Gracilis Muscular Flap for Large Urethral Defect

doi:10.4236/ss.2011.29100

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Surgical Science, 2011, 2, 456-458

doi:10.4236/ss.2011.29100 Published Online November 2011 (http://www.SciRP.org/journal/ss)

Gracilis Muscular Flap for Large Urethral Defect

Yuichiro Yoshioka, Shigeaki Moriura, Hiroshi Yuba, Atsushi Hirano, Ryohei Hattori

Department of Surgery and Urol o gy , Yachiyo Hospital, Anjo, Japan

E-mail: [email protected]

Received July 22, 2011; revi sed Octobe r 13, 2011; accepted O ct o be r 28, 2011

Abstract

We report the use of Gracilis muscle to repair a large urethral defect. A 57-year-old-man with rectal cancer

underwent abdominoperineal resection including part of the prostate and seminal vesicle. Soon after surgery,

he presented with massive urinary leakage from the prostatic urethra. Conservative treatment for one month

failed. The defect of the prostatic urethra, measuring 2.5 cm in diameter, was closed with the right gracilis

muscular flap. About five years and 6 months after surgery, the patient can void spontaneously without in-

continence. Cystoscopy demonstrated good epithelization of the reconstructed urethra without stenosis. The

gracilis muscular flap was easily available and useful for closure of a large urethral defect.

Keywords: Urethral Injury, Reconstruction

1. Introduction

In a case of rectal cancer with a limited invasion to the

prostate, partial resection of the prostate should be tried

to avoid pelvic exenteration. However, there is a risk of

urethral injury, which may cause urethral fistula. We

describe a case of a postoperative urethral rupture in

which a gracilis muscular flap was useful for repair.

2. A Case Report

A 57-year-old man was referred to our hospital with a

diagnosis of lower rectal cancer. Abdominoperineal re-

section was performed. We resected the posterior part of

the prostate and right seminal vesicle because of the tu-

mor invasion to the prostate. There was no apparent in-

jury to the urethra. The resected prostate was round and

measured 2 cm in diameter, 2 - 4 mm in thickness. Soon

after surgery, there was significant urinary discharge

from the pelvic drain. Cystogr aphy demonstrated urinary

leakage from the prostatic urethra to the pelvic cavity

(Figure 1). The balloon of the catheter was seen in the

pelvic cavity. We changed the urethral catheter to that

with a larger balloon and tried to close the fistula con-

servatively. One month later, there was no improvement

of leakage or change in fistula size. We decided to close

the fistula surgically.

The patient was placed in the lithotomy position and

we re-opened the perineal wound. There were no signs of

infection in the pelvic cavity. The size of the urethral

defect was about 2.5 cm in diameter (Figure 2). Two

thirds of the muscular body of the gracilis muscle was

separated from the proximal end and the vascular pedicle

located at the proximal part was preserved. The gracilis

muscular flap was transferred to the pelvic cavity

through a subcutaneous route. The urethral defect was

closed using the middle part of the flap with absorbable

sutures as if the muscle were a patch. The pelvic cavity

was filled with the distal p art of the flap (Figure 3) Suc-

tion drains were placed in the pelv ic cavity and th e donor

site and a cystostomy was established. Postoperatively,

there was slight urinary leakage, which was treated con-

servatively. Cysto graph y 4 w eeks po stoper atively d id no t

demonstrate any leakage (Figure 4). The indwelling

urethral catheter was removed 7 weeks postoperatively

and the cystostomy catheter was removed 12 weeks after

surgery. The patient complained of occasional urinary

incontinence, which improved gradually, and there was

almost no incontinence 14 months postoperatively. His-

tological examination demonstrated that rectal cancer

had invaded the prostate. About five years and 6 months

after the surgery, cystoscopy demonstrated good epi-

thelization of the reconstructed urethra without stenosis.

The patient can void spontaneously withou t incontinence

and there are no symptoms of urethral stenosis.

3. Discussion

In the current case, urinary leakage manifested in the early

postoperative period. The cystography demonstrated that

Y. YOSHIOKA ET AL.

457

Figure 1. Cystography shows urinary leakage from the

prostatic urethra to the pelvic cavity. The balloon of the

catheter is seen in the pelvic cavity.

