RECONSTRUCTIVE UROLOGY

Flap technology for reconstructions of urogenital organs
Ninkovic M, Dabernig W
From the Department of Plastic and Reconstructive Surgery, University of Innsbruck, Innsbruck, Austria
Curr Opin Urol. 2003; 13: 483-8

• Purpose of Review: The purpose of this review is to summarize the different reconstructive options for urogenital indications. The development of various flap techniques to restore congenital and acquired urogenital defects is presented.
• Recent Findings: Various reconstructive techniques have been demonstrated recently. On the basis of the reconstructive requirements, two main techniques can be defined: the standard local or regional flap technique (pedicled flap) and the more sophisticated microvascular free flap technique. Free tissue transplantation (transfer) is a procedure that involves microvascular transplantation of a flap (a fasciocutaneous, muscle or composite flap) in one stage from a donor site in the body to a distant recipient site. The viability of the transplanted flap is maintained by microvascular anastomosis between the flap’s vessels (at least one artery and one vein) and recipient vessels. Re-innervation and functioning muscle contraction is achieved by suturing the vessels and a motor nerve in the recipient area to a motor nerve of a free transplanted muscle. After regeneration of the nerve and re-innervation of the transplanted muscle, a functioning free transplanted muscle offers enough contractile capacity and strength to replace the function of the missing muscles at the recipient site. The technique of microvascular free tissue transfer necessitates extensive experience in microvascular technique and this approach could be efficiently applied in cooperation with other specialists. Recent studies show the development and clinical application of these new surgical techniques in urology (e.g. in the treatment of bladder acontractility using innervated free latissimus dorsi muscle and in the use of a free microvascular fillet lower leg flap for the reconstruction of a large pelvic-floor defect).
• Summary: Various reconstructive requirements define the techniques for reconstruction. The main principle is to obtain optimal anatomical and functional reconstruction with minimal donor site morbidity. Depending on the etiology of the defect, different reconstructive options are available to optimize the reconstructive result. Optimal reconstruction might best be achieved by adopting an interdisciplinary approach in which the primary objective is to provide the best possible outcome for each patient. This review presents the main indications for and principles of flap selection according to the reconstructive requirements.
  
  
• Editorial Comment
  In reconstructive urology as in many other areas indications and possibilities can be considerably improved by co-operation with other disciplines. The current paper written by an expert plastic surgeon published in an urological journal shows how sophisticated flap techniques can be used in urologic surgery.
  Another important aspect is the fact that pre-fabrication as seen by these authors is an alternative for reconstruction of segments in the urinary tract. Contrary to tissue engineering, where the organ is primarily generated in the laboratory to be implanted into the body later on, the pre-fabrication technique composes organs with one or several different flaps in the body itself and transplants or transposes the finished “product” to the desired location when it is ready to use. When we look at the many open questions and problems that need to be solved in tissue engineering before we can apply it on a large scale in urology, pre-fabrication may be a way for a broader clinical use in the nearer future.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany