Post-operative outcomes in rectourethral fistula repair using gracilis interposition flap

To assess outcomes of rectourethral fistula repair utilizing a gracilis flap in a largely radiated cohort.

We performed a retrospective review of all gracilis interposition flap reconstruction surgeries performed for RUF at a university hospital in South Carolina between January 2010 and June 2023. All repairs utilized a multidisciplinary approach with urology, colorectal, and plastic surgery teams. Post-operatively, patients were maximally drained with foley catheter and suprapubic tube (SPT). Initial voiding cystourethrogram (VCUG) was performed at 4 weeks post-repair. If there was a persistent leak, catheter drainage was maintained for 4 additional weeks and VCUG was repeated. Success was defined as absence of leak on VCUG within 3 months after surgery.

22 patients met inclusion criteria. 68% of patients had history of external beam radiation therapy (EBRT), 13.6% had brachytherapy, and 40.9% had cryotherapy. Initial post-operative VCUG was negative in 10 patients (45.5%). Of the 12 patients with a persistent fistula, 5 (42%) had no evidence of fistula on subsequent VCUG after 4 weeks. Overall, 68% of patients were successfully treated with gracilis interposition flap. There was a significant difference of repair success based on EBRT status (p < 0.05).

We report a success rate of 68% for gracilis flap repair of RUF. Our cohort had a higher rate of prior radiation therapy compared to other studies. A clinically significant portion of patients with an initial positive VCUG will seal their fistula with prolonged catheter drainage. Gracilis interposition flap is a reasonable surgical treatment for RUF.