Bilateral Puborectalis Interposition Repair of Rectourethral Fistula

BACKGROUND: Rectourethral fistula is a rare but significant complication that often requires operative intervention. OBJECTIVE: A new perineal approach using the medial aspect of the puborectalis muscles as a double-breasted rotational interposition flap to repair the rectourethral fistula is hereby described. PROCEDURE: With the patient in a modified Lloyd-Davies position, a vertical midline incision from the base of the scrotum to 2 cm anterior to the anal verge is made. The dissection continues along the anterior rectal wall through the Denonvilliers fascia until the rectourethral fistula is reached. The dissection through the fused Denonvilliers fascia continues a further 1 to 2 cm above the fistula. The openings in the rectum and the urethra are then closed vertically (urethra) and horizontally (rectum) with interrupted 3/0 and 4/0 polyglactin sutures. The puborectalis muscles are then mobilized as a 1-cm strip bilaterally and released posteriorly at the level of the anorectum. The 2 strips of the puborectalis muscles are then rotated medially and superiorly along its anterior attachments, forming a double -breasted overlapping flap overlying the fistula openings. The flaps are anchored into the superior and contralateral aspect of the surgical field with the use of 2/0 polyglactin sutures. RESULTS: From November 2011 to December 2012, 4 patients underwent this procedure. No perioperative complications, including those related to the harvesting of the puborectalis muscles, were identified. Subsequent radiological studies confirmed the success of the procedure. After a median follow-up of 8 (6-18) months, 3 patients had their colostomy reversed and remained continent, whereas the last patient had a permanent ileostomy. None of the patients reported any urinary leakage through the perineum. CONCLUSIONS: The double-breasted puborectalis interposition flap is an alternative transperineal procedure in the management of rectourethral fistula. It avoids a laparotomy and is rectum sparing.