case_images: PMC10733929_01
case_images: PMC10733929_02
case_images: PMC10733929_03
case_images: An inverted trapezoidal incision centered over the mid raphe is made in the perineum with the proximal aspect of the lateral incisions starting at the level of the ischial tuberosities. The distal aspect of the trapezoidal flap reaches up to the mid portion of the scrotum.
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case_images: F1
case_images: The distal aspect of the trapezoidal flap reaches up to the mid-portion of the scrotum (Fig. 1).
case_images: The testicles surrounded by the tunica vaginalis are completely freed and positioned temporarily over the lower abdomen (a). The newly formed flap has a wide trapezoidal perineal base and a wide rectangular shape along the scrotal raphe and includes dartos, subcutaneous tissue, and scrotal septum (b, c). The flap is elevated closely following the ventral aspect of the urethra starting at the penoscrotal angle and dissecting up to the central tendon of the perineum (d, e).
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case_images: F2
case_images: The flap was elevated following the ventral aspect of the urethra starting at the penoscrotal angle and dissecting up to the central tendon of the perineum (Fig. 2a-e).
case_images: The mid-perineal scrotal flap (MPSF) incorporates all the subcutaneous tissue between the skin and the bulbar urethra. The testicles surrounded by the tunica vaginalis are completely freed and positioned temporarily over the lower abdomen. This approach allows a complete dissection of the proximal aspect of the urethra and exposure of the surgical plane between the rectum and the posterior aspect of the prostate.
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case_images: F3
case_images: The complete bulbar urethra was visible at this stage of the surgical technique and allows a complete dissection of its proximal aspect and the exposure of the surgical plane between the rectum and the posterior aspect of the prostate (Fig. 3).
case_images: Identification of the fistula is facilitated by the previous insertion of the ureteric catheter through the fistula.
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case_images: F4
case_images: Fistula can be identified by the previous insertion of the ureteric catheter through the fistula (Fig. 4).
case_images: In case that a urethral stricture is associated with the fistula, an anastomotic urethroplasty is performed, either bulbo-prostatic or urethro-vesical in case that the patient had previously undergone a radical prostatectomy. Stepwise maneuvers of the elaborated perineal posterior urethroplasty may be used as necessary to achieve a tension-free anastomosis. The urethra is transected at the point of the fistula and mobilized distally beyond the crus as far as the penoscrotal junction. Then corporeal body separation in bloodless plane is performed from the crus distally for 3-5 cm (a). If after corporal body separation, and inferior wedge pubectomy, a tension-free anastomosis cannot be achieved, the urethra is routed around the lateral side of the left corporal body. A small furrow of the bone should be gouged from the left ischiopubic ramus where the urethra runs, to avoid its compression between the corpus and bone (b).
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case_images: F5
case_images: Stepwise maneuvers of the elaborated perineal posterior urethroplasty may be used as necessary to achieve a tension-free bulbo-prostatic anastomosis (Fig. 5a, b).
case_images: To avoid recurrence of the fistula, the distal aspect of the MPSF is de-epithelialized and used as interposition flap. De-epithelialization can be done with scalpel or scissors and care should be taken to avoid damage of the subcutaneous vascularization (a-d).
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case_images: F6
case_images: To avoid recurrence of the fistula, the distal aspect of the MPSF is de-epithelialized and used as interposition flap (Fig. 6a-d).
case_images: The fistulous tract is resected, the borders of the rectal orifice refreshed and closed with a single or double layer of absorbable stitches (a). The distal aspect of the de-epithelialized MPSF is fixed with 3 or 4 stitches to the anterior rectal wall, proximally to the location of the fistula to provide complete coverage of the rectal suture. The elasticity of the fat tissue allows the flap to adapt well and efficiently to the space created between the rectum and the prostate (b, c).
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case_images: F7
case_images: The distal aspect of the de-epithelialized MPSF was fixed with 3 or 4 stitches to the anterior rectal wall, proximally to the location of the fistula to provide complete coverage of the rectal suture (Fig. 7a-c).
case_images: The distal skin of the flap devoted of subcutaneous fat tissue is resected (a). A drain is left, the testicles are repositioned to its original position, and the skin is closed. The remnant scrotal skin has enough elasticity to allow a tension-free closure of the scrotal skin (b).
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case_images: F8
case_images: The remnant scrotal skin has enough elasticity to allow a tension-free closure of the scrotal skin (Fig. 8a, b).