Gracilis muscle interposition for the treatment of recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases.
BACKGROUND
Several surgical procedures for the repair of fistulas between the rectum and the urethra or vagina have been reported. Our study was designed to assess the efficacy of the gracilis muscle flap in repairing recto-urethral and rectovaginal fistulas.


METHODS
Gracilis muscle interposition flaps were performed in 35 patients (aged 38-78 years, mean: 58 years) using a perineal approach. Nine patients had rectovaginal fistulas due to Crohn's disease (n=3), previous surgery and pelvic irradiation for rectal (n=2) or cervical cancer (n=4). Twenty-six fistulas were recto-urethral. The aetiologies were Crohn's disease (n=4), brachytherapy after prostate cancer (n=14), iatrogenic injury to the rectum during radical retropubic prostatectomy (n=4), transurethral resection of the prostate (n=2) and recurrent peri-anal abscesses with fistulas (n=2). Twenty-five patients had undergone previous repair attempts; of these four underwent multiple procedures. Patient outcomes were assessed after surgical repair. The success rate was measured as the percentage of patients with a healed fistula after stomal closure.


RESULTS
The mean follow-up was 28+/-15 months from muscle transposition and 22+/-14 months from stomal closure. Fistula closure with no recurrence could be achieved in 33 patients (94%). Two of the seven patients (29%) with Crohn's disease had a persistent fistula. There were neither intra-operative complications nor problems related to muscle desinsertion surgery.


CONCLUSIONS
Recto-urethral and rectovaginal fistula closure using the perineal approach with pedicled gracilis muscle interposition is associated with minimal morbidity and a high success rate. It is an excellent option for patients with complicated fistulas for whom other surgical treatments have failed. Underlying Crohn's disease is associated with a higher complication rate.
Ulrich
Dietmar
D
Department of Plastic Surgery, Hand Surgery, Burn Unit, University Hospital, Medical Faculty of the University of Technology, Pauwelsstrasse 30, D-52074 Aachen, Germany. dulrich@ukaachen.de
Roos
Joachim
J
Jakse
Gerhard
G
Pallua
Norbert
N
D000328:Adult; D000368:Aged; D001918:Brachytherapy / Q000009:adverse effects; D003424:Crohn Disease / Q000150:complications; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000098:blood supply / Q000637:transplantation*; D011468:Prostatectomy / Q000009:adverse effects; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply; D014522:Urethral Diseases / Q000209:etiology / Q000601:surgery*; D014548:Urinary Fistula / Q000209:etiology / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*