Dr. Sean Elliott, MD
Reconstructive Urologist
bladder
Rectourethral Fistula Repair
A rectourethral fistula is an abnormal hole or tunnel that forms between the rectum and the urethra. Fistulas can also occur between the rectum and bladder. This allows stool to get into the urine and urine to get into the stool. Stool in the urine leads to bladder infections and pain and smelly pee. Urine in the stool leads to watery, frequent bowel movements, and sometimes difficulty controlling bowel movements.
There are many possible causes of a fistula. These include diverticulitis (which causes a fistula between the colon and bladder, not rectum and bladder), prostate surgery or prostate radiation. Diverticulitis fistulas can be repaired by removing the infected colon — the bladder needs little to no repair. Rectourethral fistulas after prostate cancer treatment are harder to fix and require a reconstructive urologist.
Bladder
Urethra
Front
Back
Rectum
Prostate
The fistula surgery is usually done through an incision in the perineum which is the skin between the scrotum and the rectum. This is done with the patient asleep, lying on their back with their legs in stirrups.
Bladder
Urethra
Front
Back
Rectum
Prostate
After opening the skin and dissecting to the fistula, the fistula is cut out by dividing at to spot where it inserts into the rectum and at the spot where it inserts into the urethra.
Bladder
Urethra
Front
Back
Rectum
Prostate
With the fistula removed there are now two holes left to close, one in the urethra and one in the rectum.
Bladder
Urethra
Front
Back
Rectum
Prostate
The hole in the rectum can nearly always be closed with stitches.
If the man has not had previous radiation and if the urethral hole is not too big (1 cm or less) then this hole can also usually be close with stitches.
Bladder
Urethra
Front
Back
Rectum
Prostate
If the urethra hole is larger than 1cm or if the patient has had radiation, then the edges may not come back together again with stitches. In that case we can cover the hole in the urethra with a graft taken from the inside of the cheek (buccal mucosa graft).
Bladder
Urethra
Front
Back
Rectum
Prostate
Gracilis muscle rotation
The gracilis muscle (in brown) is located on the inner thigh. There are other inner thigh muscles that can compensate for it when we use the gracilis muscle so that walking is not affected.
An incision is made on the inner thigh (dotted red line).
The muscle is cut where it connects to the bone just above the knee.
The lower part of the muscle is then rotated up into the perineum where the fistula is located.
When we do this we take care to keep the blood supply to the muscle intact so that the muscle will remain healthy and bring blood supply to the graft. The blood vessels are the red and blue tubes near the top 1/3rd of the muscle.
The buccal mucosa graft is sewn to the hole in the urethra. However, the graft will not survive without a good blood supply because it traveled from the mouth without it’s own blood supply. The radiated prostate does not give it good blood supply. So, we can rotate in a muscle flap from the inner thigh to keep the graft alive.
Bladder
Urethra
Front
Back
Rectum
Prostate
The gracilis muscle is sewn to the back side of the buccal mucosa graft. In a couple of days, blood vessels will grow into the graft from the muscle, to keep the graft alive. The muscle will also serve as a barrier between the rectum and the urethra so that the fistula won’t come back again.
The skin incision is closed.
Bladder
Gracilis muscle from inner thigh
Front
Urethra
Rectum
Prostate