Journal of Surgical Case Reports, 2015; 2 , 1–3

doi: 10.1093/jscr/rjv004
Case Report

CASE REPORT

Vesicocutaneous fistula treatment by using omental

flap interposition
Cem Basatac* and Mehmet Cagatay Cicek
Department of Urology, Kars State Hospital, Kars, Turkey
*Correspondence address. Tel: +90-474-212-56-74; E-mail: cembasatac@hotmail.com

Abstract
A fistula is defined as an abnormal association of two or more epithelial lining. Therefore, vesicocutaneous fistula (VCF)
represents an extra anatomic communication between the bladder wall and the external surface of the skin. The most common
cause is iatrogenic; however, numerous factors may play a role in the formation of VCFs. When a VCF is identified, it should be
treated properly due to its bothersome complaints and social effects. Nonetheless, no certain consensus has been achieved, yet.
In this case, we report the feasibility and efficacy of omental flap interposition during VCF repair.

INTRODUCTION CASE REPORT

It is well known that vesicocutaneous fistulae (VCFs) result in un-
controllable urine leakage from the bladder to the skin. It causes
bothersome complaints and dramatically impairs patients’ qual-
ity of life. Most of these fistulae are iatrogenic, but this condition
can also be caused by extensive trauma with pelvic fractures,
postoperative causes of radical pelvic surgery, after irradiation
of pelvic malignancies, hip arthroplasty and large bladder calcu-
lus, and other different etiologic causes have been also reported
[1–4]. In addition, untreated VCF leads to continuous wetness and
odor. As a result, when VCF is recognized, it should be treated
properly. However, there is no consensus regarding the treat-
ment of this situation, yet. Simple repair with tissue approxima-
tion is often difficult because of the extent of tissue destruction
and cicatrization. Since VCFs are usually referred as complex fis-
tulae, interposition grafts or flaps can be used to enhance repair
of the fistula tract. Nevertheless, surrounding tissue may not be
suitable for this procedure due to severe inflammation, radiation
and fibrosis. In this study, we present a case of VCF treated with
omental flap interposition.
A 32-year-old male presented to our outpatient clinic with com-
plaints of dysuria and continuous leakage of urine from the fistula
tract located at the midpoint of the symphysis pubis and the um-
bilicus for a long time. In his medical history, he underwent open
surgery due to a large bladder stone at 24 years of age. A nontender
mass was palpable around the orifice on physical examination.
The urinalysis revealed pyuria and microscopic hematuria, but
the urine culture was sterile. An abdominal ultrasonography was
done, but no remarkable pathology was reported. A computerized
tomography (CT) cystogram demonstrated an aberrant connection
between the anterior bladder wall and the external surface of the
skin (Fig. 1A). Subsequently, under general anesthesia, patient was
placed in a low lithotomy position. Cystoscopy was performed to
visualize and cannulate the fistula tract with a 6-Fr ureteral cath-
eter. A midline infraumblical incision was made involving the
circumscribing incision around the fistula. The fistula tract was
identified until the bladder with blunt dissection. After excision
of fistula tract with wide perivesical tissue debridement, a periton-
eal cavity was opened and an omental V-shaped flap was prepared

