Gracilis muscle interposition for the treatment of recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases.

Background: Several surgical procedures for the repair of fistulas between the rectum and the urethra or vagina have been reported. Our study was designed to assess the efficacy of the gracilis muscle flap in repairing recto-urethral and rectovaginal fistulas.

Methods: Gracilis muscle interposition flaps were performed in 35 patients (aged 38-78 years, mean: 58 years) using a perineal approach. Nine patients had rectovaginal fistulas due to Crohn's disease (n=3), previous surgery and pelvic irradiation for rectal (n=2) or cervical cancer (n=4). Twenty-six fistulas were recto-urethral. The aetiologies were Crohn's disease (n=4), brachytherapy after prostate cancer (n=14), iatrogenic injury to the rectum during radical retropubic prostatectomy (n=4), transurethral resection of the prostate (n=2) and recurrent peri-anal abscesses with fistulas (n=2). Twenty-five patients had undergone previous repair attempts; of these four underwent multiple procedures. Patient outcomes were assessed after surgical repair. The success rate was measured as the percentage of patients with a healed fistula after stomal closure.

Results: The mean follow-up was 28+/-15 months from muscle transposition and 22+/-14 months from stomal closure. Fistula closure with no recurrence could be achieved in 33 patients (94%). Two of the seven patients (29%) with Crohn's disease had a persistent fistula. There were neither intra-operative complications nor problems related to muscle desinsertion surgery.

Conclusions: Recto-urethral and rectovaginal fistula closure using the perineal approach with pedicled gracilis muscle interposition is associated with minimal morbidity and a high success rate. It is an excellent option for patients with complicated fistulas for whom other surgical treatments have failed. Underlying Crohn's disease is associated with a higher complication rate.