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Rectourethral fistula associated with two short segment urethral strictures in the anterior and posterior urethra: Single-stage reconstruction using buccal mucosa and a radial forearm fasciocutaneous free flap
SURGICAL TECHNIQUES IN UROLOGY
RECTOURETHRAL FISTULA ASSOCIATED WITH TWO SHORT SEGMENT URETHRAL STRICTURES IN THE ANTERIOR AND POSTERIOR URETHRA: SINGLE-STAGE RECONSTRUCTION USING BUCCAL MUCOSA AND A RADIAL FOREARM FASCIOCUTANEOUS FREE FLAP BRADLEY A. ERICKSON, GREGORY A. DUMANIAN, MARK SISCO, THOMAS L. JANG, AMY L. HALVERSON, and CHRIS M. GONZALEZ
ABSTRACT Introduction. We report a novel surgical technique used to repair a rectourethral fistula associated with two short-segment urethral strictures located in the anterior and posterior segments of the urethra in a patient with prior unsuccessful repairs. Technical Considerations. The anterior urethral stricture was reconstructed with a ventral onlay of buccal mucosa in the exaggerated lithotomy position. In a modified prone position, the rectourethral fistula was repaired using the transrectal transsphincteric (York-Mason) technique and the posterior urethral stricture with a radial forearm fasciocutaneous free flap which was anastomosed to the inferior gluteal artery and vein. The coexistence of a rectourethral fistula and distal urethral stricture requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. Reconstructive efforts should be tailored to minimize disruption of the urethral blood supply in patients with previous pelvic trauma. Rectal and urethral repairs should be separated by well-vascularized tissue to prevent fistula recurrence. Conclusions. The radial fasciocutaneous flap may offer the reconstructive surgeon another surgical option for complex urethral stricture and rectourethral fistula reconstruction when the local blood supply is in question. Longer follow-up and more cases are needed to further evaluate the continued use of this technique. UROLOGY 67: 195–198, 2006. © 2006 Elsevier Inc.
R
ectourethral fistulas are a rare, but devastating condition that are usually a result of pelvic trauma, radiation, or prostate surgery.1 The association of a rectourethral fistula with one or more urethral strictures has been reported, yet remains uncommon.2 Various reconstructive techniques have been described for rectourethral fistula repair, although little has been mentioned regarding concomitant reconstruction of both a fistula and a urethral stricture. The coexistence of a rectourethral
fistula and a urethral stricture distal to the fistula requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. When the urethral blood supply is in question, as is often the case after pelvic trauma and/or previous urethral surgery, reconstructive efforts should be tailored to minimize urethral mobilization to avoid the potential for ischemic necrosis of the urethral anastomosis.3 MATERIAL AND METHODS
From the Departments of Urology and Surgery and Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois Reprint requests: Bradley A. Erickson, M.D., Department of Urology, Northwestern University Feinberg School of Medicine, 675 North St. Clair, Galter 20-150, Chicago, IL 60611. E-mail: [email protected] Submitted: December 29, 2004, accepted (with revisions): August 1, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
CASE REPORT A 30-year-old Kenyan man presented to our institution with urine leakage per rectum and recurrent pyelonephritis. He had been involved in a motor vehicle collision 4 years prior and suffered severe pelvic trauma. He subsequently underwent two unsuccessful surgeries in Kenya in an attempt to repair a posterior rectourethral fistula that was eventually managed with a diverting loop sigmoidostomy. On presentation to our institution, he underwent cystoscopy and retrograde ure0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.002 195
FIGURE 2. Radial forearm fasciocutaneous free flap (asterisk) left in continuity with radial vessels.
