Minimally invasive gracilis muscle transposition: Initial report

A 60 years old male submitted to radical prostatectomy for prostatic adenocarcinoma present RUF postoperatively. Fecal diversion and 2 attempt of perineal and abdominal repairs were performed without success in other center. Cistoscopic evaluation reveal 1.5cm RUF with ischaemic borders at anastomotic area. We plan to perform an initial perineal approach with repair and interposition of gracilis muscle. If necessary abdominal approach combined to perineal dissection will be done.

Repair of RUF is a challenging surgical procedure. There are some possible approaches but transperineal is the most utilized.
In cases of complex istulas interposition of muscle laps between the rectum and urethra is highly recommended. Gracilis muscle transposition (GMT) is the preferred, due to excellent mobility and vascularization for perineal reconstruction [5,6]. Dissection of the gracilis muscle is done using one, 2 or 3 large incisions in the medial border of the thigh.
The aim of this report is present a new minimally invasive access to obtain a pediculate lap of gracilis muscle to interposition between bladder and rectum to treat RUF.

Case report
A 60 years old male submitted to radical prostatectomy for prostatic adenocarcinoma present RUF postoperatively. Fecal diversion and 2 attempt of perineal and abdominal repairs were performed without success in other center. Cistoscopic evaluation reveal 1.5cm RUF with ischaemic borders at anastomotic area. We plan to perform an initial perineal approach with repair and interposition of gracilis muscle. If necessary abdominal approach combined to perineal dissection will be done.

Surgical technique
We idealize and perform successfully a new technique throught a small incision utilizing laparoscopic matherial following this 10 standardized steps: 1) After perineal approach and RUF repair, external rotation and abduction of left limb was performed.
2) Identi ication by palpation of the gracilis muscle and its distal tendon, differentiation of the rest of the muscular structures.
6) Complete dissection of the muscle is performed from its distal portion to its proximal portion preserving its main pedicle ( Figure 2).

Results
Operative time was 60 min, no complications was observed and discharge occurred at irst post-operative day. At 6 months of follow up no recurrence of RUF was obtained.

Discussion
Gracilis muscle is utilized as interposition tissue for repair of genitourinary istulas [5].
Classical access to obtain gracilis is open approach with large and few aesthetic incisions [5,6].
With this new technique gracilis muscle could be endoscopically dissected offering minimal pain and postoperative scar, with excellent functional and cosmetic results. This initial experience was exploratory but results was promising.
As a new option of dissection, there are no comparative data besides our clinical impression based in this irst case. It seems an easy and fast procedure, offering few pain and the smaller incision than previously described at literature.
In conclusion minimally invasive gracilis muscle dissection was feasible and safe with potential bene its. However, further studies with large number of patients with longer follow-up will be necessary to answer if this new surgery will have some application in urological armamentarium.