THE USE OF A RECTUS MUSCLE FLAP IN THE REPAIR OF A PROSTATO-RECTAL FISTULA

Abstract

Prostato-rectal fistulae secondary to external beam radiation and cryosurgery are extremely challenging surgically. We report on the incorporation of a rectus muscle flap to facilitate healing of this visceral defect. CASE REPORT A 74-year-old man presented with a prostato-rectal fistula. He complained of continuous leakage of urine per the rectum, urinary tract infections and passage of “stones” through the urethra and rectum. History was significant for prostate cancer detected at biopsy 7 years earlier elsewhere after the discovery of increased prostate specific antigen (PSA). Treatment had included approximately 65 Gy. external beam radiation initially and leuprolide acetate after PSA increased. While on leuprolide acetate PSA became undetectable but for unclear reasons cryosurgical ablation of the prostate was performed. A prostato-rectal fistula developed postoperatively, which was treated unsuccessfully elsewhere with a diverting colostomy. Excretory urogram showed normal upper tracts and filling defects in the bladder. Cystoscopy revealed foreign bodies, which appeared to be fecaliths. There was a fistula, approximately the size of an index finger, leading from the prostatic fossa to the rectum. Because of the heavily irradiated tissue and prior use of a cryosurgical probe, we elected to use a vascularized tissue flap. A transabdominal appproach was used to close the fistula. Abdominal adhesions were lysed and the bladder was opened. Multiple fecaliths were removed from the bladder. The bladder was then bivalved from the dome down through the trigone until the fistulous tract was reached. Stay sutures were placed on either side of the fistula and the tract was cored out. The rectal defect was closed in 2 layers with 2-zero polydioxanone sutures and a right rectus abdominis flap based on the inferior epigastric pedicle was mobilized and placed over the rectal closure. Because of the tenuous nature of the posterior prostate fossa and bladder wall, the rectus flap was incorporated into the bladder closure between the halves of the bladder. Ureteral stents and a 3-way urethral catheter were used for drainage. A cystogram on postoperative day 17 showed no bladder leak and successful closure of the fistula (see figure). The patient plans to have the colostomy closed at a future date.