Gracilis Muscle Interposition Research Articles

Recto-urethral fistula repair using gracilis muscle interposition: Complications, functional results and management of residual stress urinary incontinence

Recto-urethral fistula repair using gracilis muscle interposition: Complications, functional results and management of residual stress urinary incontinence

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience.

Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.

MP78-15 MANAGEMENT AND OUTCOMES OF ILEAL POUCH-URETHRAL FISTULAS

You have accessJournal of UrologyCME1 Apr 2023MP78-15 MANAGEMENT AND OUTCOMES OF ILEAL POUCH-URETHRAL FISTULAS João Pedro Emrich Accioly, Marianna Maspero, Hanson Zhao, Roger K. Khouri, Olga Lavryk, Kenneth W. Angermeier, Tracy Hull, and Hadley M. Wood João Pedro Emrich AcciolyJoão Pedro Emrich Accioly More articles by this author , Marianna MasperoMarianna Maspero More articles by this author , Hanson ZhaoHanson Zhao More articles by this author , Roger K. KhouriRoger K. Khouri More articles by this author , Olga LavrykOlga Lavryk More articles by this author , Kenneth W. AngermeierKenneth W. Angermeier More articles by this author , Tracy HullTracy Hull More articles by this author , and Hadley M. WoodHadley M. Wood More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fistulas may develop following ileal pouch anal anastomosis (IPAA), but urinary tract involvement in this setting is rare. We thus aim to describe our experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with IPAA. METHODS: We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort through keywords and procedure codes. In a retrospective medical record review, we obtained demographic, clinical and operative data, including diagnostic methods, individual management strategies and outcomes and described our findings. RESULTS: We identified thirteen patients with a diagnosis of IPUF managed from 2005–2022. Median age at IPAA was 29 years (range 11–53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Interval events included IPAA dilations (n=5) and dual radiation therapy for prostate cancer (n=2). Median time from IPAA to fistula diagnosis was 15 years (range 0.5–38.5). Initial management consisted of urinary diversion with either suprapubic tube (n=6) or Foley catheter (n=1) and fecal diversion with either loop (n=8) or end ileostomy (n=3); five had dual urinary/fecal diversion. Four patients experienced resolution with either urinary (n=2) or fecal (n=2) diversion alone. Eight patients eventually required pouch excision and end ileostomy, of which seven underwent concomitant urethral repair. Gracilis muscle interposition was employed in addition to primary closure in five patients. Only one patient successfully underwent re-do IPAA. With a median follow-up of 4 years (range 0.3–13 years), all patients had resolution of their fistulas without recurrence. CONCLUSIONS: IPUFs are an uncommon complication of IPAA. In this cohort, all patients had urinary tract preservation, but in most instances, permanent fecal diversion was necessary. These results can help guide management of this complex issue. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1137 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information João Pedro Emrich Accioly More articles by this author Marianna Maspero More articles by this author Hanson Zhao More articles by this author Roger K. Khouri More articles by this author Olga Lavryk More articles by this author Kenneth W. Angermeier More articles by this author Tracy Hull More articles by this author Hadley M. Wood More articles by this author Expand All Advertisement PDF downloadLoading ...

Gracilis Muscle Interposition to Fill the Perianal Dead Space May Decrease Hospital Length of Stay in Fournier's Gangrene.

The treatment of Fournier's gangrene (FG) includes aggressive debridement of the affected necrotic area, broad-spectrum antibiotic therapy, and reconstructive procedures, respectively. One of the main reasons of unfavorable outcomes in FG surgery is that the dead space occurs in the perianal region because of destruction of fascias and soft tissues. In this study, we aimed to evaluate the results of gracilis muscle flap transposition to fill the FG-associated perianal dead spaces. Patients treated for FG-associated dead spaces in their perianal region between the years 2017 and 2021 were included in the study. The patients who underwent the pedicled gracilis muscle flap surgery were included in group 1, whereas group 2 consisted of the patients with no additional surgical procedure for dead spaces but only the reconstruction of the soft tissue defects. Demographic data (age, sex), comorbid diseases, localization and length of perianal dead space, and management method for the soft tissue defects and complications were noted. The length of hospital stay and discharge day after surgery were also recorded. In group 1, the mean duration of hospital stay was 23.5 ± 5.0 (range, 14-48) days, whereas the mean period between the surgery and discharge was 5.1 ± 2.2 (range, 3-12) days. These numbers were 31 ± 8.3 (range, 19-58) days and 12.7 ± 6.1 (range, 7-22) days in group 2, respectively. Statistical comparison of the periods between the surgery and discharge was found to be significantly different ( P = 0.022). The duration of hospital stay was also shorter in the patients with gracilis muscle flap ( P = 0.039). Perianal dead spaces accompanying many of the patients with FG provide appropriate conditions for bacterial colonization. Filling these pouches by the gracilis muscle flap prevented the progression of infection and enabled the patients to return to their normal life earlier.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer.

Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment. This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications. This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008). Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature.

Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF. PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data. Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I2 = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I2 = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I2 =61%). The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.

Management and Outcomes of Ileal Pouch-Urethral Fistulas

To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.

Surgical Intervention is Effective for the Treatment of Crohn's-related Rectovaginal Fistulas: Experience From a Tertiary Inflammatory Bowel Disease Practice.

Rectovaginal fistula occurs in up to 10-20% of women with Crohn's disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions. A retrospective review of all adult patients with a Crohn's-related rectovaginal fistula, who underwent an operation between 1995 and 2021, was performed. Data collected included patient demographics, Crohn's-related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes. A total of 166 patients underwent 360 operations; mean age was 42.8 [+/-13.2] years; 34 [20.7%] patients were current and 58 [35.4%] former smokers. The most commonly performed procedure was: a local approach [n = 160, 44.5%] using fibrin glue, fistulotomy/fistulectomy, or seton placement; followed by a transvaginal/transanal approach [n = 113, 31.4%] with an advancement flap repair [including Martius advancement flap] and episoproctotomy; a transabdominal approach [n = 98, 27.2%] including proctectomy or re-do anastomosis; and finally gracilis muscle interposition [n = 8, 2.2%]. The median number of operative interventions per patient was 2 [1.0-3.0] procedures. The overall fistula healing rate per patient was 71.7% [n = 119] at a median follow-up of 5.5 [1.2-9.8] years. Factors that impaired healing included former smoking (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.87, p = 0.014) and seton insertion [OR 0.42, 95% CI 0.21-0.83, p = 0.012]. Over two-thirds of Crohn's-related rectovaginal fistulas can achieve closure with multiple surgical interventions. Smoking and seton usage negatively affect healing rates and should be avoided.

Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

Watch a video of a live Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap procedure in addition to hundreds more peer-reviewed surgical video journals - only at CSurgeries.com

Objective Perfusion Assessment in Gracilis Muscle Interposition-A Novel Software-Based Approach to Indocyanine Green Derived Near-Infrared Fluorescence in Reconstructive Surgery.

Background: Gracilis muscle interposition (GMI) is an established treatment option for complex perineal fistulas and reconstruction. The outcome is limited by complications such as necrosis, impaired wound healing and fistula persistence or recurrence. Quantifiable methods of assessing muscle flap perfusion intraoperatively are lacking. This study evaluates a novel and objective software-based assessment of indocyanine green near-infrared fluorescence (ICG-NIRF) in GMI. Methods: Intraoperative ICG-NIRF visualization data of five patients with inflammatory bowel disease (IBD) undergoing GMI for perineal fistula and reconstruction were analyzed retrospectively. A new software was utilized to generate perfusion curves for the specific regions of interest (ROIs) of each GMI by depicting the fluorescence intensity over time. Additionally, a pixel-to-pixel and perfusion zone analysis were performed. The findings were correlated with the clinical outcome. Results: Four patients underwent GMI without postoperative complications within 3 months. The novel perfusion indicators identified here (shape of the perfusion curve, maximum slope value, distribution and range) indicated adequate perfusion. In one patient, GMI failed. In this case, the perfusion indicators suggested impaired perfusion. Conclusions: We present a novel, software-based approach for ICG-NIRF perfusion assessment, identifying previously unknown objective indicators of muscle flap perfusion. Ready for intraoperative real-time use, this method has considerable potential to optimize GMI surgery in the future.

