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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01061-7
10.1016/j.ijscr.2024.110280
110280
Case Report
Successful posterior urethroplasty with gracilis muscle flap interposition and a V—Y gluteal flap of the perineal wound gap following abdominal-perineal resection: A case report
Chiloleti Geofrey geofrey.sage@gmail.com
a⁎
Mtaturu Gabriel b
Mchele Godfrey b
Ringo Yona b
Mmbando Theoflo b
Mwanga Ally a
a Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
b Department of Urology, Muhimbili National Hospital, Dar es salaam, Tanzania
⁎ Corresponding author. geofrey.sage@gmail.com
16 9 2024
10 2024
16 9 2024
123 11028028 7 2024
5 9 2024
9 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
An iatrogenic urethral perineal fistula can cause challenging problems for surgical reconstruction. In most cases, treatment is performed in three steps: double-diversion urinary and intestinal diversion, closure, and diversion. The augmented posterior urethroplasty interposition with a gracilis muscle function flap for the repair of the perineal gap was successful.

Case presentation

We reviewed a patient aged 42 years old male who presented to the urology department with leakage of urine per perineum after abdominal perineal resection and end colostomy due to anal-rectal malignancy 2 months earlier. He subsequently had a gapped perineal wound post abdominal-perineal resection (APR). Suprapubic Cystostomy and urethral catheter and a cystoscope showed a normal verumontanum, and there was a left para-verumontanum fistula approximately 3 cm in size that communicated with the perineum gapped wound. Tissue histology revealed chronic inflammation. Augmentation posterior urethroplasty with interposition of the gracilis muscle flap.

Clinical discussion

Urethral perineal fistulas have different etiologic origins, such as inflammatory, neoplastic, traumatic, or iatrogenic injury. Treatment is performed in three steps: double diversion urinary and intestinal, closure, and no diversion. In our case, the perineal gapped wound allowed us to access the posterior urethra and this potential space for gracilis muscle interposition, aiming to facilitate fistula repair and cover perineal gap wound repair.

Conclusion

Posterior urethral perineal fistulas can be repaired by a gracilis muscle flap, providing acceptable treatment results. However, more research is needed in fistula studies evaluating patients' sexual and urinary efficiency to achieve more accurate results.

Highlights

• Gracilis muscle flap

• augmented posterior urethroplasty

• Cystoscopy

• V—Y Gluteal flap

Keywords

Gracilis muscle flap
Augmented posterior urethroplasty
V-Y gluteal flap
Cystoscopy
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pmc1 Introduction and importance

Posterior urethral fistula with a gapped wound post-abdominal-perineal resection was a challenge due to the high number of fistulae at the posterior urethra at the level of the para-verumontanum. Another challenge was augmentation urethroplasty of the fistula together with interposition of the gracillis flap to cover the perineal defect post abdominal-perineal resection (APR), friability of the tissue around the fistula, post-radiation, and a negative free margin around the urethra. All these were considerations to consider in this case [1].

2 Case presentation

We reviewed a patient aged 42 years old male who presented to the urology department with leakage of urine per perineum underwent abdominal perineal resection and end colostomy due to anal-rectal malignancy 2 months earlier. On course of his anal cancer treatment which histology revealed to be squamous cell carcinoma, he received neo-adjuvant radiation before underwent APR. He subsequently had a gapped perineal wound after the APR, dressed for 2 months, and failed to close the perineal wound. The patient had erectile dysfunction and did not have a morning erection. Additionally, the patient reported semen fluid exiting from the anus during night orgasm. He underwent examination under anesthesia (EUA), and cystostomy was performed with a urethral catheter but still experienced significant urine leakage despite maximum bladder drainage.

Cystoscopy revealed a normal anterior urethra, with normal coaptation of external urethral sphincter (EUS) and normal verumontanum. There was a left para-verumontanum fistula approximately 3 cm in length that communicated with the perineum gapped wound. The tissue around the fistula was freshened, and histological analysis revealed chronic inflammation (Fig. 1).Fig. 1 Cystoscopy show verumontanum, and left paraverumontanum a fistula, approximate 3cm, communicating to the.

Fig. 1

The patient was prepared for perineal-gap wound repair with a gracillis muscle flap to cover the defect post-APR. The skin was incised anteriorly to identify the adductor longus, the great saphenous vein was protected, and the adductor longus was retracted to visualize the pedicle and nerve in the septum. The incision was made posteriorly through the subcutaneous tissue to the gracilis [2].

