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

KEVIN R. LOUGHLIN AND DENNIS P. ORGILL

From the Divisions of Urology and Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School,Boston, Massachusetts

KEY WORDS: cryosurgery, rectal fistula, rectus abdominis, surgical flaps

Prostato-rectal fistulae secondary to external beam radia-tion and cryosurgery are extremely challenging surgically.We report on the incorporation of a rectus muscle flap tofacilitate 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 theurethra and rectum. History was significant for prostatecancer detected at biopsy 7 years earlier elsewhere after thediscovery of increased prostate specific antigen (PSA). Treat-ment had included approximately 65 Gy. external beam ra-diation initially and leuprolide acetate after PSA increased.While on leuprolide acetate PSA became undetectable but forunclear reasons cryosurgical ablation of the prostate wasperformed. A prostato-rectal fistula developed postopera-tively, which was treated unsuccessfully elsewhere with adiverting colostomy.

Excretory urogram showed normal upper tracts and fillingdefects in the bladder. Cystoscopy revealed foreign bodies,which appeared to be fecaliths. There was a fistula, approx-imately the size of an index finger, leading from the prostaticfossa to the rectum. Because of the heavily irradiated tissueand prior use of a cryosurgical probe, we elected to use avascularized tissue flap. A transabdominal appproach wasused to close the fistula. Abdominal adhesions were lysed andthe bladder was opened. Multiple fecaliths were removedfrom the bladder. The bladder was then bivalved from thedome down through the trigone until the fistulous tract wasreached. Stay sutures were placed on either side of the fistulaand the tract was cored out. The rectal defect was closed in 2

layers with 2-zero polydioxanone sutures and a right rectusabdominis flap based on the inferior epigastric pedicle wasmobilized and placed over the rectal closure. Because of thetenuous nature of the posterior prostate fossa and bladderwall, the rectus flap was incorporated into the bladder clo-sure between the halves of the bladder. Ureteral stents and a3-way urethral catheter were used for drainage. A cystogramon postoperative day 17 showed no bladder leak and success-ful closure of the fistula (see figure). The patient plans tohave the colostomy closed at a future date.

DISCUSSION

Prostato-rectal fistulae can occur after external beamradiation and/or cryosurgical ablation for prostate can-cer.1, 2 The combination of both modalities creates an areathat is likely to be poorly vascularized and, therefore,difficult to close successfully surgically. A review of theliterature revealed only 1 report of the use of a rectus flapto close a bladder fistula3 and another to close a bladderdefect in a patient with a jejunal-vesical fistula.4 Thevesico-cutaneous fistula developed in a diabetic renal allo-graft recipient and the jejunal-vesical fistula occurred in apatient with metastatic rectal cancer. To our knowledge wereport the first case of closure of a prostato-rectal fistulawith a rectus flap. The rectus flap is an attractive solutionbecause of its proximity to the prostatic fossa, ease ofharvesting and the predictability of its vascular supply.The muscle is below the anterior fascia, which allows fortransportation in the abdomen and pelvis with a low risk ofherniation of the abdominal contents. In conclusion, werecommend that the rectus flap be considered for closuresof prostato-rectal fistulae.Accepted for publication March 2, 2001.

Postoperative cystogram. A, fistula closure is shown with rectus flap incorporated into bladder closure. B, oblique view

0022-5347/01/1662-0620/0THE JOURNAL OF UROLOGY® Vol. 166, 620–621, August 2001Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.

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REFERENCES

1. Fengler, S. A. and Abcarian, H.: The York Mason approach to repair ofiatrogenic rectourinary fistulae. Am J Surg, 173: 213, 1997

2. Kalbhen, C. L., Salomon, C. G., Dudiak, C. M. et al: Complica-tions of prostate cryosurgery: CT findings in three patients.Abdom Imaging, 23: 442, 1998

3. Shabtai, M., Walter, W. C., Frischer, Z. et al: Rectus muscle flapfor repair of refractory bladder fistula following renal trans-plantation: a case report. J Urol, 143: 354, 1990

4. Schilling, M. K., Forssmann, V., Kollmar, O. et al: Rectus abdo-minis musculoperitoneal flap for the closure of bladder defect.J Urol, 163: 1517, 2000

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