Surgical Science, 2011, 2, 456-458
doi:10.4236/ss.2011.29100 Published Online November 2011 (
Copyright © 2011 SciRes. 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
Received July 22, 2011; revi sed Octobe r 13, 2011; accepted O ct o be r 28, 2011
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
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]
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
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.
[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.
[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.
[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.
[6] R. H. Frederick, “Gracilis Myocutaneous and Muscle
Flap,” Clinics in Plastic Surgery, Vol. 7, No. 1, 1980, pp.