The pedicle of adductor longus and magnus were dissected until the adductor longus branch was reached. After mobilization of the muscle proximally and then the tendon distally, the nerve was left intact to create a functional flap, which was then closed in the layer and drained in situ. The patient was discharged 3 weeks post-surgery without any problems, catheter was removed at 4th week and suprapubic cystotomy (SPC) was clamped to allow trial voiding at first thereafter SPC was removed at 6th.week, Patient voided with some episode of incontinence, no urgency, no feeling of incomplete bladder emptying and at 8th week incontinence resolved. He had weak morning erection (Fig. 2, Fig. 3, Fig. 4).Fig. 2 Intraoperaative, gracil dissection and mobilization to the perineal gap.

Fig. 2

Fig. 3 Intraoperative, V-Y gluteal flap after mobilisation of gracil flap to the perineal gap wound.

Fig. 3

Fig. 4 Intraoperative, V-Y gluteal flap and gracil flap after closure of the wound.

Fig. 4

3 Clinical discussion

Urethral perineal fistula is a rare but devastating disease with many different etiologic origins, such as inflammatory, neoplastic, traumatic, or iatrogenic injury. Iatrogenic urethral perineal fistula can cause challenging problems for surgical reconstruction. In most cases, treatment is performed in three steps: double diversion urinary and intestinal, closure, and diversion; however, for this patient, the patient underwent permanent colostomy due to a colorectal tumor. Urologists tend to prefer the trans-perineal technique for related cases, such as rectal-urethral fistula (RUF) repair, which allows full exposure of the bladder neck and prostate and makes urethral repair possible after RUF repair [2]. Therefore, in our case, the perineal gapped wound gave us access to the posterior urethra and this potential space for the gracillis muscle interposition, aiming to facilitate the closure of a fistula and cover the perineal gap post-APR as an interposition flap as a second layer. Other types of interposition grafts used by researchers in many different areas include the dartos muscle, penile skin, levator muscle, and bladder [3]. The use of these tissue flaps is associated with complications such as hematoma formation, infections, and wound loss [4]. The graft muscle in this patient was a functional flap with an intact nerve supply; thus, it may preserve and facilitate sexual function. Postoperatively he had post operative follow 2 weeks after surgery, there after 3 monthly for 1-year, currently 6 monthly, he is now 2-year post surgery (Fig. 5, Fig. 6).Fig. 5 Postoperative, after 4 weeks, gluteal wound healed.

Fig. 5

Fig. 6 Postoperative, after 4 weeks, wound healed.

Fig. 6

4 Conclusion

Posterior urethral perineal fistula is a rare but devastating disease that poses a serious surgical challenge. Surgical experience in this case revealed that the use of augmented posterior urethroplasty to repair perineal gap via a gracillis muscle flap provided acceptable treatment results for patients with the same presentation. However, more research is needed in fistula studies evaluating patients' sexual and urinary efficiency to achieve more accurate results.

Method

The work has been reported in line with the SCARE criteria [5,6].

Consent

Written informed consent was obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.

Ethical approval

The present study was exempted by the Ethics Committee of The Affiliated Hospital of Muhimbili national hospital, Tanzania, as this paper reports a case that emerged during normal surgical practice.

Funding

No funding concerning this article.

Author contribution

Dr. Geofrey Chiloleti – Assistant Surgeon, Study concept & writing Manuscript.

Dr. Mtaturu – Chief Surgeon, Correction manuscript.

Dr. Godfrey M Mchele Chief surgeon.

Dr. Yona Ringo Assistant surgeon.

Dr. Ally Mwanga-Supervisor.

Dr. Theoflo Mmbando- Assistant surgeon.

Guarantor

Dr Gabriel Mtaturu.

Dr Theoflo Mmbando.

Dr Godfrey Mchele.

Research registration number

Nil.

Conflict of interest statement

The authors declare that they have no conflicts of interest.
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References

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2 Report C. Clinical Images and Medical Case Reports Posterior urethroplasty and recto-urethral fistula repair by bulbospongiosus muscle flap: a new surgical technique. 17–20.
3 Wisenbaugh E.S. Gelman J. The use of flaps and grafts in the treatment of urethral stricture disease Adv. Urol. 2015 2015
4 Morasch M.D. Sam A.D. Kibbe M.R. Hijjawi J. Dumanian G.A. Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery J. Vasc. Surg. 39 6 2004 1277 1283 15192569
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6 Gracilis flap-anatomy, technique, indications theplasticsfella.com