FIGURE 1. Preoperative retrograde urethrogram showing membranous and bulbar urethral stricture and rectourethral fistula.
thrography that showed a 2-cm rectomembranous urethral fistula in addition to a 2-cm posterior urethral stricture extending from the membranous urethra to the external sphincter. An additional 1.5-cm stricture was located in the bulbar urethra (Fig. 1). Proctoscopy confirmed the 2-cm defect in the anterior rectum consistent with the retrograde urethrography findings. The patient had been offered permanent urinary and fecal diversion at an outside hospital but desired surgical repair.
SURGICAL TECHNIQUE The patient provided informed consent before surgery. He underwent preoperative bowel preparation and received intravenous antibiotics. A 3 ⫻ 2-cm buccal mucosal graft was harvested from the left cheek with the patient in the supine position. He was then placed in the exaggerated lithotomy position and underwent perineal exploration to expose the bulbar urethral stricture. The stricture was opened ventrally, and an onlay of buccal mucosa was sutured over the stricturotomy with 4-0 Vicryl suture. Simultaneous to the anterior urethral stricture reconstruction, a 3 ⫻ 2-cm left forearm free flap was developed and harvested. After mobilization of the flap, the resulting left forearm defect was closed primarily, although the vessels to the flap were left in continuity with the arm until the pelvic recipient vessels were identified and exposed (Fig. 2). The patient was next placed in the modified prone position. A parasacral incision was made and the gluteus maximus was exposed and partially mobilized off of its origin to the sacrum and the sacrotuberous ligament. The inferior gluteal artery and vein were then identified 1 cm lateral to the sacrotuberous ligament. The incision was next extended from the coccyx to include the external and internal sphincters and posterior rectal wall for adequate fistula exposure. The fistula was mobilized and excised. An end-to-end arterial and venous anastomosis with the forearm fascial free-flap was then performed to the exposed inferior gluteal vessels (Fig. 3). The fistulotomy was extended distally to open the strictured membranous urethra that extended to the external urethral sphincter. The lumen was calibrated to 26F, and the epithelial side of the forearm free flap was sutured to the urethral mucosa using 4-0 196
Vicryl sutures, with care taken to avoid a 360° twist of the flap’s vascular pedicle. The subcutaneous component of the flap was interposed between the urethral and rectal defects. An implantable venous Doppler lead was placed on the outflow vein of the free flap for postoperative monitoring of vessel patency.4 Finally, an anterior rectal mucosal advancement flap was mobilized to cover the remaining rectal mucosal defect. Care was taken at closure to ensure rectal sphincter integrity. Postoperatively, a Clinitron bed was used to minimize the pressure on the incision and on the vascular pedicle for approximately 2 weeks.
RESULTS The patient’s postoperative course was complicated only by inadvertent self-removal of his Foley catheter at 4 weeks that was promptly replaced using cystoscopy. The catheter was removed 6 weeks postoperatively, and cystoscopy and retrograde urethrography at that time revealed a patent urethra without extravasation (Fig. 4). Takedown of the patient’s sigmoidostomy was performed 4 months later without complications. The urethral catheter placed before this surgery was done with the aid of flexible cystoscopy, which revealed a wide lumen and patent urethra. At 12 months of follow-up, the patient reported complete resolution of rectal urinary leakage, no stress or urgerelated incontinence, and an American Urological Association symptom score of 4. He had no bowel complaints. COMMENT Local fasciocutaneous flaps are commonly used for complex urethral repairs. However, to our knowledge, this is the first reported case that uses a radial forearm free flap for concomitant rectourethral fistula and posterior urethral stricture repair. This flap has long been used by plastic surgeons because of its versatility and long pedicle length.5 It proved to be a useful alternative for reconstruction in this patient in whom local tissue was unusable because of previous pelvic trauma and postoperative scarring. The epithelium of the flap was ideal UROLOGY 67 (1), 2006
FIGURE 3. (A) Exposure of inferior gluteal artery and vein. (B) Excision of rectourethral fistula tract. (C) Incorporation of radial forearm fasciocutaneous free flap.
