Introduction: Urinary fistulas are uncommon but debilitating complications post prostatectomy, presenting with pneumaturia, fecaluria and urochezia and occurring in 0.6 to 9 % of cases(1). “Conservative” management involves urinary and fecal diversion, although resolution rates are low- one study demonstrating a closure rate of 33% with catheterization and colostomy alone (2); surgical repair is thus often mandated in cases of failure. Various approaches are described- transperineal, transrectal, transsphincteric, and transanorectal. Common techniques for repair post fistula excision include direct layered closure, mucosal flaps, buccal mucosal grafts and interposition with pedicled locoregional tissue: including gracillis, omentum, rectus abdominus, dartos or levator. We describe 2 cases of pedicled gracillis interposition for post prostatectomy urinary fistula reconstruction.
Discussion and Review of literature
Outcomes of this technique have been reported in several series. Munoz-Duyos et al reported 9 cases in post-prostatectomy rectrourethral fistula with successful healing in all patients with 54 months median follow up (3). Bislengi et al. reported on 52 patients with acquired rectourethral fistulas, Gracillis interposition in this cohort approached 90% closure rates (4). A systematic review of rectourethral fistula repair techniques reported that most high volume centres (>25 patients) use tissue interposition flaps (5).
Conclusions
Gracillis interposition flap is a well described, safe and reliable method for post-prostatectomy urinary fistula reconstruction, providing well vascularized locoregional musculature with minimal donor site morbidity.