Figure 2. Perineal operative view shows the urethral defect

measuring about 2.5 cm in diameter.

the balloon of the urethral catheter had become dislo-

cated beyond the urethra. It was suspected that there had

been bladder neck injury during the combined resection

of the prostate and seminar vesicle, which allowed dis-

location of the balloon. Another cause seemed to be that

there was no suppo rting tissue behind the urinary system

after the rectal resection. The dislodged balloon of the

catheter might have caused rupture of the urethra at the

thin and weak part after can cer resection.

Traumatic urethral injury is usually treated conserva-

tively with an indwelling urethral catheter [1]. However,

Figure 3. Two thirds of the muscular body of the gracilis

muscle was separated from the proximal end. The muscular

flap was transferred to the pelvic cavity through a subcu-

taneous route. The urethral defect was closed with the mid-

dle part of the flap. The pelvic cavity was filled with the

distal part of the flap.

Figure 4. Postoperative cystography via vesicostomy shows

no leakage.

after abdominoperineal resection of the rectum, healing

of the prostatic urethra is apparently more difficult be-

cause there is no supporting tissue behind the urethra.

Another disadvantage may have been the unstable place-

ment of the balloon catheter in this case. The urethral

defect seemed too large to approximate with a direct su-

ture. Resection of the prostate seemed to be another

choice for reconstruction of the urethra. However, the

existence of dead space in the pelvis may introduce an-

astomotic failure and intractable urinary fistula.

There have been few reports describing the use of gracilis

muscle to repair the urethra [2,3]. Beckenstein et al. [2]

Y. YOSHIOKA ET AL.

458

has reported the successful reconstruction of a circum-

ferential defect of the urethra secondary to Fournier’s

gangrene using a gracilis flap. Lane et al. [3] has used a

gracilis flap for radiotherapy induced recto-urethral fis-

tula. It also have been used for reconstruction of the pe-

nis, scrotum and vagina [4,5]. Our experience with using

a gracilis flap in several cases of perineal fistula or bed

sore supported the choice of this procedure.

In the present case, good epithelization of the urethra

was observed 5.5 years after surgery and there was no

urethral stenosis. In other report, complete regeneration

of the urethra has been noted following reconstruction

using the garacilis [2]. The gracilis muscular flap is eas-

ily harvested with minimal impairment of gait [6]. We

recommend this method for closure of urethral defect,

when conservative therapy is unsuccessful.

6. References

[1] D. D. Morehouse, P. Belitsky and K. Mackinnon, “Rup-

ture of the Posterior Urethra,” Journal of Urology, Vol.

107, No. 2, 1972, pp. 255-258.

[2] M. Beckenstein, A. A. Smith, K. Dinchman, J. Wyatt-

Ashmead and N. B. Meland, “Muscle Flap Reconstruc-

tion Aids in Urethral Regeneration,” Annals of Plastic

Surgery, Vol. 36, No. 6, 1996, pp. 641-643.

doi:10.1097/00000637-199606000-00014

[3] B. R. Lane, D. E. Stein, F. H. Remzi, S. A. Strong, V. W.

Fazio and K. W. Angermeier, “Management of Radio-

therapy Induced Rectourethral Fistula,” Journal of Urol-

ogy, Vol. 175, No. 4, 2006, pp. 1387-1388.

doi:10.1016/S0022-5347(05)00687-7

[4] M. Orticochea, “A New Method of Total Reconstruction

of the Penis,” British Journal of Plastic Surgery, Vol. 25,

No. 4, 1972, pp. 347-366.

doi:10.1016/S0007-1226(72)80077-8

[5] J. B. McCraw, F. M. Massey, K. D. Shanklin and C. E.

Horton, “Vaginai Reconstruction with Gracilis Myocuta-

neous Flaps” Plastic and Reconstructive Surgery, Vol. 58,

No. 2, 1976, pp. 176-183.

doi:10.1097/00006534-197608000-00006

[6] R. H. Frederick, “Gracilis Myocutaneous and Muscle

Flap,” Clinics in Plastic Surgery, Vol. 7, No. 1, 1980, pp.

27-44.