FIGURE 4. Postoperative retrograde urethrogram showing widely patent urethra and resolution of rectourethral fistula.
for repair of the urethral mucosal defect, and the subcutaneous component of the flap provided a well-vascularized, yet thin, anatomic separation of the urethral and rectal repairs sites, an attribute believed to be important for successful repair of rectourethral fistulas.6,7 The recipient vessel was chosen intraoperatively after vessel integrity was verified by adequate Doppler tones. Dissection of these vessels is difficult in patients with large gluteus muscles and this should be taken into consideration before surgery. The use of a pedicled gracilis muscle flap for the repair of complex rectourethral fistulas has been well described and was considered in this case. However, because of the extremely proximal location of the posterior urethral stricture, only the most distal portion of the gracilis flap would likely have reached this area. The gracilis flap becomes UROLOGY 67 (1), 2006
tendinous and less robust at its distal aspect,8 and we did not want to rely on the least vascularized portion of the flap for the most important aspect of the operation. Because the gracilis flap would have been used not merely for anatomic separation of the urethra and rectum but also as a recipient for a buccal graft, we believed ventral onlay with buccal mucosa for the anterior stricture reconstruction and the transfer of well-vascularized epithelium in the form of a free flap directly to the posterior urethral fistula/stricture site were better options in an area with a potentially tenuous blood supply and contaminated with colonic flora. To our knowledge, only one series describing concomitant rectourethral fistula and urethral stricture repair has been reported. Hemal et al.2 used a transpubic approach in 7 patients with a rectourethral fistula and urethral stricture. Their report highlighted the use of omental interposition and complete excision with primary anastomosis (EPA) of the urethral stricture.2 All seven rectourethral fistulas were successfully repaired, but 2 patients ultimately required optical internal urethrotomy of anastomotic urethral strictures and 1 developed a urethrocutaneous fistula with stress urinary incontinence. Because EPA of short primary urethral strictures alone has a success rate greater than 90%,9 the recurrence of stricture in 2 of 7 men and fistula formation in 1 of 7 calls into question the reliability of the urethral blood supply in patients with complicated fistula/stricture disease and the role of EPA in these men. We believed the use of an onlay of buccal mucosa to reconstruct the anterior urethral stricture and a fasciocutaneous free flap for reconstruction of the posterior urethral fistula/stricture would preserve 197
the existing blood supply of the urethra better than EPA and minimize the potential for anastomotic necrosis and stricture recurrence. Because reoperation for stricture recurrence in this patient would have been extremely difficult, if not impossible, we believed this novel approach was justified, even if it meant a longer operative time and the potential for forearm donor site morbidity. We did not perform preoperative pelvic angiography, although it could be argued that EPA may still have been possible in this patient, if angiography had shown at least one intact internal pudendal/dorsal artery. In this particular case, however, angiography would likely not have changed our operative strategy, because we believed the extremely dense and extensive periurethral scar this patient had developed would have made urethral mobilization very challenging, putting the preexisting blood supply at too much of a risk. However, angiography should be considered in similar patients when a detailed knowledge of the pelvic blood supply is needed for preoperative strategy. The transrectal transsphincteric (York-Mason) approach for rectourethral fistula repair was chosen both for its historical success in similar patients and its limited disruption of the rectal and urethral blood supply.7,10 The incisions are made in relatively nonvascular planes and the excellent exposure the technique provides allowed for the incorporation of the free-flap gluteal anastomosis. The closure used an anterior rectal wall mucosal advancement flap that helped to offset the suture lines and decrease the risk of fistula recurrence.11 CONCLUSIONS We report a novel surgical technique in which a rectourethral fistula and two separate strictures located in different urethral segments were repaired in a single stage using buccal mucosa and a fasciocutaneous free flap. A simultaneous repair was vital to the successful closure of the rectourethral
