Radiation-induced vesico-vaginal fistula successfully repaired using a gracilis myocutaneous flap

Abstract

Surgical repair of a radiation-induced vesico-vaginal fistula by a simple closure technique is extremely difficult. Here, we report a patient with a radiation-induced vesico-vaginal fistula that was successfully reconstructed using a gracilis myocutaneous flap. The vesico-vaginal fistula developed in an 83-year-old Japanese woman who had undergone a radical hysterectomy for cervical cancer of the uterus at age 63, and had pelvic radiation therapy for recurrent disease 17 years after the surgery. The fistula was repaired by a reconstruction technique that employed a gracilis myocutaneous flap. Two-thirds of the vaginal mucosa on the side where the fistula was present was completely removed to obtain a wide mucosal defect. Irradiated fibrous tissue around the fistula was removed, and the bladder mucosa was mobilized, and then closed with absorbable sutures. An island gracilis myocutaneous flap was designed on the medial aspect of the patient's left thigh. The first incision was made through the proximal outline of the flap, and its vascular pedicle, the medial circumflex femoral vessels, was dissected. After a complete incision through the flap, the skin flap, including the entire gracilis muscle, was elevated with the pedicle vessel. The distal portion of the myocutaneous flap was then turned to overlay the mucosal defects on the vagina. Postoperatively, there was no flap necrosis and no infection in the vaginal cavity. Indwelling catheterization was required for 8 weeks. Retrograde cystography confirmed complete closure of the fistula.