Transperineal Urethroplasty with Gracilis Muscle Interposition - Expert Commentary

Pelvic fracture urethral defects (PFUDs) occur in around 10% of patients with pelvic fractures. PFUDs can sometimes be associated with urethrorectal fistulas and these have proven to be extremely difficult to operate on and repair. To date, there have not been any standardized approach to the treatment of complex PFUDs with associated URFs. Until now, surgeons have typically used various surgical approaches to repair these complex PFUDs such as utilizing various vascularized tissue flaps to interposition. The transperineal approach seems the best to expose the urethra and rectum for concurrent urethral or bladder neck stricture repairs. As the gracilis muscle is used in more than 95% of transperineal approaches to buttress the repair, the study authors attempted to perform transperineal urethroplasty with gracilis muscle interposition to treat complex PFUDs associated with URFs. Therefore, within the study, the authors aimed to review their experiences with this procedure and determine its efficacy in dealing with PFUDs associated with URFs. 

A total of 32 patients were selected to undergo transperineal urethroplasty with gracilis muscle interposition for surgical correction of post traumatic PFUDs associated with URFs. In these, the PFUDs associated with URFs developed secondary to pelvic fracture urethral and rectal injury in traffic injuries, fall injuries, or extrusion injuries. The URF repair was performed according to previously described methods as scar tissue was excised as well. Each renal defect was closed in 2 layers with tension-free end-to-end mucosa-to-mucosa urethral anastomosis. The gracilis muscle interposition procedure was then performed by the same surgeon. They ensured the length of the bulky muscular portion of the well vascularized gracilis muscle was enough for placement of the muscle between both planes to occlude the fistula tract and separate the suture lines. The patients were evaluated with retrograde and voiding urethrography and uroflowmetry at the time of catheter removal at the end of 4 weeks with a urethral silicon stent indwelling. At the 1 month follow-up, if the urethral reconstruction appeared to be successful, the ileostomy was reversed and upon successful voiding, the suprapubic tube was removed 2-15 days later. Repair was considered successful in the absence of symptoms after reversal of the urinary a Fistula nd bowel diversions. 

Follow-up was obtained for 6-64 months with a total success rate of 91% of the procedure. 100% of the patients without a previous history of repair were successfully treated whereas only 7 of the 10 patients left with a history of failed urethroplasty or urethrorectal fistula repair were cured. The 3 in which treatment failed either developed a ureteral or rectal stricture easily fixable through procedure. 

There were many strengths to this study. The authors thoroughly collected data through measurements of fistula size, length of urethral strictures, urethrorectal fistula-anus distance, and a complete write-up of each step in their procedure and reasoning. They also ensured to check for ED pre-surgery to standardize their conclusions. If they had not collected that, their rate of 22 of 32 patients (69%) developing ED would have been staggering, but if 20 of those 22 had ED pre-surgery, their rate of 2 of 32 (6%) is very manageable. Their conclusion that the gracilis muscle interposition is the best tissue to interpose is, however, unfounded as there have been no comparative studies about other tissues.

Written by: Zhamshid Okhunov, MD Department of Urology, University of California, Irvine Urology

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