Gracilis muscle flap combined with a laparoscopic transabdominal approach is effective in the treatment of post-prostatectomy rectourethral fistula: A case report

Rectourethral fistulas after treatment for prostate carcinoma: Update and new management algorithm

Rectourethral fistula (RUF) is associated with poor quality of life related to urinary functional symptoms (pneumaturia, fecaluria, urine passing through the rectum) or urinary tract infections (upper or lower, often recurrent). Most are iatrogenic, occurring after surgery such as radical prostatectomy, where their prevalence ranges from 0.03 in various series. RUF can also occur after radiation therapy administered for prostate cancer. Management of RUF is complex and depends on whether the patient has had previous radiation therapy or not. Different surgical techniques have been evaluated, but currently there is no consensus as to the best approach. The York-Mason technique is preferred for simple RUF in patients without prior irradiation, while for more complex cases, with antecedent irradiation, transperineal approaches with muscular flap interposition are often recommended. Evaluation of quality of life is crucial, because management of RUF can have severe consequences on urinary continence and sexual function. Despite successful anatomical repair, patients often continue to suffer from functional sequalae that affect their quality of life. Although progress has been achieved in the treatment of RUF, a coherent and efficient management algorithm is necessary to standardize the practical aspects and improve the outcomes. This update summarizes the different strategies that are available for management of RUF and underscores the importance of an individualized approach.

Flaps and Grafts in Robotic Reconstructive Surgery

PURPOSE OF REVIEW

The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques.

RECENT FINDINGS

Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

Narrative review of flaps and grafts in robotic reconstructive urologic surgery

Background and Objective

Flaps and grafts are used for filling dead space, ureteral substitution, and as mesh alternatives. The surgical robot is invaluable in urologic reconstructive surgery due to the ability of the robot to reach the deep pelvis, its minimally invasive access, the ability to use indocyanine green to identify structures and assess tissue perfusion and viability, and ergonomics for the surgeon. Robotic reconstruction can involve tissue transfer in the form of flaps and grafts to provide form and function to organs that have been damaged by iatrogenic injuries, trauma, infections, cancer, radiation injury, or congenital abnormalities. Common flaps and grafts can be readily adapted to the robotic approach. In this literature review, we examine the robotic use of flaps and grafts in reconstructive urology.

Methods

A thorough literature review was conducted via a PubMed search for predefined terms.

Key Content and Findings

Flaps and grafts in reconstructive urology are used for interposition, ureteral substitution, and as mesh alternatives. Omental flaps are used for tissue interposition, or to provide structure and nutrients, and are easily employed with the robot. Various robotic applications of peritoneal flaps have been described. Vascular rectus abdominis musculocutaneous flaps are well-vascularized flaps that occupy dead space and provide structural support, which can be harvested readily with the robot. Sigmoid epiploica are an excellent flap for pelvic reconstruction. Gracilis flaps and fascia lata grafts are well-tolerated and provide space occupying tissue. Boari flaps aid in robotic ureteral reconstruction, especially in the setting of long defects. Oral mucosa is excellent for ureteral or bladder neck reconstruction. Rectal mucosa is well-tolerated and easy to harvest robotically for a variety of urinary tract reconstructive applications. The appendix or ileum can be interposed for repair of damaged ureters.

Conclusions

Various flaps and grafts have been adapted for robotic reconstructive urology. As the field develops, refinement of techniques and innovation in flaps and employment of the robot will propel this field forward. More studies, especially comparative studies, are needed to elucidate the flaps and grafts that are most likely to be successful with the least morbidity for each use case.