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Preventing rectourethral fistula recurrence with gracilis flap
Keon Min Park M.D.1, Yenny Y. Rosli, B.A.2, Allen Simms, M.D.3, Rachel Lentz, M.D.4, Deepak R. Bharadia M.D., M.P.H.5, Benjamin N. Breyer M.D., M.A.S. 3, William Y. Hoffman, M.D.1 1. Division of Plastic Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA 2. School of Medicine, University of California San Francisco, San Francisco, CA 3. Department of Urology, University of California San Francisco, San Francisco, CA 4. Division of Plastic Surgery, Department of Surgery, University of Southern California, Los Angeles, CA 5. Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX

Background: Rectourethral fistula (RUF) is an uncommon serious condition with various etiologies including neoplasm, radiation therapy, and surgery. Treatment for RUF remains problematic with a high recurrence rate. Although studies have suggested the recurrence rate of RUF is lower after surgical repair using a gracilis flap, outcomes have varied and the studies were small and inadequately controlled. Here, we compare outcomes of RUF repair with and without gracilis flap to evaluate its efficacy in preventing fistula recurrence and identify risk factors for recurrence.

Methods: We retrospectively reviewed patients who had undergone surgical repair for RUF between 2007-2018 at our institution and had at least 30 days of follow-up. Patient demographics, comorbidities, and surgical outcomes were recorded and compared for patients who had gracilis flap repair and those who did not (controls). Single variable logistic regression analysis was used to identify risk factors for recurrence.

Results: The gracilis group (n = 24) and control group (n=12) had similar demographics and comorbidities. Fistula recurrence was far less frequent in the gracilis group (8% vs 50%, p=0.009). There were no significant differences in other outcomes including length of hospitalization and surgical complications. When recurrent RUF was treated with a muscle flap (gracilis or inferior gluteus), 83% of the group had no additional fistula recurrence. In the control group, history of radiation (p=0.04) and urinary incontinence (p=0.015) were associated with fistula recurrence.

Conclusions: We recommend using a gracilis flap for RUF repair given its association with lower recurrence without increased surgical complications.

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