The Uroplastic Approach to Complex Rectourethral Fistula Repair: Indications, Technique, Results

Rectourethral fistulae are complex pathologies with significant morbidity that warrant multidisciplinary care. Although gracilis muscle interposition for fistula repair has been reported, specific indications and techniques for this mode of reconstruction remain unclear.

A retrospective quasi-experimental study was previously conducted to assess outcomes of rectourethral fistula management before and after the implementation of a multidisciplinary treatment algorithm. Patients with complex rectourethral fistulae and repair with gracilis muscle flap interposition were further investigated. Plastic surgery involvement for gracilis muscle interposition was indicated for (1) radiated rectourethral fistulae less than 3 cm and (2) nonradiated rectourethral fistulae more than 2 cm. Our preferred technique for gracilis muscle flap harvest, transposition, and inset is described in detail. Primary outcomes included healing of rectourethral fistulae and secondary reversal of urinary or fecal diversions.

Twenty-three patients with complex rectourethral fistulae underwent gracilis muscle flap interposition between 2001 and 2022 before (n = 12) and after (n = 11) algorithmic implementation. The frequency of definitive rectourethral fistula healing improved in the postalgorithm group by 33%. There was no significant difference in fistula healing time or the rate of urinary or fecal diversions after algorithm implementation. The technique of gracilis muscle flap interposition is also described.

The gracilis muscle interposition flap is a valuable reconstructive option for complex rectourethral fistula repair. Implementation of a multidisciplinary treatment algorithm including plastic surgery involvement and refinement of the operative approach was associated with improved frequency of definitive healing of rectourethral fistulae.