Surgical Management of Rectourethral Fistula

Abstract

To present our experience and outcomes with the challenging problem of rectourethral fistula (RUF) using the perineal approach. RUF is a rare occurrence. This was a retrospective study of patients treated from January 1999 to December 2006. Fifteen patients (aged 16 to 64 years, mean 38) were studied, and their outcomes were assessed after surgical repair. The etiology was iatrogenic in 7, congenital in 5, and traumatic in 3. All patients presented with the passage of urine through the rectum and underwent micturating cystourethrography with retrograde urethrography, followed by preliminary cystoscopy and examination under anesthesia. All patients were treated using the perineal approach and gracilis muscle flap interposition. Six patients had associated urethral pathologic features that were managed simultaneously with RUF repair. Preoperatively, bowel diversion was done at the time of the cystourethroscopy and examination under anesthesia, if not done earlier, and the definitive repair was deferred for at least 12 weeks after bowel diversion. RUF closure was successful in all the patients. Postoperatively, 2 patients had minimal urinary leakage through the perineum that resolved after repeat catheterization for 8 weeks. One stricture at the anastomotic site was managed with optical internal urethrotomy. One patient had extrusion of the gracilis flap, for which the muscle was repositioned. The results of our study have shown that RUF closure using the perineal approach with pedicled gracilis muscle interposition is associated with low morbidity and a high success rate (100%). It is the method of choice for urologists because of their familiarity with the approach and because urethral pathologic features can be corrected simultaneously. We emphasize the need for bowel diversion before attempting reconstruction.