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Rectovaginal Fistula Repair Due to Obstetric Injury: Single Center Experience

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Rectovaginal Fistula Repair Due to Obstetric Injury: Single Center Experience

Recurrent rectourethral fistula repair: A novel technique of gracilis muscle interposition

BackgroundA perineal approach with gracilis muscle interposition (GMI) remains the most common in recurrent rectourethral fistulas (RUFs). The closure failures in10%–20% cases and urinary incontinence in 10%–80% cases referred to the disadvantages of the perineal approach owing to neurovascular damage. This article shows that the retraction of a survived muscle gracilis flap is one of the causes of fistula recurrence, and a simpler technique of the flap interposition is presented, requiring a less invasive perineal access. MethodsThree consecutive patients with RUF at the age of 5, 13 and 15 years who underwent multiple (3, 4 and 5) unsuccessful reconstructive attempts were referred to our clinic. The last procedure was performed with GMI. In all cases, these were acquired iatrogenic fistulas that occurred after operations for Hirschsprung's disease (2) or anorectal malformation (1), and subsequent dilatation of the anus. All patients had a colostomy several years ago. Reinterposition and distant anchoring of the survived graсilis flap were performed through the perineal approach, avoiding lateral and anterolateral dissection. ResultsThe early postoperative period was uneventful. In one patient, a stricture of the posterior urethra formed. Urethrotomy was performed in 3 months, with complete restoration of micturition. The colostomy was closed in all patients after 3–4 months. In the long term follow up within 4–8 years, no fistula recurrence was noted. ConclusionsThe suggested traction technique of GMI allowed: to minimize the perineal access size, hence minimizing the injury and the operating time; to place the anchoring suture outside of the inflammation zone, ensuring secure attachment; to provide precise flap positioning and intimate contact between the flap and the urethra. Level of evidenceLevel V.

Redo gracilis interposition for complex perineal fistulas.

Rectovaginal, pouch-vaginal, and recto-urethral fistulas are very challenging to treat. Gracilis muscle interposition was shown be an effective treatment for these complex fistulas. The aim of this study was to investigate the feasibility and outcomes of redo gracilis interposition for persistent and recurrent complex perineal fistulas. A retrospective analysis of all patients who had redo gracilis muscle interposition for complex perineal fistulas at our institution from 1995 to 2019 was performed. Nine patients (5 males, mean age 55years) were included for analysis. The types of fistulas were recto-urethral (n = 5), rectovaginal (n = 2) and pouch-vaginal (n = 2). The success rate was 56% with 5 patients achieving complete healing of the fistula. Only 1 patient (11%) experienced a postoperative complication. Redo gracilis muscle interposition is feasible and safe with promising resultsin healing of complex perineal fistula.

Successful repair of the rectovaginal fistula with gracilis muscle interposition

Introduction: Rectovaginal fistulas represent an often devastating condition in patients and a challenge for surgeons. Successful management of this condition must take into account a variety of variables including the etiology, size, and location of the fistula. We retrospectively evaluated our experience with the gracilis interposition procedure to assess its efficacy in repairing rectovaginal fistulas. Materials and Methods: We performed a retrospective study of all patients who underwent gracillis muscle interposition flap in our institution from January 2015 to November 2018 for the repair of fistulas between the rectum and vagina arising from diverse etiologies. Results: Rectovaginal fistula repair with gracilis muscle interposition was done in twelve patients. The etiologies were obstetric trauma (n=7), trauma (n=3), post arteriovenous malformation excision (n=1) and one patient had fistula after excision of squamous papilloma of rectum. Overall all the patients with gracilis interposition flap resulted in complete healing, a success rate of 100 percent. Discussion: Various surgical procedures have been suggested for the repair of these fistulas, including fecal diversion, primary repair, endorectal advancement flap, transvaginal repair, coloanal sleeve anastomosis, and interposition flaps. The reported success rate for the repair of rectovaginal or rectourethral fistulas using the gracilis muscle interposition technique is generally much higher than that reported for other repair techniques. Conclusion: Given the high success rate and low complication rate, repair with gracilis muscle interposition is recommended for fistulas with unfavorable local conditions, such as those present after radiation or subsequent to long-term, persistent infection, and especially after failed previous repairs. Keywords: Rectovaginal fistula, Gracilis muscle, Interposition.

Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas

BackgroundRectourethral fistulas (RUFs) are rare but devastating complications after surgery or radiation therapy to the urethra, prostate, or rectum. RUF repair is challenging, especially in irradiated patients. ObjectiveTo evaluate the efficacy of the York Mason (YM) procedure with or without concomitant gracilis muscle interposition (graciloplasty) for RUF repair. Design, setting, and participantsRecords of patients with an iatrogenic RUF who underwent the YM procedure between 2008 and 2018 in two university hospitals were reviewed. Data on etiology, diagnostic and operative procedures, urinary and fecal diversion, and postoperative follow-up were collected. InterventionTwenty-eight patients underwent 33 YM procedures. Concomitant graciloplasty was performed in four (14%) primary repairs and two (7%) repairs for recurrent RUFs. Outcome measurements and statistical analysisThe primary endpoint was successful RUF repair, defined as absence of symptoms and no leakage on control urethrocystography. The secondary endpoint was colostomy reversal rate. Results and limitationsMedian follow-up was 24 mo. Ten patients (36%) were irradiated previously. The ultimate success rate was 75% after a maximum of three YM procedures. Success rates were 89% and 50% in patients with nonirradiated and irradiated fistulas, respectively. In irradiated patients, the success rates of the first YM procedure with and without graciloplasty were 100% and 29%, respectively. In recurrent cases, concomitant graciloplasty did not result in better outcomes. Colostomy reversal was possible in 15 patients after successful repair. In all patients, fecal continence was intact and no anal stenosis was reported. Limitations of the study include small sample size and the retrospective design. ConclusionsCombination of the YM procedure with graciloplasty resulted in higher success rates of RUF repair in patients with irradiated fistulas. Fecal continence was preserved, and colostomy reversal is feasible. Patient summaryWe analyzed the outcomes, complications, and colostomy reversal rate of the York Mason procedure for the repair of rectourethral fistulas (RUFs). We found that concomitant graciloplasty increases success rates in case of prior radiation therapy. Colostomy reversal is feasible after RUF repair.

The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula

To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF). RUF may appear after radical prostatectomy. Their treatment represents a challenge; many therapies have been proposed, from conservative to aggressive surgical approaches. Transanal endoscopic surgery (TEO or TEM) is a minimally invasive technique to access the site of the RUF to perform repair. This is an observational study with prospective data collection, conducted between September 2006 and December 2015. All patients were diagnosed with RUF following management of prostate cancer. Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion. If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition. If this failed, gracilis muscle was applied as salvage therapy. Ten patients were diagnosed with RUF. In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion. Eight patients underwent repair by TEO or TEM, 4 with biological mesh interposition; all 4 presented recurrence. In the other 4 patients treated via TEO or TEM, 2 had early recurrence, whereas the others had healed at follow-up visits after 4-6 months (2 of 8)-a success rate of 25%. The 6 patients who recurred were treated with gracilis muscle interposition via a transperineal approach. The low rate of positive results obtained by TEO or TEM argues against its use as technique of choice in RUF, and against the use of biological meshes.

Gracilis Muscle Interposition for Rectourethral Fistula After Laparoscopic Prostatectomy: A Prospective Evaluation and Long-term Follow-up.

