Urethrovaginal fistulas (UVF) are a rare consequence of iatrogenic injury during pelvic surgery. UVF can be treated in uncomplicated cases with indwelling catheterization, but most require surgical intervention. If the proximal urethra or bladder neck is involved, the continence mechanism may be compromised and an anti-incontinence procedure (e.g., suburethral sling) may be necessary at the time of fistula repair [1]. The gracilus muscle flap (GMF) represents a versatile option utilized in a diverse variety of complex reconstructive approaches [2]. To date, no literature exists describing its use for recurrent UVF in adults. We present the use of GMF in the management of a recurrent proximal UVF.

This video presents the case of a 34-year-old woman with a persistent UVF. She initially presented for evaluation due to persistent leakage of urine from the vagina and stress urinary incontinence (SUI). These symptoms were consequent to an iatrogenic UVF that developed following the management of a urethral diverticulum, which was misdiagnosed as a vaginal wall abscess and errantly incised. Initial primary repair and subsequent urethral diverticulectomy with UVF repair using a Martius flap proved unsuccessful at resolving her fistula. Thus, the decision was made to proceed with a GMF and concomitant pubovaginal sling to treat her persistent UVF and SUI. This video highlights the major operative steps of her successful UVF repair which included fistula excision, bladder neck, and urethral reconstruction, GMF harvest, flap interposition, and a brief discussion of pubovaginal sling placement.

Intraoperatively, a second proximal UVF was identified along with a previously unrecognized vesicourethral fistula which required excision and reconstruction. In total three fistulous tracts were present. Repair was completed using a left GMF. The available overlying muscle fascia was unviable due to suboptimal tissue quality, prompting the use of biologic a xenograft for the pubovaginal sling. She was discharged on postoperative day three with her thigh drain and urethral catheter. The thigh drain was removed in the office on postoperative day seven. Unfortunately, her catheter was dislodged before completing a voiding cystourethrogram. Two months postoperatively, she was found to develop a superficial wound infection at the pubovaginal sling trocar sites which resolved with oral antibiotics. 3 months postoperatively, she continued to endorse no SUI and denied any urinary leakage per vagina.

The GMF appears to be a viable option for treating recurrent UVF refractory to conventional techniques. This approach may also permit concomitant sling placement with autologous fascia if the tissue is viable and readily available.

Chodisetti S, Boddepalli Y, Kota MR. Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience. Indian J Urol. 2016 Jul-Sep;32(3):229-31. doi: 10.4103/0970-1591.185097. PMID: 27555683; PMCID: PMC4970396.
Kua EH, Leo KW, Ong YS, Cheng C, Tan BK. Vascularisation of urethral repairs with the gracilis muscle flap. Arch Plast Surg. 2013 Sep;40(5):584-8. doi: 10.5999/aps.2013.40.5.584. Epub 2013 Sep 13. PMID: 24086814; PMCID: PMC3785594.

Continence 12S (2024) 101638
DOI: 10.1016/j.cont.2024.101638