The Posterior Scrotal Artery Adipofascial Flap for Rectourethral Fistulae

Acquired rectourethral fistulas (RUF) are uncommon but challenging problems in colorectal and urologic surgery. They are most commonly iatrogenic or secondary to trauma, inflammatory bowel disease, or infection. Standard management consists of colonic diversion, fistula tract division or excision, repair of defects of the structures involved (ie, urethra and rectum), and tissue interposition. Several techniques have been described for soft tissue interposition for RUF repair; however, there is a paucity of literature describing outcomes and comparing surgical options. Here, we present the posterior scrotal artery adipofascial (PSAF) flap, used to interpose healthy, vascularized soft tissue between the repaired rectum and urethra following division of RUF and to provide soft tissue coverage of other urologic defects. To our knowledge, this is the first description of this adipofascial flap in a male patient.

We describe the surgical technique of the PSAF flap used as an interposition flap for iatrogenic urologic defects, most commonly RUF, by a single surgeon at a single institution. A retrospective case series is performed evaluating recurrence rates and other complications.

The PSAF flap was used in 8 male patients from 2014 to 2026. Average age at time of surgery was 69.4±9.7 years. Six patients underwent PSAF flap for repair of RUF, 1 for urethrocutaneous fistula, and 1 for urethrectomy defect. Five patients reported a history of smoking, and 2 patients had prior radiation. Average follow-up was 40.0±45.8 weeks. Postoperatively, there were no fistula recurrences or other major complications in patients who underwent PSAF for RUF. One patient with a diagnosis of urethrocutaneous fistula experienced a recurrent fistula, and 1 patient reported persistent scrotal numbness. Six patients reported urinary incontinence postoperatively; 2 of these patients had reported incontinence before undergoing PSAF flap.

The PSAF flap is a novel, safe option for tissue interposition in the setting of RUF repair. It can be reliably identified and dissected for coverage of iatrogenic urologic defects, even in the setting of advanced age, prior instrumentation, radiation, or prior smoking. High-powered studies with long-term follow-up are necessary to evaluate outcomes and compare the effectiveness of the PSAF flap to other reconstructive options.