Intersphincteric approach with omental interposition for the treatment of a rectourethral fistula

Abstract Background A rectourethral fistula is an abnormal passage between the urethra and distal rectum. Spontaneous healing is rare, and most will require definitive surgical repair. The transperineal approach with gracilis flap is widely used, but post-operative urinary incontinence remains high. We propose an intersphincteric approach with greater omental flap that may be associated with improved patient outcomes. Method Transabdominal approach: Lower midline vertical laparotomy incision is made, and the omentum is mobilised from the transverse colon. Rectal mobilisation is achieved via bilateral lateral and posterior dissection. Then, the anterior rectum is dissected after incising the peritoneal reflection until the fistula tract proper is encountered. Further dissection is accomplished along either side of the fistula tract anterior to the rectum as far inferiorly as access allows. Intersphincteric approach: A 3cm anterior, curvilinear incision is made along the intersphincteric plane. This plane is carefully dissected to join the plane created during the transabdominal approach on either side of the fistula. The tract is divided, and the anterior rectal wall defect is primarily closed. Omental interposition flap fixture: The omental flap is placed between the rectum and the urethra and secured onto the rectal wall. The perineal incision and skin are closed. Result This novel technique has been utilised in two patients at our institution with favourable functional outcomes in the form of complete maintenance of faecal and urinary continence at 11- and 9-years post-op.