Comparison of Vesicovaginal Fistula Repair with Omental transposition versus perivesical fat emplacement.

Objectives: To compare the outcome of Vesicovaginal fistula repair by omental transposition and perivesical fat emplacement in terms of recurrence and maximum bladder capacity. Study Design: Randomized control trial. Setting: Urology department of Peoples University Hospital Nawabshah, Sindh, Pakistan. Period: From January 2018 to December 2018. Material & Method: Overall 40 patients with VVF were added in the research, split into two identical groups, each consisting of 20. In group 1, omental transposition and in group 2, perivesical fat emplacement was done. Adult female patients with Vesicovaginal fistula, resulting from obstetrical and as a complication of surgery was included. This was confirmed by physical examination, IVU, pelvic computerized tomography scan with contrast, retrograde uretherocystogram, ultrasound KUB and cystoscopy. Exclusion criteria were Patients with systemic illness like diabetes mellitus, chronic renal failure and chronic liver disease etc, immunosuppressant therapy like: steroids intake, patient’s undergone irradiation of the pelvis due to any malignant disease. Follow up after 6, 12 and 24 weeks, all the patients were assessed for recurrence. The complications like wound infections, urgency, urge incontinence and paralytic ileus were also noted. The data was collected in a specially designed proforma. Results: In this study 40 patients fulfilling the inclusion criteria were included, 20 patients in each group. The success rate was 95 %( 19 /20) in group 1, only one case had recurrence. While in group 2 all the cases were successful. Chi square analysis was employed for comparison of adequacy of both the techniques, the P value was found to be 0.311 which suggests that the difference between the efficacies was not statistically significant. Conclusion: It is concluded that both the techniques of Vesicovaginal fistula repair, either with omental transposition or perivesical fat emplacement are equally good in terms of recurrence and maximum bladder capacity.

Less Invasive Pedicled Omental-Cranial Transposition in Pediatric Patients With Moyamoya Disease and Failed Prior Revascularization

BACKGROUND: Patients with moyamoya disease and progressive neurological deterioration despite previous revascularization pose a major treatment challenge. Many have exhausted typical sources for bypass or have ischemia in areas that are difficult to reach with an indirect pedicled flap. Omental-cranial transposition has been an effective, but sparingly used technique because of its associated morbidity. OBJECTIVE: We have refined a laparoscopic method of harvesting an omental flap that preserves its gastroepiploic arterial supply. METHODS: The pedicled omentum can be lengthened as needed by dividing it between the vascular arcades. It is transposed to the brain via skip incisions. The flap can be trimmed or stretched to cover ischemic areas of the brain. The cranial exposure is performed in parallel with pediatric surgeons. We performed this technique in 3 pediatric patients with moyamoya disease (aged 5-12 years) with previous superficial temporal artery to middle cerebral artery bypasses and progressive ischemic symptoms. In 1 patient, we transposed omentum to both hemispheres. RESULTS: Blood loss ranged from 75 to 250 mL. After surgery, patients immediately tolerated a diet and were discharged in 3 to 5 days. The ischemic symptoms of all 3 children resolved within 3 months postoperatively. Magnetic resonance imaging at 1 year showed improved perfusion and no new infarcts. Angiography showed excellent revascularization of targeted areas and patency of the donor gastroepiploic artery. CONCLUSION: Laparoscopic omental harvest for cranial-omental transposition can be performed efficiently and safely. Patients with moyamoya disease appear to tolerate this technique much better than laparotomy. With this method, we can achieve excellent angiographic revascularization and resolution of ischemic symptoms.