title: Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas.
abstract: BACKGROUND
  Urogenital fistulas are devastating complications occurring after tumors or trauma. Surgical treatment is challenging. Thus, further surgical repair options are needed for treatment of complex fistulas within the pelvic region.
  
  
  METHODS
  Twelve patients with urogenital fistulas were surgically treated in our department from 2004 to 2012. These selected cases fulfilled eligibility criteria for continence-preserving surgery - a history of fistula recurrences with ongoing incontinence after receiving at least two surgical attempts. Five VRAM and eight gracilis flaps were used to cover up given tissue defects and to perform functional continence-preserving reconstruction with mean follow-up of 6.3 years. Data were retrospectively reviewed, and standardized survey was performed to evaluate quality of life of all living patients (n = 10).
  
  
  RESULTS
  In all cases, final surgical treatment of the given fistulae by VRAM or gracilis flaps could be achieved, with mean operating time of 5:31 h (range: 4:50-6:48 h) for VRAM flap and 3:11 h (range: 2:04-4:42 h) for gracilis flap. Outcome measures were primarily to avoid fistula recurrence after plastic surgical treatment, and secondary quality of life and survival. All patients had their continence preserved, but two patients died during follow-up period. Postoperative assessment revealed the following: VRAM flap patients (n = 3) showed slight incontinence during the follow-up period, whereas continence was restored in all patients with gracilis flap reconstruction (n = 7). Quality-of-life assessment indicated restoration of quality of life in comparison to general population (women > men). Furthermore, key points of the two presented surgical techniques are demonstrated in detail.
  
  
  CONCLUSIONS
  With preformed VRAM or gracilis flaps, complex urogenital fistulas can be successfully eradicated and continence is restored. The main focus should be the recovery of quality of life, which could be successfully regained. Nevertheless, the continence success rate has to be defined on an individual, case-by-case basis.
  
  
  METHODS
  Original work, cohort study level III.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Agaplesion Diakonieklinikum Rotenburg, Elise-Averdieck-Straße 17, 27356 Rotenburg (Wümme), Germany. Electronic address: felix.paprottka@me.com.
authors.forename: Felix J
authors.initials: FJ
authors.lastname: Paprottka
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Centre, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
authors.forename: Nicco
authors.initials: N
authors.lastname: Krezdorn
authors.affiliation: Department of Plastic Surgery, Agaplesion Diakonieklinikum Hamburg, Hohe Weide 17, 20259 Hamburg, Germany.
authors.forename: Jörn A
authors.initials: JA
authors.lastname: Lohmeyer
authors.affiliation: Department of Hand and Plastic Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom.
authors.forename: Katie
authors.initials: K
authors.lastname: Young
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Centre, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
authors.forename: Jörn
authors.initials: J
authors.lastname: Kuhbier
authors.affiliation: Department of Plastic Surgery and Reconstructive Surgery, Allgemeines Krankenhaus der Stadt Wien, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090 Vienna, Austria.
authors.forename: Maike
authors.initials: M
authors.lastname: Keck
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Agaplesion Diakonieklinikum Rotenburg, Elise-Averdieck-Straße 17, 27356 Rotenburg (Wümme), Germany.
authors.forename: Stefan Klaus
authors.initials: SK
authors.lastname: Rösler
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Agaplesion Diakonieklinikum Rotenburg, Elise-Averdieck-Straße 17, 27356 Rotenburg (Wümme), Germany.
authors.forename: Nils-Kristian
authors.initials: NK
authors.lastname: Dohse
authors.affiliation: Department of Plastic and Reconstructive Surgery, Hand Surgery, Agaplesion Diakonieklinikum Rotenburg, Elise-Averdieck-Straße 17, 27356 Rotenburg (Wümme), Germany.
authors.forename: Detlev
authors.initials: D
authors.lastname: Hebebrand
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D052776:Female Urogenital Diseases / Q000601:surgery*; D005402:Fistula / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D052801:Male Urogenital Diseases / Q000601:surgery*; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000637:transplantation*; D011788:Quality of Life; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013997:Time Factors; D016896:Treatment Outcome
keywords: Continence-preserving reconstruction; Pelvic region; Plastic reconstructive surgery; Recovery of quality of life; Urogenital fistula; VRAM/gracilis flap