Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas.

BACKGROUND: Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature.

OBJECTIVE: The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures.

DESIGN, SETTING, AND PARTICIPANTS: From January 1985 to December 2007, 31 patients (age: 6-61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic-perineal approach.

INTERVENTIONS: A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic-perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic-perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients).

MEASUREMENTS: Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk.

RESULTS AND LIMITATIONS: One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal-inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic-perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients.

CONCLUSIONS: Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal-inferior pubic approach may be appropriate as a first-line procedure.