Omental wrap for salvaging bladder repair: A novel approach

Abstract

Background: The bladder represents one of the genitourinary organs most vulnerable to iatrogenic injuries. Ideal repair can be challenging and may require augmentation to fully preserve bladder structure and function. The omentum has been employed as a flap or graft to close bladder defects.

Objective: This study presented a novel approach involving a complete omental wrap for repairing a small-capacity, irreparably damaged bladder following cystotomy in a complex transvesical vesicouterine fistula repair.

Methods: Salvage repair was performed on a severely damaged bladder that had resulted from a chronic vesicouterine fistula, using an omental wrap for augmentation. The omental wrap fully enclosed the bladder to enhance its recovery. The patient had an uneventful post-operative recovery, and follow-up cystography showed a small-capacity bladder with no leakage. Extended follow-up demonstrated resolution of the patient's symptoms and an improvement in bladder capacity.

Results: This was the first documented application of the omentum as a complete wrap to support an irreparable bladder. The omentum's mechanical and anti-inflammatory properties provided significant support, leading to a rapid and complete healing of a bladder that initially appeared to have an unfavorable outcome due to extensive inflammation.

Conclusion: The use of omental wrap for bladder repair leverages the omentum's unique properties to support and augment challenging repairs, resulting in outstanding outcomes and expedited restoration in what would be considered a poor outcome procedure.

Keywords: Cystotomy; Fistula; Omentum.

Figure 1

Contrast-enhanced computed tomography images (A and B) in the delayed excretory phase show a full urinary bladder and contrast filling into what was initially believed to be the vaginal vault through a communicating vesicovaginal fistula of around 3 cm in length and of sizable diameter. A digital three-dimensional reconstruction of the excretory phase (C) highlights the fistula.

Figure 2

Intraoperative photographs show (A) cystoscopic identification of the vesical end of the fistula at the left posterior urinary bladder wall and (B) retrieval of the ureteric catheter from the uterine cavity after guided cannulation of the fistula, which revealed its other end opening on the lower anterior uterine wall, as confirmed by hysteroscopy.

Figure 3

Diagrammatic illustrations of the procedural steps: (A) dissection of layers down to the urinary bladder, (B) fistulectomy and uterine avulsion, (C) bladder repair, leak test, and omental interposition, and (D) final “omental-wrap” of the urinary bladder.

Figure 4

Ascending cystogram shows a small-capacity urinary bladder with Foley’s catheter balloon in situ and no leakage on anteroposterior (A) and right lateral oblique images (B); after removal of Foley’s Catheter, micturating cystourethrographic images were obtained (C), and no leak was identified.