Received: September 27, 2014. Revised: December 30, 2014. Accepted: January 6, 2015
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.
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1
 2 | C. Basatac and M.C. Cicek
Figure 1: (A) A CT cystogram demonstrates an aberrant connection between the anterior bladder wall and the external surface of the skin. (B) A CT cystogram shows no
leakage from the bladder on postoperative day 21.
Figure 2: (A) An omental V-shaped flap prepared to enhance repair of VCFs. (B) An omental flap was sutured and quilted on the bed of the anterior bladder wall.
(Fig. 2A). An omental flap was based on a more reliable right gas-
troepiploic artery and brought down to the surgical field and
placed upon the anterior bladder wall. The omental flap was su-
tured and quilted on the bed of the anterior bladder wall with
the interrupted 2-0 polyglactin sutures (Fig. 2B). The border of
the suture lines included from the bladder neck to the posterior
bladder wall and up to endopelvic fascia at the lateral sides. A
closed pelvic drain was also placed. No intraoperative and post-
operative complications were noted. The drain was removed day
after surgery, and the patient was discharged at the postoperative
day 2. A Foley catheter was removed at the postoperative day 21
after a CT cystogram revealed no leakage from the bladder
(Fig. 1B). At the last follow-up visit, patient was relieved of all his
complaints.
DISCUSSION
After cutaneous fistulous tracts are excised and bladder defects
are closed, attention is turned to cover suture lines with graft or
flap interposition over the bladder to anchor securely to the site
of fistula. Myocutaneous rectus abdominis grafts should be con-
sidered primarily [5]. These grafts can be used based on the infer-
ior epigastric arterial pedicle for the repair of VCF. However,
myocutaneous grafts sometimes may not be available because
of dens adjacent tissue fibrosis and severe inflammation. In
this context, the omentum may be an acceptable alternative.
Interposition of an omental flap during VCF repair does not
only add an extra layer to the VCF repair to prevent recurrence,
but also increases lymphatic drainage and decreases the risk of
infected fluid collection. The use of omental flap in urinary
tract fistula repair was first described by Kiricuta and Goldstein
in 1972 [6]. Since then, numerous studies have demonstrated
feasibility of omental flap with considerable success rates [7].
Orford and Theron [8] successfully repaired 52 patients with vesi-
covaginal fistulae (VVFs) by means of omental flap interposition
and reported a 93% cure rate. Evans et al. reported 29 patients who
underwent transabdominal VVF repair with or without omental
flap. Ten patients in whom omental flap was used were
 Omental flap used during vesicocutaneous fistula repair | 3

successful (100%). Nevertheless, only 12 of the remaining 19 pa- REFERENCES

tients who did not receive omental flap were cured (63%). Because
1. Kotkin L, Koch MO. Morbidity associated with nonoperative
of this reason, the authors concluded that omental flap should be
management of extraperitoneal bladder injuries. J Trauma
routinely used during transabdominal VVF repair even in benign
1995;38:895–8.
fistulas with well-preserved surrounding tissue [9]. Though
2. Lau KO, Cheng C. A case report. Delayed vesico cutaneous fis-
omentum most commonly has been used as an interpositional
tula after radiation therapy for advanced vulvar cancer. Ann
layer between the bladder and vagina during transabdominal
Acad Med Singapore 1998;27:705–6.
VVF repair, data are lacking in the literature whether omental
3. Petru E, Herzo Kurschel S, Tamussino K, Winter R. Vesicocuta-
flap would be efficacious in the repair of VCF. Lau and Cheng [2]
neous fistula mimicking an abdominal wall abscess 2 years
have shown a favorable result with omental flap interposition
after radical abdominal hysterectomy. Gynecol Oncol
in their case of VCF that occurred after radiation therapy. As in
2003;90:494.
this case, when the surrounding tissues do not appear healthy
4. Toufique H, Merani AJ. Vesicocutaneous fistula. J Pak Med Assoc
and well vascularized, omental V-shaped flap based on the
2011;61:918–9.
right gastroepiploic artery may be a suitable alternative to reduce
5. Kishore TA, Bhat S, Jhon PR. Vesicocutaneous fistula arising
recurrence. This report may encourage the use of omental flap
from a bladder diverticulum. Indian J Med Sci 2005;59:265–7.
when the surrounding tissue is not appropriate. In conclusion,
6. Kiricuta I, Goldstein AMB. The repair of extensive vesicovagi-
interposition of omental flap during the treatment of VCF can
nal with pedicled omentum: a review of 27 cases. J Urol
be a suitable and feasible alternative because of its rich vascular
1972;108:724–7.
and lymphatic supply, together with its resistance to infection,
7. Fitzpatrick C, Elkins TE. Plastic surgical techniques in the
when the surrounding tissue is not available. However, high-
repair of vesicovaginal fistulas: a review. Int Urogynecol J
volume and comparative studies are needed so as to determine
1993;4:287–95.
optimal treatment modality in this condition.
8. Orford HJ, Theron JL. The repair of vesicovaginal fistulas with
omentum. A review of 59 cases. S Afr Med J 1985;67:143–4.
9. Evans DH, Madjar S, Politano VA, Bejany DE, Lynne CM,
CONFLICT OF INTEREST STATEMENT Gousse AE. Interposition flaps in transabdominal vesicovaginal
None declared. fistula repairs: are they really necessary? Urology 2001;57:670–4.