198
fistula. Extensive mobilization of the urethra was not performed, minimizing the potential risk of urethral or anastomotic necrosis. The use of the radial fasciocutaneous free flap for complex urethral stricture and rectourethral fistula reconstruction may offer the reconstructive surgeon another surgical option in the treatment of this difficult patient population. Longer follow-up and more cases are needed to evaluate further the continued use of this technique. REFERENCES 1. Bukowski TP, Chakrabarty A, Powell IJ, et al: Acquired rectourethral fistula: methods of repair. J Urol 153: 730 –733, 1995. 2. Hemal AK, Sharma SK, and Goswami AK: Urethrorectal fistulas complicated by posterior urethral stricture: an appraisal of management by transpubic approach. Urol Int 46: 329 –333, 1991. 3. Barbagli G, Selli C, and Tosto A: Reoperative surgery for recurrent strictures of the penile and bulbous urethra. J Urol 156: 78 –79, 1996. 4. Swartz WM, Izquierdo R, and Miller MJ: Implantable venous Doppler microvascular monitoring: laboratory investigation and clinical results. Plast Reconstr Surg 93: 152–163, 1993. 5. Serafin D: Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia, WB Saunders, 1996, 389 – 401. 6. Ryan JA Jr, Beebe HG, and Gibbons RP: Gracilis muscle flap for closure of rectourethral fistula. J Urol 122: 124 –125, 1979. 7. Sans JV, Redorta JP, Teigell JP, et al: Management and treatment of eighteen rectourethral fistulas. Eur Urol 11: 300 – 305, 1985. 8. Hasen KV, Gallegos ML, and Dumanian GA: Extended approach to the vascular pedicle of the gracilis muscle flap: anatomical and clinical study. Plast Reconstr Surg 111: 2203– 2208, 2003. 9. Koraitim MM: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 173: 135–139, 2005. 10. Wood TW, and Middleton RG: Single-staged transrectal transsphinteric (modified York-Mason) repair of rectourinary fistulas. Urology 35: 27–30, 1990. 11. Johnson WR, Druitt DM, and Masterton JP: Anterior rectal advancement flap in the repair of benign rectoprostatic fistula. Aust NZ J Surg 51: 383–385, 1981.
UROLOGY 67 (1), 2006
RECTOURETHRAL FISTULA ASSOCIATED WITH TWO SHORT SEGMENT URETHRAL STRICTURES IN THE ANTERIOR AND POSTERIOR URETHRA: SINGLE-STAGE RECONSTRUCTION USING BUCCAL MUCOSA AND A RADIAL FOREARM FASCIOCUTANEOUS FREE FLAP BRADLEY A. ERICKSON, GREGORY A. DUMANIAN, MARK SISCO, THOMAS L. JANG, AMY L. HALVERSON, and CHRIS M. GONZALEZ
ABSTRACT Introduction. We report a novel surgical technique used to repair a rectourethral fistula associated with two short-segment urethral strictures located in the anterior and posterior segments of the urethra in a patient with prior unsuccessful repairs. Technical Considerations. The anterior urethral stricture was reconstructed with a ventral onlay of buccal mucosa in the exaggerated lithotomy position. In a modified prone position, the rectourethral fistula was repaired using the transrectal transsphincteric (York-Mason) technique and the posterior urethral stricture with a radial forearm fasciocutaneous free flap which was anastomosed to the inferior gluteal artery and vein. The coexistence of a rectourethral fistula and distal urethral stricture requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. Reconstructive efforts should be tailored to minimize disruption of the urethral blood supply in patients with previous pelvic trauma. Rectal and urethral repairs should be separated by well-vascularized tissue to prevent fistula recurrence. Conclusions. The radial fasciocutaneous flap may offer the reconstructive surgeon another surgical option for complex urethral stricture and rectourethral fistula reconstruction when the local blood supply is in question. Longer follow-up and more cases are needed to further evaluate the continued use of this technique. UROLOGY 67: 195–198, 2006. © 2006 Elsevier Inc.
