Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula.

Shrikant Jai,Vinod Bopaiah,Mahesh Desai,Arvind Ganpule,Abhishek Singh,Ravindra Sabnis,Mohankumar Vijaykumar

doi:10.12688/f1000research.10245.1

Shrikant Jai, Vinod Bopaiah + Show 5 more

Open Access

https://doi.org/10.12688/f1000research.10245.1

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Abstract

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. To our knowledge this is first case in which rectourethral fistula secondary to HIFU was repaired with buccal mucosa graft (BMG) over a harvest bed of gracilis flap. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the "first chance is the best chance".

Highlights

High intensity focused ultrasound (HIFU) is a treatment option in the management of prostate cancer[1]
Urethrorectal fistula is a serious complication of HIFU
Literature reports a rate of urethrorectal fistula following HIFU2 of approximately 0.7%

Summary

Introduction

High intensity focused ultrasound (HIFU) is a treatment option in the management of prostate cancer[1]. Literature reports a rate of urethrorectal fistula following HIFU2 of approximately 0.7%. He underwent an initial TURP to debulk the gland. On the 15th POD, the patient had urine leak via the rectum. As conservative management failed in form of suprapubic catheter (SPC), he underwent robotic assisted laparoscopic excision of the fistula. On the 6th POD following robotic repair, the patient developed fecaluria which was managed with loop sigmoid colostomy and SPC. Repeat cystoscopy after 3 months showed persistent fistula (Figure 1). He was planned for repeat surgery via perineal approach in view of his previous failed abdominal surgery and faecal contamination of abdomen. The fistula was at the 1 o’ clock position between the prostatic urethra and rectum (Figure 3). On follow-up visits at 3 and 6 months, the patient was asymptomatic

Discussion

Findings

Conclusion

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