A Novel Perivesical Fat Rotational Flap as an Alternative to Omental Interposition in Challenging Urological Reconstruction.

OBJECTIVE: We aim to introduce the application of the perivesical fat rotational flap as a substitute for omental interposition during several complex urologic reconstruction. We highlight our technique using a case of salvage prostatectomy after initial high intensity focused ultrasound (HIFU) for recurrent high risk prostate cancer requiring future adjuvant radiation treatment. We have also successfully used this technique in the management of recurrent vesicovaginal, colovesical, rectourethral fistulas, and post radiation salvage prostatectomy setting.

MATERIALS AND METHODS: Our first patient underwent salvage radical prostatectomy after developing high risk localized prostate cancer after initial high intensity focused ultrasound. The prostate was radically resected after stepwise posterior and anterior dissections. A flap of perivesical fat with a wide-based pedicle overlying the bladder dome was developed until it was rotated, positioned, and tethered overlying the anterior rectal wall in a tension-free manner. This perivesical fat interposition may have protected a radiated anterior rectal wall from future complications. In the second case, a recurrent vesicovaginal fistula that persisted for two years post abdominal hysterectomy was repaired using the robotic approach. After fistula excision, layer closure, and perivesical flap interposition, successful repair was achieved. The third patient, who had a history of colon cancer managed with partial colectomy and radiation, developed a recurrent colovesical fistula, which was successfully repaired. Post-repair, a perivesical flap was developed and secured over the site.

RESULTS: In the immediate postoperative follow up period, there were no surgical complications. Long term follow-up ranges from one month to three years without evidence of complication.

CONCLUSIONS: In cases where omentum interposition is not feasible, our novel technique of a perivesical fat flap is a successful alternative for complex reconstruction.