R
ectourethral fistulas are a rare, but devastating condition that are usually a result of pelvic trauma, radiation, or prostate surgery.1 The association of a rectourethral fistula with one or more urethral strictures has been reported, yet remains uncommon.2 Various reconstructive techniques have been described for rectourethral fistula repair, although little has been mentioned regarding concomitant reconstruction of both a fistula and a urethral stricture. The coexistence of a rectourethral
fistula and a urethral stricture distal to the fistula requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. When the urethral blood supply is in question, as is often the case after pelvic trauma and/or previous urethral surgery, reconstructive efforts should be tailored to minimize urethral mobilization to avoid the potential for ischemic necrosis of the urethral anastomosis.3 MATERIAL AND METHODS
From the Departments of Urology and Surgery and Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois Reprint requests: Bradley A. Erickson, M.D., Department of Urology, Northwestern University Feinberg School of Medicine, 675 North St. Clair, Galter 20-150, Chicago, IL 60611. E-mail: [email protected] Submitted: December 29, 2004, accepted (with revisions): August 1, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
CASE REPORT A 30-year-old Kenyan man presented to our institution with urine leakage per rectum and recurrent pyelonephritis. He had been involved in a motor vehicle collision 4 years prior and suffered severe pelvic trauma. He subsequently underwent two unsuccessful surgeries in Kenya in an attempt to repair a posterior rectourethral fistula that was eventually managed with a diverting loop sigmoidostomy. On presentation to our institution, he underwent cystoscopy and retrograde ure0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.002 195
FIGURE 2. Radial forearm fasciocutaneous free flap (asterisk) left in continuity with radial vessels.
FIGURE 1. Preoperative retrograde urethrogram showing membranous and bulbar urethral stricture and rectourethral fistula.
thrography that showed a 2-cm rectomembranous urethral fistula in addition to a 2-cm posterior urethral stricture extending from the membranous urethra to the external sphincter. An additional 1.5-cm stricture was located in the bulbar urethra (Fig. 1). Proctoscopy confirmed the 2-cm defect in the anterior rectum consistent with the retrograde urethrography findings. The patient had been offered permanent urinary and fecal diversion at an outside hospital but desired surgical repair.
SURGICAL TECHNIQUE The patient provided informed consent before surgery. He underwent preoperative bowel preparation and received intravenous antibiotics. A 3 ⫻ 2-cm buccal mucosal graft was harvested from the left cheek with the patient in the supine position. He was then placed in the exaggerated lithotomy position and underwent perineal exploration to expose the bulbar urethral stricture. The stricture was opened ventrally, and an onlay of buccal mucosa was sutured over the stricturotomy with 4-0 Vicryl suture. Simultaneous to the anterior urethral stricture reconstruction, a 3 ⫻ 2-cm left forearm free flap was developed and harvested. After mobilization of the flap, the resulting left forearm defect was closed primarily, although the vessels to the flap were left in continuity with the arm until the pelvic recipient vessels were identified and exposed (Fig. 2). The patient was next placed in the modified prone position. A parasacral incision was made and the gluteus maximus was exposed and partially mobilized off of its origin to the sacrum and the sacrotuberous ligament. The inferior gluteal artery and vein were then identified 1 cm lateral to the sacrotuberous ligament. The incision was next extended from the coccyx to include the external and internal sphincters and posterior rectal wall for adequate fistula exposure. The fistula was mobilized and excised. An end-to-end arterial and venous anastomosis with the forearm fascial free-flap was then performed to the exposed inferior gluteal vessels (Fig. 3). The fistulotomy was extended distally to open the strictured membranous urethra that extended to the external urethral sphincter. The lumen was calibrated to 26F, and the epithelial side of the forearm free flap was sutured to the urethral mucosa using 4-0 196
Vicryl sutures, with care taken to avoid a 360° twist of the flap’s vascular pedicle. The subcutaneous component of the flap was interposed between the urethral and rectal defects. An implantable venous Doppler lead was placed on the outflow vein of the free flap for postoperative monitoring of vessel patency.4 Finally, an anterior rectal mucosal advancement flap was mobilized to cover the remaining rectal mucosal defect. Care was taken at closure to ensure rectal sphincter integrity. Postoperatively, a Clinitron bed was used to minimize the pressure on the incision and on the vascular pedicle for approximately 2 weeks.
