Traumatic rectourethral fistula repair: A potential application of porcine small intestinal submucosa
A 45-year-old male met with road traffic accident a year ago and sustained pelvic fracture with urethral injury and traumatic rectourethral fistula. He underwent diversion loop colostomy and suprapubic cystostomy elsewhere immediately after injury. Six months later, he came to us for further management. He had mild difficulty in squatting and complete loss of penile erection. Clinical examination revealed normally functioning pelvic loop colostomy, well-positioned functioning suprapubic cystostomy and an indurated opening of 1 cm × 1 cm size in the anterior wall of rectum, 6 cm above the anal verge. Opposing cystourethrography revealed complete obliterative stricture at the level of proximal bulbar urethra and extravasation of contrast into rectum from bulbomembranous urethra [Panel A, ]. MR urethrogram showed a 6 cm long distraction defect with callous tissue. His blood and urine investigations were normal. Anastomotic urethroplasty by progressive perineal approach (upto inferior pubectomy) was done. The fistulous communication between the posterior aspect of membranous urethra and rectum was disconnected. Rectum was closed in 2 layers with 3-0 polydiaxonone absorbable sutures. Bulboprostatic anastomotic urethroplasty was done by the parachute technique. Porcine small intestinal submucosal graft (Biodesign™ (Surgisis®) 4-Layer Tissue Graft, Cook Medical Inc. Bloomington, USA) was used for interposition between the repaired ends of urethra and rectum []. He was on continuous per urethral catheter for 8 weeks. After catheter removal, he voided well with a peak flow of 36 ml/s at a voided volume of 560 ml. Post-operative voiding cystourethrogram [Panel B, ] revealed well-healed bulboprostatic urethral anastomosis and absence of contrast extravasation. Subsequently he had loop colostomy closure 6 months later. At follow-up of 1 year, he is voiding well.