Urologist La Paz University Hospital, Madrid, Spain
Introduction: Rectourethral fistula (RUF) is the least common but most devastating complication of the treatment of prostate cancer. Herein we describe a new surgical approach that incorporates a partially de-epithelialized mid-perineal scrotal flap (MPSF), used as interposition flap, that can be used in almost all patients with RUF after radiotherapy regardless of having or not a concomitant stricture or contracture of the posterior urethra or bladder neck that might require a simultaneous urethroplasty. Methods: From March 2019 to March 2021 3 men with complex RFU that had failed previous intent of surgical correction underwent surgical repair by means of the MPSF technique. In all cases the RUF is stented leaving a ureteric catheter inserted through the urethra and exteriorized through the anus.An inverted trapezoidal incision centered over the mid raphe is made in the perineum with the proximal aspect of the lateral incisions starting at the level of the ischial tuberosities. The distal aspect of the trapezoidal flap reaches the mid portion of the scrotum. A mid-perineal scrotal flap (MPSF) is harvested that incorporates all the subcutaneous tissue between the skin and the bulbar urethra following the surgical technique described by Gil-Vernet et al. for the elevation of scrotal skin flaps for urethroplasty. During this maneuver the testicles surrounded by the tunica vaginalis are completely freed and positioned temporarily over the lower abdomen. The complete bulbar urethra is visible and allows resection and closure of the fistulous tract. In case that a urethral stricture is associated with the fistula an anastomotic urethroplasty can be fashioned. To avoid recurrence of the fistula the distal aspect of the MPSF is de-epithelialized and used as interposition flap. Results: The 3 patients with complex rectourethral fistulas were operated upon with the MPSF technique. After a median follow-up of 14 months all the patients are cured. Case Age Etiology Previous repairs Previous Urinary diversion Colostomy Treatment with MPSF Outcome Follow-up (m) 1 59 Open prostatectomy+adjuvant radiotherapy + TUR DVIU, TUR, Laser Suprapubic tube During repair Yes Cured 18 2 52 RARP Trasperineal, transrectal Bladder catheter Preoperative Yes Cured 14 3 72 Radiotherapy, cryotherapy, urethral dilatations No No During repair Yes Cured 8 Conclusions: The MPSF is a straightforward procedure that allows excellent access both to the bulbar urethra and to the surgical plane between rectum and prostate. It does not require a separate incision for the flap harvesting procedure in case it is necessary. SOURCE OF Funding: None
