# Excision primary anastomosis urethroplasty with gracilis muscle flap for management of complex stricture with prostatorectal fistula and failure of multiple surgeries: A case report

## TL;DR

A patient with a complex urethral stricture and a prostatorectal fistula was successfully treated with a specialized surgery combining muscle flap and urethroplasty.

## Contribution

This case report demonstrates the successful use of gracilis muscle flap with EPA urethroplasty for complex stricture and fistula repair after multiple failures.

## Key findings

- EPA urethroplasty combined with gracilis flap improved outcomes in a patient with complex stricture and fistula.
- Postoperative uroflowmetry showed a Qmax of 14.8 mL/s with no complications at six months.
- Inferior pubectomy allowed tension-free anastomosis of the urethra.

## Abstract

Complex urethral strictures are challenging to manage, particularly after failed urethroplasty and associated complications. We report a case of a 32-year-old male with a nine-year history of urinary retention following pelvic trauma and six prior surgeries, including an iatrogenic prostatorectal fistula. The patient underwent re-do excision and primary anastomotic (EPA) urethroplasty combined with gracilis muscle flap interposition for fistula repair. Inferior pubectomy and bulbar urethra transection were performed. Postoperative recovery was uneventful, and uroflowmetry showed satisfactory flow (Qmax: 14.8 mL/s). EPA urethroplasty with gracilis flap may improve outcomes in complex urethral stricture with fistula.

•EPA urethroplasty was used to manage complex stricture after multiple failed surgeries.•Gracilis muscle flap provided vascular support and fistula coverage.•Inferior pubectomy enabled tension-free urethral anastomosis.•Postoperative Qmax was 14.8 mL/s with six-month follow-up.•This case supports gracilis flap use in complex urethral repairs.

EPA urethroplasty was used to manage complex stricture after multiple failed surgeries.

Gracilis muscle flap provided vascular support and fistula coverage.

Inferior pubectomy enabled tension-free urethral anastomosis.

Postoperative Qmax was 14.8 mL/s with six-month follow-up.

This case supports gracilis flap use in complex urethral repairs.