A perineal, rectal sphincter preserving approach was used in all patients. In the postoperative RUF cohort the success rate was 100%. Only 2 patients had an IMF, which was obtained from scrotal dartos tissue. The success rate in the radiation/energy ablation cohort was lower at 61.5% and an IMF was used in 5 of the 13 patients. There was no formal treatment algorithm to guide muscle flap placement in this more challenging cohort. A buccal mucosa graft was not used during urinary repair, which differs from a recent publication.3
While we support the use of buccal grafts, we do not believe that they are absolutely necessary.
An IMF is not an absolute necessity in the setting of postoperative RUFs. In the absence of radiation/energy ablation RUF cure can be achieved. Two recent studies attest to this fact.2,4
Mundy and Andrich reported 23 postoperative RUFs.4
In 1 patient bladder neck contracture developed, while the remainder fared well. A muscle flap was not used in the last 11 patients since the investigators thought that nonoverlapping suture lines would suffice. Durable outcomes in the strict absence of an IMF were reported in a separate series of postoperative RUFs.6
The anterior transsphincteric approach (ie York-Mason) was successfully used in 43 of 44 postoperative RUF cases.
The presence of energy ablation adds complexity to RUF repair. Radiation and/or energy ablation (cryotherapy or high intensity focused ultrasound) can result in added morbidity, such as impaired tissue healing, pubic osteomyelitis, urethral or rectal stricture, pelvic abscess, cavitation defects and severe genital/rectal/pelvic pain. These added morbidities are a primary reason for advocating a concomitant IMF. In the setting of radiation/energy ablation fecal diversion before formal RUF repair is also recommended to decrease inflammation. Furthermore, magnetic resonance imaging should be considered to assist with preoperative surgical planning and patient counseling.4
We did not follow an algorithm for IMF placement during radiation/energy ablative RUF repair. A mixture of muscle flaps were used, including the dartos, rectus and gracilis muscles. Approximately 39% of our patients underwent repair while in the lithotomy position, which provides easy access to the gracilis muscle. However, this muscle was only harvested using the lithotomy position in the 2 patients in whom a gracilis IMF was harvested. A dartos flap was harvested in the only other patient in the lithotomy cohort.
The prone position was used in 15 of 23 RUF repairs. This position provides excellent surgical exposure since the pubic bone is not present to limit upward retraction. The improved visibility afforded by prone positioning aids in decreasing operative time. Since we used the prone position during 15 of 23 RUF repairs, we were cognizant of avoiding overlapping suture lines. When this was not possible, a dartos IMF was harvested using the prone position. While we previously reported our success with the dartos flap,7
we have since stopped using the dartos flap due to the poor reliability of its pedicle.
An obvious limitation of this study is the small number and heterogeneous nature of the patients in the cohort. However, a series of 23 patients is respectable, given the low incidence of RUFs. A purpose of this study was to highlight the success of radiation/energy ablative RUF repair in the absence of an IMF. While we do not advocate avoiding a flap in this circumstance, our results will assist with physician knowledge and patient counseling. Unfortunately, the 2 patients in whom a gracilis IMF was harvested died in the first month after surgery, precluding our ability to assess the impact of this muscle flap. Despite this, we still advocate using gracilis IMFs. Another limitation is followup duration. We aim to continue to follow our patients to assess whether the absence of an IMF will impair the durability of RUF repair. Lastly, we acknowledge that the prevalence of stress incontinence after RUF repair is likely higher. Given the improved quality of life after RUF repair, patients may be less likely to proceed with additional surgical care, ie stress urinary incontinence surgery, especially if surgery was the original reason for RUF development.