Introduction: Complex rectourethral fistulas (RUF) present a challenge to the reconstructive surgeon, as these seldom heal spontaneously and often fail repair attempts. No procedure has gained widespread acceptance, however, tissue interposition is usually required. Gracilis muscle is an excellent flap because it is easily mobilized, well vascularized, and has been successfully used for other complex perineal wounds. This video demonstrates our technique for the use of gracilis muscle interposition in the transperineal repair of complex RUF.

Methods: Preoperative urinary and fecal diversion allow fistula maturation. Voiding cystourethrogram (VCUG) and/or gastrograffin enema (GGE), with examination under anesthesia and cystourethroscopy help define the location, size, and complexity of the defect. Surgical repair is conducted in exaggerated lithotomy position. Dissection is carried out between the rectum and the urethra and bladder to identify the fistula and mobilize structures to allow tension-free closure. The rectal defect is closed primarily. The prostatic defect is closed using buccal mucosa. Gracilis muscle is harvested and interposed between the rectum and urethra.

Results: VCUG performed 6 weeks postoperatively revealed no fistula recurrence allowing removal of urinary catheters. A GGE 5 months following surgery demonstrated an intact closure and fecal diversion was taken down. The only complication has been mild incontinence not requiring treatment.

Conclusion: A transperineal approach with gracilis muscle interposition is an excellent option for the repair of complex RUF. Our initial experience demonstrates good outcomes in patients who are candidates for reconstruction of both the urinary and anorectal systems.