ABSTRACT Introduction: Distal urogenital fistulas (DUF) are usually iatrogenic and are uncommon in Europe. They occur in the urethra or near the bladder neck, and can be caused by vaginal hysterectomy, para-urethral cyst surgery, or erosion of the bladder or urethra from tension-free slings or meshes. The psychological and physical health consequences of DUF are devastating because most patients consider themselves “healthy” before surgery. Incontinence can appear after successful DUF closure due to previously occult incontinence or urethral incompetence. Additional surgery for incontinence is sometimes necessary to achieve satisfactory outcome. Materials and Methods: A Martius flap was used in 23 patients between 2000 and 2015. Patient age range was 38-75 years (mean, 58.7). DUF was due to gynecologic surgery for benign disease (15 / 23; 65.2%), mesh / sling erosion (2 / 23; 8.7%), and malignancy (6 / 23; 26.1%). The follow-up period was one year. Results: DUF was closed in 22 patients (95.6%). Satisfaction and complete dryness was achieved in 16 patients (69.6%) after the first procedure. Postoperative complications were: postoperative hematoma in 1 (4.4%), primary failure in 1 (4.4%), overactive bladder (OAB) syndrome in 3 (13.2%) and postoperative incontinence in 6 (26.4%) patients. A fascial sling was placed in patients with incontinence. All patients were dry after the secondary surgery. Anticholinergics were used for the treatment of OAB syndrome. Discomfort at the flap harvesting site was of minor importance. Finally, 22 out of 23 patients (95.6%) were satisfied. Conclusion: A Martius flap and additional fascial sling could be successfully used to optimize DUF treatment.

The treatment of long urethral strictures is based on the use of buccal mucosa graft (BMG). Postoperative failures commonly occur in patients with the obliterative strictures, and the long augmented part of the urethra which is prone to fibrotic changes. Combined approach with the resection of the obliterative part of the urethral plate located in the bulbar urethra, together with the ventral placement of BMG was performed in 36 patients. Etiology of the stricture was: idiopathic in 19/36 (52.7%), iatrogenic in 14/36 (38.8%), and other causes in 3/36 (8.3%). Mean length of the stricture was 7.2±1.6 cm, and the length of the augmented graft 4.5±1.2 cm (due to resected urethral plate) so, the single BMG was enough in 25/36 (69.4%) patients. The medium postoperative follow up was 24 months (20–28 months) months. Success of the surgery was defined as no need for additional surgery neither dilatation. Cystoscopy was performed 4–6 months after the surgery and additional follow up with IPSS and uroflowmetry. Overall success was achieved in 31/36 (86.1%) patients. Mean postoperative IPSS was 9.5±2.1 in these patients. Complications were according to Clavien Dindo scale: grade II in 11/36 (30.5%-infection, orchialgia, scrotal pain), grade III in 4/36 (11.1%-fistula) and grade IV in 5/36 (14.5% - restenosis). Postoperative Qmax= 13.2±1.2 ml/s. Bell shaped curve was present in 14/36(38.8%). Our results suggest that overall success rate is similar to the expected values for BMG surgery, and the number of the grafts used is lower due to reduced stricture length.