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Use of fascia lata in urology
SURGEON’S WORKSHOP
USE OF FASCIA LATA IN UROLOGY C. ALAN CORR, M.D. STEPHEN
R. SHAPIRO,
M.D.
From the Department of Urology, University of California, Davis, School of Medicine, Sacramento, California
Fascial transplants have been utilized sparingly by the urologic surgeon despite their frequent use by other surgical specialties including buttressing of ventral hernia repairs.‘m5 Peacock6 has done extensive research into the biochemistry of wound healing and has found a tenfold increase in collagen synthesis and deposition in fascia transplants as compared with scar tissue in hernia repairs. In addition, he postulates that the physical weave of the collagen subunits prevents attenuation leading to the recurrences seen in normal scar tissue. We have recently utilized fascia lata in 2 urologic patients.
vulvectomy for carcinoma of the vulva. Despite two attempts at bladder neck suspension with mersilene tape and vaginal pessary, the woman remained incontinent and was suffering continued perineal ulcerations. Foley catheter drainage provided a substantial improvement in dryness, but her perineal ulcers were still indolent. Bladder neck ligation and permanent suprapubic drainage was selected for her management and, to prevent perineal fistulas,
Case Reports Case 1 A seventy-five-year-old white female was found to be totally incontinent after radical
FIGURE
UROLOGY
1. Extensive
/ MAY1978
parastomal
/ VOLUMEXI,
hernia.
NUMBER5
FIGURE 2. The harvesting of fascia lata. Lateral aspect of thigh. Fascia lata exposed vertical incision. (B) Free patch of fascia lata.
(A) via
507
FIGURE 3. Parastomal hernia repair using fascia lata. (A and B) Conduit mobilized through peristoma1 incision. (C and D) Fascia plicated. Fascia lata applied and sutured in place. (E and F) Skin closed.
the ligated bladder neck was buttressed with a free patch of fascia lata. Nine months postoperatively, the patient remains dry with a healed perineum. Case 2 A six-year-old white female with meningomyelocele had undergone ileal diversion at another hospital at three years of age for upper tract deterioration. Since surgery, she had persistent problems in keeping her ileostomy bag in place due to a parastomal hernia (Fig. 1). A parastomal hernia repair buttressed with a graft of fascia lata was performed. Eight months postoperatively, her repair is intact, and her appliance does not leak. Technique The steps in parastomal hernia repair using fascia lata are shown in Figures 2 and 3. The lateral thigh is prepared and draped midway between the greater trochanter and lateral condyle of the femur. A longitudinal incision is made down to the tensor fascia lata (Fig. 2A). Subcutaneous dissection along the fascia lata creates skin flaps sufficient to expose the desired area
508
for harvesting the graft. A rectangular patch of fascia is then excised (Fig. 2B), and the subcutaneous tissue and skin closed in the desired fashion. Compressive dressings or hemovac drainage are recommended to prevent seromas. Smaller strips of fascia lata may be harvested with a scissor through smaller transverse skin incisions or by utilizing special fascia lata stripping devices which are passed blindly subcutaneously.’ The parastomal hernia repair is completed as shown in Figure 3. Comment The morbidity from harvesting even large areas of fascia lata is minimal. In a review of 57 patients undergoing extensive fascia lata harvest for the creation of heart valves, Dubiel and Wigrena found only minor weakness of hip flexion and knee extension but no gait disturbances. Muscle hemiation was common but of only minor cosmetic consideration, and may be preventable with a long-term supportive dressing during the postoperative period. _( Fascia lata in the genitourinary tract has been utilized in the repair of ureter-al stenosis,
UROLOGY
/ MAY 1978 I
VOLUME
XI, NUMBER
5
as a bladder substitute,g*‘O and in urethroplasties. ‘* Although the results of ureteral repair in 8 patients and urethroplasties in 9 dogs are reported to be encouraging, the experience is small and no long-term follow-up is currently available. In bladder substitution, a larger experience, predominantly in the laboratory animal, has evolved. Here, fascia is supposed to serve the purpose of a template, allowing regenerating epithelium and muscle to form while maintaining bladder size and integrity. In practice, grafts used in this way often shrink with time and, in most cases, have become ossified. The use of fascia lata as a sling in the repair of stress incontinence has been well documented in the gynecologic literature.” It is used in cases of recurrent stress incontinence following a Marshall-Marchetti-Krantz procedure. Ivanovici and Bocancea13 recommended the use of fascia lata and a buried skin tube to prevent urinary incontinence in the postprostatectomy patient as a modification of the Berry procedure. Leakage of urine from the urinary drainage bag is one of the most frequent complaints in patients with ileal conduits and parastomal hernias-l4 The hernia usually occurs superiorly where the mesentery enters, but may be quite extensive. Most extensive hernias have been treated by moving the conduit to the opposite side of the abdomen. The short size of the ileal conduit in our patient precluded this possibility. It is possible that, with the use of fascia lata, even extensive parastomal hernias may be repaired in situ.
UROLOGY
I
MAY 1978
/
VOLUME
XI, NUMBER
5
4301 X Street, Suite 249 Sacramento, California 95817 (DR. SHAPIRO)
ACKNOWLEDGMENT. allowing us to include
To John D. Trelford, M.D., a patient of his in this article.
for
References 1. Crawford JS: Nature of fascia lata and its fate after implantation, Am. J. Ophthalmol. 67: 906 (1969). 2. Trimble AS: First international roundtable on fascia lata heart valves, Surgery 71: 10 (1972). 3. Brea A, Jr, Allen MS, Jr, and Muller WH: Superior vena cava replacement with autogenous fascia: an experimental study, Am. Surg. 31: 610 (1965). 4. Beecham CT, and Beecham JB: Correction of prolapsed vagina or enterocele with fascia lata, Obstet. Gynecol. 42: 542 (1973). 5. Hamilton JE: The repair of large or diflicult hernias with mattressed onlay grafts of fascia lata: a 2l-year experience, Ann. Surg. 167: 85 (1968). 6. Peacock EE: Subcutaneous extraperitoneal repair of ventral hernias: a biologic basis for fascial transplantation, ibid. 181: 722 (1975). 7. Drever JM: A simple method for obtaining fascia lata grafts, Plast. Reconstr. Surg. 56: 196 (1972). 8. Dubiel WT, and Wigren A: Functional status of the lower extremity after resection of fascia lata, Acta Orthop. Stand. 45: 599 (1974). 9. Alonzo RH, and Laughlin VC: Experimental fasciocysto~lastv, 1. Int. Coil. Surg. 42: 648 (1964). 10: Tsuji I, et al: A clinical‘ and experimental study on cystoplasty not using the intestine, J. Ural.-89: 214 (1963). 11. Tilak GH: Use of deen fascia for urethral reconstruction in dogs, Ind. J. Med. Res. 53: 997 (1965). 12. Beck RP, Grove D, Amasch D, and Harvey J: Recurrent urinary stress incontinence treated by fascia lata sling procedure, Am. J. Obstet. Gynecol. 120: 613 (1974). 13. Ivanovici F, and Bocancea D: The management of urinary incontinence following prostatectomy by the procedure of tubular cutaneous flap: a preliminary note of operative technique, J. Urol. 163: 202 (1970). 14. Marshall FF, Leadbetter WF, and Dretler SP: Ileal conduit parastomal hernias, ibid. 114: 49 (1975).
509
USE OF FASCIA LATA IN UROLOGY C. ALAN CORR, M.D. STEPHEN
R. SHAPIRO,
M.D.
From the Department of Urology, University of California, Davis, School of Medicine, Sacramento, California
Fascial transplants have been utilized sparingly by the urologic surgeon despite their frequent use by other surgical specialties including buttressing of ventral hernia repairs.‘m5 Peacock6 has done extensive research into the biochemistry of wound healing and has found a tenfold increase in collagen synthesis and deposition in fascia transplants as compared with scar tissue in hernia repairs. In addition, he postulates that the physical weave of the collagen subunits prevents attenuation leading to the recurrences seen in normal scar tissue. We have recently utilized fascia lata in 2 urologic patients.
vulvectomy for carcinoma of the vulva. Despite two attempts at bladder neck suspension with mersilene tape and vaginal pessary, the woman remained incontinent and was suffering continued perineal ulcerations. Foley catheter drainage provided a substantial improvement in dryness, but her perineal ulcers were still indolent. Bladder neck ligation and permanent suprapubic drainage was selected for her management and, to prevent perineal fistulas,
Case Reports Case 1 A seventy-five-year-old white female was found to be totally incontinent after radical
FIGURE
UROLOGY
1. Extensive
/ MAY1978
parastomal
/ VOLUMEXI,
hernia.
NUMBER5
FIGURE 2. The harvesting of fascia lata. Lateral aspect of thigh. Fascia lata exposed vertical incision. (B) Free patch of fascia lata.
(A) via
507
FIGURE 3. Parastomal hernia repair using fascia lata. (A and B) Conduit mobilized through peristoma1 incision. (C and D) Fascia plicated. Fascia lata applied and sutured in place. (E and F) Skin closed.
