari et al. Cystoscopy and biopsy of abnormal-appearing tissue or an established fistula tract in the setting of a history of malignancy are indicated to evaluate for the possibility of a malignant fistula. Ultrasonography has also been reported to be useful in the diagnosis of colovesical fistulae. A characteristic "beak" sign may be noted; however, this study is not usually performed in the routine evaluation of the patient with a suspected enterovesical fistula (Chen et al. Management Nonoperative management is a viable option in selected patients with vesicoenteric fistula. At 1 and 3 years after diagnosis there was no difference in mortality between these two groups (Radwan et al. In nontoxic, minimally symptomatic patients with nonmalignant causes of enterovesical fistulae, a trial of medical therapy including intravenous total parenteral nutrition, bowel rest, and antibiotics may be warranted. This may be the preferred initial approach, especially in patients with Crohn disease, in whom the notion of immediate exploratory laparotomy and bowel resection is often discouraged because of the chronic relapsing nature of the disease (Evans et al. There is also the potential for successful medical management of other fistulae resulting from inflammatory bowel disease (Mahadevan et al. Ileovesical fistula in Crohn disease may be managed with antibiotics, nutritional support, often including total parenteral nutrition, and various combinations of immunomodulatory agents. In a nonsystematic review of the management of internal fistulae in Crohn disease, Levy and Tremaine (2002) described the drugs that have been reported to close internal fistulae partially or completely, including azathioprine, 6-mercaptopurine, mycophenolate mofetil, cyclosporine A, tacrolimus, and infliximab. One case series of 500 patients with Crohn disease included 17 with enterovesical fistulae; all received sulfasalazine, most were treated with corticosteroids and antibiotics intermittently, and 8 in addition received 6-mercaptopurine. Although it is not clear that their fistulae closed completely, 6 continued on medical treatment alone for several years (Margolin and Korelitz, 1989). Adverse events were very common, but complete resolution of all fistulae was achieved in 55%, and 50% reduction in fistulous drainage was achieved in 68% of patients on 5-mg infliximab. This study did not include intestinovesical fistulae, although a case of successful use of infliximab in an ileovesical fistula has been reported (Game et al. The goal of operative management is to separate and close the involved organs with minimal anatomic disruption and normal long-term function of both systems. Unfortunately, enterovesical fistulae may be complicated by intense pelvic inflammation, pelvic abscess, and phlegmon formation (in some cases), requiring complex staged reconstructions (Shackley et al. Bowel resection and/ or partial cystectomy may be necessary to obtain viable tissue margins to ensure adequate, watertight closure of the involved viscera. An interpositional flap of greater omentum is often placed between the Chapter 129 repaired bowel and urinary bladder to prevent overlapping suture lines and provide a well-vascularized surface for healing. Single and multistage procedures have been advocated, depending on the clinical circumstances (Harris et al. A one-stage procedure involves removal of the fistula, closure of the involved organs, and primary reanastomosis of the bowel after resection of the involved bowel segment. A two-stage approach advocates removal of the fistula, closure of the involved organs, and creation of a temporary proximal diverting colostomy, with a later return to the operating room for colostomy takedown once the fistula tract has been demonstrated to be closed. Patients with an inflammatory cause of the fistula but without gross contamination can be treated with a one-stage procedure, whereas those with an unprepared bowel, gross contamination, or abscess may require a multistage procedure (Mileski et al. As noted previously, most patients with colovesical fistulae present themselves electively with lower urinary tract symptoms, not emergently in extremis with sepsis. Therefore adequate preoperative support, eventually including bowel preparation, nutritional supplementation, and appropriate antibiotics, can be used in the majority of patients, allowing an elective one-stage approach. The authors of many case series have advocated a one-stage approach in the majority of cases but have indicated that this should be limited to patients whose nutritional state is good and in whom there is no evidence of severe inflammation, radiation injury, advanced malignancy, intestinal obstruction, major medical problem, or advanced age. More recent series have tended to imply a greater advocacy of the one-stage approach; Garcea et al. In addition to the aforementioned criteria, it is intuitive that the more complex a fistula tract, the more relevant a phased approach to treatment becomes. Laparoscopic management of colovesical fistulae has been reported, albeit with a relatively high rate of conversion to open repair (Badic et al. Several reports have described a laparoscopic approach to one-stage treatment of colovesical fistulae. The overall conversion rate was seen to be higher for fistulae involving the duodenum, vagina, and sigmoid colon than for those involving the bladder (10%), although a low threshold for conversion to open surgery was advocated in one series (Pokala et al. Rectal injury during radical prostatectomy occurs in less than 1% to 2% of patients (Borland and Walsh, 1992; Guillonneau et al. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable longterm urinary and bowel function results (Kheterpal et al. Nine of 10 patients had a two-layer closure performed with an omental interpositional flap at the time of injury. One patient underwent a temporary diverting colostomy; the rectal injury was diagnosed and repaired on postoperative day 2. Anal sphincter dilation was performed on all patients, and they received 7 to 14 days of postoperative antibiotics. Contrast material is seen posterior to the bladder on this voiding image from voiding cystourethrography. A retrograde urethrogram demonstrates filling of the rectum in this patient who was seen several years after brachytherapy with fecaluria. Fistulae caused by Crohn disease are complex, and management should be individualized (Cools et al. Digital rectal examination often permits palpation of the fistula tract along the anterior rectal wall. Cystoscopy and sigmoidoscopy visualize the fistula tract in the majority of cases and provide a mechanism for biopsy. In patients with a history of pelvic malignancy, biopsy of the fistula is suggested to evaluate for a local recurrence of the tumor (Shin et al. Lateral projections may be necessary to visualize small fistulae, because contrast in the rectum or urethra can sometimes obscure extremely thin fistulous tracts (Karsten et al. Additional procedures may be needed to bring about a satisfactory result in these patients; this is an important issue to discuss in preoperative patient counseling. After prostate cancer treatment 201 patients underwent rectourethral fistula repair. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared with 65% in the prostatectomy group. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success (Harris et al. Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47%). Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion and 6 (20%) after fecal diversion. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent (Keller et al. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% versus 16% and 11%, respectively. Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion, and 6 (20%) after fecal diversion. Only 2 patients (7%) required an abdominal approach (positive oncologic margins or nonfunctioning bladder). Fifteen out of the 20 patients (75%) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17%. The controversy surrounding the staged repair centers on the issue of whether to perform fecal diversion at all, or whether to perform it before or at the time of repair of the urinary tract. This is considered the standard conservative approach and, in combination with an indwelling urethral catheter, permits a trial of spontaneous healing of the fistula without open manipulation of the urinary tract. In support of the single-stage repair, a successful one-stage approach limits the potential morbidity and cost of multiple procedures that, by design, accompany the staged repair. Staged repairs may be considered in cases of large fistulae, those associated with radiation therapy, uncontrolled local or systemic infection, immunocompromised states, or inadequate bowel preparation at the time of definitive repair. Tissue interposition flaps, predominantly gracilis muscle, were used in 72% of repairs. Most high-volume centers (25 patients) performed transperineal repairs with tissue flaps in 100% of cases. Regardless of complexity, Urinary Tract Fistulae 2957 rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems. The York-Mason procedure is a transrectal, transsphincteric approach that has been found to be effective and to have low morbidity. However, in patients with small, nonirradiated fistulae, a single-stage approach can be used, provided that a vigorous bowel preparation and broad-spectrum antibiotics are used (Renschler and Middleton, 2003). For repair of the urinary tract, the patient is placed prone on the operating room table in the jackknife position. A full-thickness incision through the posterior anus and dorsal rectal wall is performed and deepened down to the level of the coccyx through the external anal sphincter. Later in the procedure during closure, careful anatomic reapproximation of the layers of the external anal sphincter is necessary to avoid the devastating complication of anal incontinence postoperatively. The anorectal incision as described provides excellent exposure of the fistula in the anterior rectal wall. The fistula tract is excised, and the anterior rectal wall is mobilized circumferentially around the fistula margins. Closure of the incision is performed by reapproximating the posterior rectal wall and then sequentially closing the layers of the anal sphincter in an anatomic fashion. In the largest series of patients undergoing the York-Mason procedure, Renschler and Middleton (2003) reported a successful repair in 22 of 24 patients. One of the two failures was subsequently repaired with another York-Mason procedure. No serious complications were reported, and no patient developed anal incontinence or anal stenosis. The major disadvantage to this approach is the relatively poor exposure and lack of maneuverability within the operative field. Anatomically, this is a familiar approach for many urologists and has the added advantage of local access to a variety of potential interpositional flaps. Excellent results have been obtained with the perineal approach in combination with an interpositional flap, including gracilis muscle (Choi et al. The principal advantage of this technique is the availability of greater omentum for an interpositional flap. Potential disadvantages include the morbidity and prolonged postoperative convalescence associated with a laparotomy incision, poor exposure of the operative field (with limited maneuverability in the deep pelvis), and the risk of urinary and fecal incontinence. These fistulae may be large and are associated with considerable induration, fibrosis, and ischemia for a variable distance around the fistula, limiting reconstructive options.

References

• Lee SK: Modern tendon repair techniques. Hand Clin 28(4):565-570, 2012.
• Grau AJ, Weimar C, Buggle F, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 2001;32(11):2559-66.
• Guo Y, Saunders T, Su H, et al, University of California, San Francisco Brain Arteriovenous Malformation (UCSF bAVM) Study Project. Silent intralesional microhemorrhage as a risk factor for brain arteriovenous malformation rupture. Stroke 2012;43: 1240-6.
• Lieskovsky G, Boyd SD, Skinner DG: Management of late complications of the Kock pouch form of urinary diversion, J Urol 137(6):1146n1150, 1987.