musculocutaneous flap, pressure injury, pressure ulcer, urethral reconstruction, urinary derivation, urinary fistula



  1. Zogheib, Serge MD
  2. Khalil, Nour MD, MSc
  3. Mjaess, Georges MD
  4. Feghaly, Charbel MD
  5. Daou, Bechara MD
  6. Hanna, Cyril MD
  7. Nasr, Marwan MD


OBJECTIVE: To review the literature about combined urologic and reconstructive management of pressure injuries (PIs) with urethral fistulas.


DATA SOURCES: Authors searched the PubMed, MEDLINE, EMBASE, and Cochrane databases using the following keywords: "Perineum" or "Perineal" and "Pressure Ulcers" or '' Pressure Injury'' and "Urethral Fistula."


STUDY SELECTION: The search yielded a total of 95 articles. Study selection followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement, and the study was designed according to the PICOS (Population, Intervention, Comparison, Outcomes, Study) guidelines. Congress abstracts, letters to the editor, and editorial comments were excluded. After screening, a total of 9 studies (30 patients) were included in the review.


DATA EXTRACTION: Included patients received treatment for a perineal or ischial PI associated with a urinary fistula. The outcomes were recovery, complications, treatment failure, recurrence, and illness-related death.


DATA SYNTHESIS: Pressure injuries were mainly ischiatic (50%) and perineal (43%). Forty-six percent of patients had spinal cord injuries, and at least 40% reported voiding dysfunction. Sixteen percent had previous ischiectomy. Flaps such as posterior thigh flap, biceps femoris flap, and inferiorly based transverse rectus abdominal muscle flap had 88% to 100% success rates when used with urinary diversion techniques. Suprapubic cystostomy, the simplest method of urinary diversion, was successful in 47% of cases when performed alone and in 100% when combined with a pedicled omental flap or a transverse rectus abdominal muscle flap.


CONCLUSIONS: Prevention and wound care are essential for PI management, but when combined with a urinary fistula, surgical management is unavoidable. Urinary diversion is essential before undergoing any type of ulcer reconstruction. Urethral reconstruction showed favorable results, further strengthened when combined with a musculocutaneous flap.