the ligated bladder neck was buttressed with a free patch of fascia lata. Nine months postoperatively, the patient remains dry with a healed perineum. Case 2 A six-year-old white female with meningomyelocele had undergone ileal diversion at another hospital at three years of age for upper tract deterioration. Since surgery, she had persistent problems in keeping her ileostomy bag in place due to a parastomal hernia (Fig. 1). A parastomal hernia repair buttressed with a graft of fascia lata was performed. Eight months postoperatively, her repair is intact, and her appliance does not leak. Technique The steps in parastomal hernia repair using fascia lata are shown in Figures 2 and 3. The lateral thigh is prepared and draped midway between the greater trochanter and lateral condyle of the femur. A longitudinal incision is made down to the tensor fascia lata (Fig. 2A). Subcutaneous dissection along the fascia lata creates skin flaps sufficient to expose the desired area
508
for harvesting the graft. A rectangular patch of fascia is then excised (Fig. 2B), and the subcutaneous tissue and skin closed in the desired fashion. Compressive dressings or hemovac drainage are recommended to prevent seromas. Smaller strips of fascia lata may be harvested with a scissor through smaller transverse skin incisions or by utilizing special fascia lata stripping devices which are passed blindly subcutaneously.’ The parastomal hernia repair is completed as shown in Figure 3. Comment The morbidity from harvesting even large areas of fascia lata is minimal. In a review of 57 patients undergoing extensive fascia lata harvest for the creation of heart valves, Dubiel and Wigrena found only minor weakness of hip flexion and knee extension but no gait disturbances. Muscle hemiation was common but of only minor cosmetic consideration, and may be preventable with a long-term supportive dressing during the postoperative period. _( Fascia lata in the genitourinary tract has been utilized in the repair of ureter-al stenosis,
UROLOGY
/ MAY 1978 I
VOLUME
XI, NUMBER
5
as a bladder substitute,g*‘O and in urethroplasties. ‘* Although the results of ureteral repair in 8 patients and urethroplasties in 9 dogs are reported to be encouraging, the experience is small and no long-term follow-up is currently available. In bladder substitution, a larger experience, predominantly in the laboratory animal, has evolved. Here, fascia is supposed to serve the purpose of a template, allowing regenerating epithelium and muscle to form while maintaining bladder size and integrity. In practice, grafts used in this way often shrink with time and, in most cases, have become ossified. The use of fascia lata as a sling in the repair of stress incontinence has been well documented in the gynecologic literature.” It is used in cases of recurrent stress incontinence following a Marshall-Marchetti-Krantz procedure. Ivanovici and Bocancea13 recommended the use of fascia lata and a buried skin tube to prevent urinary incontinence in the postprostatectomy patient as a modification of the Berry procedure. Leakage of urine from the urinary drainage bag is one of the most frequent complaints in patients with ileal conduits and parastomal hernias-l4 The hernia usually occurs superiorly where the mesentery enters, but may be quite extensive. Most extensive hernias have been treated by moving the conduit to the opposite side of the abdomen. The short size of the ileal conduit in our patient precluded this possibility. It is possible that, with the use of fascia lata, even extensive parastomal hernias may be repaired in situ.
UROLOGY
I
MAY 1978
/
VOLUME
XI, NUMBER
5
4301 X Street, Suite 249 Sacramento, California 95817 (DR. SHAPIRO)
ACKNOWLEDGMENT. allowing us to include
To John D. Trelford, M.D., a patient of his in this article.
for
References 1. Crawford JS: Nature of fascia lata and its fate after implantation, Am. J. Ophthalmol. 67: 906 (1969). 2. Trimble AS: First international roundtable on fascia lata heart valves, Surgery 71: 10 (1972). 3. Brea A, Jr, Allen MS, Jr, and Muller WH: Superior vena cava replacement with autogenous fascia: an experimental study, Am. Surg. 31: 610 (1965). 4. Beecham CT, and Beecham JB: Correction of prolapsed vagina or enterocele with fascia lata, Obstet. Gynecol. 42: 542 (1973). 5. Hamilton JE: The repair of large or diflicult hernias with mattressed onlay grafts of fascia lata: a 2l-year experience, Ann. Surg. 167: 85 (1968). 6. Peacock EE: Subcutaneous extraperitoneal repair of ventral hernias: a biologic basis for fascial transplantation, ibid. 181: 722 (1975). 7. Drever JM: A simple method for obtaining fascia lata grafts, Plast. Reconstr. Surg. 56: 196 (1972). 8. Dubiel WT, and Wigren A: Functional status of the lower extremity after resection of fascia lata, Acta Orthop. Stand. 45: 599 (1974). 9. Alonzo RH, and Laughlin VC: Experimental fasciocysto~lastv, 1. Int. Coil. Surg. 42: 648 (1964). 10: Tsuji I, et al: A clinical‘ and experimental study on cystoplasty not using the intestine, J. Ural.-89: 214 (1963). 11. Tilak GH: Use of deen fascia for urethral reconstruction in dogs, Ind. J. Med. Res. 53: 997 (1965). 12. Beck RP, Grove D, Amasch D, and Harvey J: Recurrent urinary stress incontinence treated by fascia lata sling procedure, Am. J. Obstet. Gynecol. 120: 613 (1974). 13. Ivanovici F, and Bocancea D: The management of urinary incontinence following prostatectomy by the procedure of tubular cutaneous flap: a preliminary note of operative technique, J. Urol. 163: 202 (1970). 14. Marshall FF, Leadbetter WF, and Dretler SP: Ileal conduit parastomal hernias, ibid. 114: 49 (1975).
509