Postoperative rectourethral fistula after radical prostatectomy is an infrequent but very serious problem. We aimed to describe our experience with transperineal repair and unilateral gracilis muscle interposition in patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. This was a cohort study. All of the procedures were performed at the same hospital by the same multidisciplinary team made up of a senior colorectal surgeon and a senior urologist. Patients with postoperative rectourethral fistula after laparoscopic prostatectomy were included. Transperineal fistula repair and gracilis muscle interposition were included. Fistula healing rate was measured. Nine patients with postoperative rectourethral fistula were treated between November 2009 and February 2016. Four of them had received other previous treatments without success, and 5 had previously been treated with this technique. Seven patients had a fecal diverting stoma. After a median follow-up of 54 months (range, 2-72), all of the fistulas had successfully healed, and, to date, the patients remain asymptomatic without urinary diversion. Fecal diversion was closed in all but 1 patient. No intraoperative or infectious complications were detected. With the results of our series, we present specific technical details of our technique and hope to provide additional evidence of the low morbidity profile and excellent healing rate of this treatment. Moreover, we note that, although small, this series corresponds with a homogeneous group of patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. This is a small but very homogeneous group of patients. Simple repair with perineal gracilis muscle interposition is a safe and effective technique for the treatment of postoperative rectourethral fistulas after nonradiated prostate cancer surgery.

Experience with 32 Pelvic Fracture Urethral Defects Associated with Urethrorectal Fistulas: Transperineal Urethroplasty with Gracilis Muscle Interposition

Pelvic fracture urethral defects associated with urethrorectal fistulas are rare and difficult to repair. The aim of this study was to evaluate the efficacy of transperineal urethroplasty with gracilis muscle interposition for the repair of pelvic fracture urethral defects associated with urethrorectal fistulas. We identified 32 patients who underwent transperineal urethroplasty with gracilis muscle interposition to repair pelvic fracture urethral defects associated with urethrorectal fistulas. Patient demographics as well as preoperative, operative and postoperative data were obtained. Mean followup was 33 months (range 6 to 64). The overall success rate was 91% (29 of 32 cases). One-stage repair was successful in 17 of 18 patients (94%) using perineal anastomosis with separation of the corporeal body and in 12 of 14 (86%) using perineal anastomosis with inferior pubectomy and separation of the corporeal body. All 22 patients (100%) without a previous history of repair were successfully treated. However, only 7 of 10 patients (70%) with a previous history of failed urethroplasty and urethrorectal fistula repair were cured. Recurrent urethral strictures developed in 2 cases. One patient was treated successfully with optical internal urethrotomy and the other was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent urethrorectal fistulas associated with urethral strictures developed in an additional patient. Transperineal urethroplasty with gracilis muscle interposition is a safe and effective surgical procedure for most pelvic fracture urethral defects associated with urethrorectal fistulas. Several other factors may affect its postoperative efficiency.

Transperineal approach to complex rectourinary fistulae

We sought to present our experience and outcomes in patients with complex rectourethral fistulae (RUF) treated using the transperineal approach with gracilis muscle flap interposition. Complex RUF was defined as having prior radiation, failed repair attempts, and large size (>2 cm). A retrospective review identified 10 patients presenting with complex RUF between July 2009 and November 2013. Three were excluded due to large fistula defects managed with urinary diversion. Seven patients met inclusion criteria and underwent reconstruction. Six of 7 patients had prostate cancer, and one patient had colon cancer treated with low anterior resection with adjuvant radiation. The primary modality of prostate cancer therapy was brachytherapy (n=3), external beam radiotherapy (n=2) and radical retropubic prostatectomy (RRP) (n=1). Three patients had salvage cancer therapy, including RRP (n=1), cystoprostatectomy with ileal conduit (n=1), and cryotherapy (n=1). One patient developed RUF post-primary RRP without radiation. Mean fistula size was 2.8cm (2-4 cm). No fistulas recurred at mean follow-up 11.4 months (6-20 months). Three patients have had colostomy reversal, one is pending reversal and three have permanent colostomies. Five patients have stress urinary incontinence, with two managed with one to four pads per day, one managed with a condom catheter, and two waiting for artificial urinary sphincter (AUS). One patient developed a perineal wound infection and one developed a pulmonary embolus treated medically. Complex RUF defects are effectively treated with transperineal repair using gracilis muscle interposition. The procedure has low morbidity and high success. Concomitant stress incontinence and bladder outlet contracture are prevalent in this population and may require ongoing management.

Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.

The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation. Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up. Mean age was 60years (50-73) with median follow-up of 28.7months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p=0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2months (3.5-24.9). In irradiated patients, 18/20 (90%) developed BOD compared with 1/7 (14%) who were not radiated (p=0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p=0.0458). Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.