RESULTS The patient’s postoperative course was complicated only by inadvertent self-removal of his Foley catheter at 4 weeks that was promptly replaced using cystoscopy. The catheter was removed 6 weeks postoperatively, and cystoscopy and retrograde urethrography at that time revealed a patent urethra without extravasation (Fig. 4). Takedown of the patient’s sigmoidostomy was performed 4 months later without complications. The urethral catheter placed before this surgery was done with the aid of flexible cystoscopy, which revealed a wide lumen and patent urethra. At 12 months of follow-up, the patient reported complete resolution of rectal urinary leakage, no stress or urgerelated incontinence, and an American Urological Association symptom score of 4. He had no bowel complaints. COMMENT Local fasciocutaneous flaps are commonly used for complex urethral repairs. However, to our knowledge, this is the first reported case that uses a radial forearm free flap for concomitant rectourethral fistula and posterior urethral stricture repair. This flap has long been used by plastic surgeons because of its versatility and long pedicle length.5 It proved to be a useful alternative for reconstruction in this patient in whom local tissue was unusable because of previous pelvic trauma and postoperative scarring. The epithelium of the flap was ideal UROLOGY 67 (1), 2006
FIGURE 3. (A) Exposure of inferior gluteal artery and vein. (B) Excision of rectourethral fistula tract. (C) Incorporation of radial forearm fasciocutaneous free flap.
FIGURE 4. Postoperative retrograde urethrogram showing widely patent urethra and resolution of rectourethral fistula.
for repair of the urethral mucosal defect, and the subcutaneous component of the flap provided a well-vascularized, yet thin, anatomic separation of the urethral and rectal repairs sites, an attribute believed to be important for successful repair of rectourethral fistulas.6,7 The recipient vessel was chosen intraoperatively after vessel integrity was verified by adequate Doppler tones. Dissection of these vessels is difficult in patients with large gluteus muscles and this should be taken into consideration before surgery. The use of a pedicled gracilis muscle flap for the repair of complex rectourethral fistulas has been well described and was considered in this case. However, because of the extremely proximal location of the posterior urethral stricture, only the most distal portion of the gracilis flap would likely have reached this area. The gracilis flap becomes UROLOGY 67 (1), 2006
tendinous and less robust at its distal aspect,8 and we did not want to rely on the least vascularized portion of the flap for the most important aspect of the operation. Because the gracilis flap would have been used not merely for anatomic separation of the urethra and rectum but also as a recipient for a buccal graft, we believed ventral onlay with buccal mucosa for the anterior stricture reconstruction and the transfer of well-vascularized epithelium in the form of a free flap directly to the posterior urethral fistula/stricture site were better options in an area with a potentially tenuous blood supply and contaminated with colonic flora. To our knowledge, only one series describing concomitant rectourethral fistula and urethral stricture repair has been reported. Hemal et al.2 used a transpubic approach in 7 patients with a rectourethral fistula and urethral stricture. Their report highlighted the use of omental interposition and complete excision with primary anastomosis (EPA) of the urethral stricture.2 All seven rectourethral fistulas were successfully repaired, but 2 patients ultimately required optical internal urethrotomy of anastomotic urethral strictures and 1 developed a urethrocutaneous fistula with stress urinary incontinence. Because EPA of short primary urethral strictures alone has a success rate greater than 90%,9 the recurrence of stricture in 2 of 7 men and fistula formation in 1 of 7 calls into question the reliability of the urethral blood supply in patients with complicated fistula/stricture disease and the role of EPA in these men. We believed the use of an onlay of buccal mucosa to reconstruct the anterior urethral stricture and a fasciocutaneous free flap for reconstruction of the posterior urethral fistula/stricture would preserve 197
