EP252 - Abdominoperineal resection with en bloc prostatectomy, with urethral reconstruction reinforced by a gracilis flap for locally advanced rectal cancer

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Purpose/Background: Locally-advanced rectal cancer (LARC) may invade adjacent structures, and may then require a multivisceral resection (MVR), such as an abdominoperineal resection (APR) with en bloc prostatectomy. Urethral reconstruction after this extensive surgery presents significant challenges, particularly in creating a functional vesicourethral anastomosis, which has a high leak rate (50-60%). The introduction of advanced flap techniques, such as a gracilis flap, aims to reduce complications associated with anastomotic leaks.

Methods/Interventions: Case Series
We present 3 male patients in their 6th decade of life with rectal cancer involving the prostate. All patients underwent total neoadjuvant therapy (TNT), following the RAPIDO protocol (short-course radiotherapy with consolidation chemotherapy). Each patient subsequently underwent an abdominoperineal resection (APR) with en bloc prostatectomy and urethral reconstruction, reinforced using a gracilis flap. (In one patient, post-TNT assessment revealed bilateral inguinal lymph nodes, necessitating a superficial inguinal lymph node dissection. These turned out to be negative.) The gracilis flap was used to support the urethral anastomosis, with postoperative outcomes monitored through clinical assessment and cystography.

Results/Outcomes: All patients had an uneventful postoperative period, with bowel function returning within a mean of 3 days (range 3-4 days). A mandatory postoperative immobilization of 10 days was ordered by Plastic Surgery; thus, a mean length of stay of 10 days (range 10-11). Histopathology showed tumor regression in all, with one patient having persistence of prostatic invasion by tumor. All had clear surgical margins. Two patients had successful urethral healing, while one experienced a urinary leak that has required extended catheterization. One patient presented with urinary incontinence 2 months postoperatively, managed with pelvic floor exercises, He has shown marked improvement of symptoms.

Conclusion/Discussion: We documented the use of a gracilis flap for urethral reconstruction following APR with en bloc prostatectomy. The technique showed promising results in reducing vesicourethral anastomotic leaks, and its morbid consequences. In patients to undergo adjuvant therapy, the avoidance of complications allows them to proceed with treatment uninterrupted. The success of our initial attempts at using this approach suggests potential for wider adoption, although further studies are needed to evaluate long-term outcomes.