Rectourethral (RUF) fistula is a rare surgical condition with a variety of etiologies from congenital to acquired. The management of RUF remains a surgical challenge which is evident by the numerous procedures described in the literature with none of them gaining widespread acceptance. We describe our experience with the management of RUF using gracilis muscle flap interposition.

A retrospective study of the three patients with RUF treated at our institute between 2017-2020 was performed. The study included the acquisition of data from clinical records and telephonic calls. The information recorded was age, etiology, clinical presentation, prior surgeries, diagnostic workup, operative details, complications and follow up.

Age of the three patients were 37, 38 and 39 years. Two patients had simple direct fistulas, one patient had complex fistula with one opening in the urethra and two openings in the rectum.  Two patients had a history of pelvic fracture following a road traffic accident and one patient had a history of bicycle bar trauma to the perineum. All patients were initially managed elsewhere. One patient had RUF following pelvic fracture at the time of primary trauma, the other patient developed RUF following multiple blind metallic dilations for management of urethral stricture following the perineal injury. The third patient developed RUF following traumatic rupture of Foley’s catheter balloon using instillation with ether while removing the catheter after end to end anastomotic urethroplasty for pelvic fracture urethral distraction defect. All patients had urinary diversion in the form of suprapubic cystostomy and two patients also had fecal diversion in the form of colostomy prior to definitive surgical repair three to six months later. The surgical technique used was transperineal excision of the fistula, repair of the rectal and urethral defects with interposition of the gracilis flap in between the rectal and urethral repairs. The right gracilis flap was harvested successfully in all three patients. The operative times were 320 mins, 300 mins and 210 mins and the blood loss was 400ml, 300ml, and 250ml. One patient had thigh wound site hematoma in the post-operative period that required the opening of sutures, clot evacuation and then secondary suturing later on. One patient had surgical site infection that was managed conservatively with daily dressings. The follow-up period for the three patients were 4 months, 26 months and 30 months. All the patients have been dry without any recurrence. One patient developed urethral stricture in the follow-up period that required endodilation.

Repair of rectourethral fistula using gracilis muscle flap interposition has a very high success rate (100% in our series) with few minor complications in the postoperative period.

The repair of rectourethral fistula using gracilis muscle flap interposition is associated with a high success rate and low morbidity. Using the perineal approach offers the advantage of anatomic familiarity to the urologists which makes the procedure easier as compared to the other methods described in the literature.