the existing blood supply of the urethra better than EPA and minimize the potential for anastomotic necrosis and stricture recurrence. Because reoperation for stricture recurrence in this patient would have been extremely difficult, if not impossible, we believed this novel approach was justified, even if it meant a longer operative time and the potential for forearm donor site morbidity. We did not perform preoperative pelvic angiography, although it could be argued that EPA may still have been possible in this patient, if angiography had shown at least one intact internal pudendal/dorsal artery. In this particular case, however, angiography would likely not have changed our operative strategy, because we believed the extremely dense and extensive periurethral scar this patient had developed would have made urethral mobilization very challenging, putting the preexisting blood supply at too much of a risk. However, angiography should be considered in similar patients when a detailed knowledge of the pelvic blood supply is needed for preoperative strategy. The transrectal transsphincteric (York-Mason) approach for rectourethral fistula repair was chosen both for its historical success in similar patients and its limited disruption of the rectal and urethral blood supply.7,10 The incisions are made in relatively nonvascular planes and the excellent exposure the technique provides allowed for the incorporation of the free-flap gluteal anastomosis. The closure used an anterior rectal wall mucosal advancement flap that helped to offset the suture lines and decrease the risk of fistula recurrence.11 CONCLUSIONS We report a novel surgical technique in which a rectourethral fistula and two separate strictures located in different urethral segments were repaired in a single stage using buccal mucosa and a fasciocutaneous free flap. A simultaneous repair was vital to the successful closure of the rectourethral
198
fistula. Extensive mobilization of the urethra was not performed, minimizing the potential risk of urethral or anastomotic necrosis. The use of the radial fasciocutaneous free flap for complex urethral stricture and rectourethral fistula reconstruction may offer the reconstructive surgeon another surgical option in the treatment of this difficult patient population. Longer follow-up and more cases are needed to evaluate further the continued use of this technique. REFERENCES 1. Bukowski TP, Chakrabarty A, Powell IJ, et al: Acquired rectourethral fistula: methods of repair. J Urol 153: 730 –733, 1995. 2. Hemal AK, Sharma SK, and Goswami AK: Urethrorectal fistulas complicated by posterior urethral stricture: an appraisal of management by transpubic approach. Urol Int 46: 329 –333, 1991. 3. Barbagli G, Selli C, and Tosto A: Reoperative surgery for recurrent strictures of the penile and bulbous urethra. J Urol 156: 78 –79, 1996. 4. Swartz WM, Izquierdo R, and Miller MJ: Implantable venous Doppler microvascular monitoring: laboratory investigation and clinical results. Plast Reconstr Surg 93: 152–163, 1993. 5. Serafin D: Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia, WB Saunders, 1996, 389 – 401. 6. Ryan JA Jr, Beebe HG, and Gibbons RP: Gracilis muscle flap for closure of rectourethral fistula. J Urol 122: 124 –125, 1979. 7. Sans JV, Redorta JP, Teigell JP, et al: Management and treatment of eighteen rectourethral fistulas. Eur Urol 11: 300 – 305, 1985. 8. Hasen KV, Gallegos ML, and Dumanian GA: Extended approach to the vascular pedicle of the gracilis muscle flap: anatomical and clinical study. Plast Reconstr Surg 111: 2203– 2208, 2003. 9. Koraitim MM: On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol 173: 135–139, 2005. 10. Wood TW, and Middleton RG: Single-staged transrectal transsphinteric (modified York-Mason) repair of rectourinary fistulas. Urology 35: 27–30, 1990. 11. Johnson WR, Druitt DM, and Masterton JP: Anterior rectal advancement flap in the repair of benign rectoprostatic fistula. Aust NZ J Surg 51: 383–385, 1981.
UROLOGY 67 (1), 2006