it occurs due to various causes ; radiation , postradical prostatectomy , complex trauma , tuberculosis , and malignancy of rectum and prostate . traumatic ruf mainly occurs during wartime injuries and are difficult to manage due to their complexity . various methods are used to repair ruf , the most common being the transanal transsphincteric method of repair . urologists prefer to repair the ruf by perineal route especially when urethral reconstruction also has to be done . interposition of the tissue flaps after ruf repair is followed by reconstructive surgeons as a method of reinforcement . we report the first case of ruf repaired successfully with porcine small intestinal submucosal graft biodesign ( surgisis ) interposition . a 45-year - old male met with road traffic accident a year ago and sustained pelvic fracture with urethral injury and traumatic rectourethral fistula . clinical examination revealed normally functioning pelvic loop colostomy , well - positioned functioning suprapubic cystostomy and an indurated opening of 1 cm  1 cm size in the anterior wall of rectum , 6 cm above the anal verge . opposing cystourethrography revealed complete obliterative stricture at the level of proximal bulbar urethra and extravasation of contrast into rectum from bulbomembranous urethra [ panel a , figure 1 ] . bulboprostatic anastomotic urethroplasty was done by the parachute technique . porcine small intestinal submucosal graft ( biodesign ( surgisis ) 4-layer tissue graft , bloomington , usa ) was used for interposition between the repaired ends of urethra and rectum [ figure 2 ] . after catheter removal , he voided well with a peak flow of 36 ml / s at a voided volume of 560 ml . post - operative voiding cystourethrogram [ panel b , figure 1 ] revealed well - healed bulboprostatic urethral anastomosis and absence of contrast extravasation . subsequently he had loop colostomy closure 6 months later . at follow - up of 1 year ( panel a ) opposing cystourethrogram delineates the communication between the bulbomembranous urethra and rectum with urethral distraction defect . ( panel b ) postoperative voiding cystourethrogram showing completely healed anastomosis with the absence of contrast extravasation into rectum completed bulboprostatic urethral anastomosis and interposition of biodesign ( surgisis ) graft between the urethra and rectum ( hollow arrow ) . they may be of varied etiological factors : congenital , iatrogenic , inflammatory , neoplastic , or traumatic etiologies . traumatic ruf is often seen in wartime injuries and is accompanied with extensive urethral injury which leads to extensive stricture . this condition is very uncommon , no single procedure has been proven most effective and become the technique of choice . spontaneous closure of the ruf after double diversion or by means of a one - stage procedure is possible only in a few cases . in most cases , the treatment proceeds in three stages ( double diversion  urinary and bowel , closure technique , undiversion ) . ruf is being repaired by various techniques ; york - mason inter - sphincteric approach is the common technique used for repair . it allows for complete exposure of bladder neck and prostate and allows for urethral reconstruction after repair of ruf . interposition grafts are used as a second layer of reinforcement after closure of ruf to prevent recurrence due to proximity of overlapping suture lines . many interposition grafts are used for this purpose : gracilis muscle , dartos muscle , tunica vaginalis flap , penile skin , levator muscle , and bladder . harvesting these tissue flaps are associated with complications like hematoma formation , infection , and wound dehiscence . surgisis ( cook surgical , bloomington , in ) is a naturally occurring , acellular , resorbable biomaterial derived from the extracellular matrix of porcine small intestinal submucosa . it is a three - dimensional matrix comprising collagen , non - collagenous proteins , and other molecules , including glycosaminoglycans , proteoglycans , and glycoproteins . surgisis is vacuum dried , packed , and sterilized to ensure minimal transmission of bacteria , viruses , and prions . it acts as a scaffold for the surrounding tissue to grow , supports vessel growth , and fosters cellular differentiation and gets completely incorporated in it . surgisis is being used for various purposes in urology ; urethral reconstruction , ureteric reconstruction , urethral diverticular surgery , bladder neck fistula closure after exstrophy repair , surgery for peyronie 's disease , penile prosthetic surgery , and nephron sparing surgery . surgisis is available in various sizes and for ruf closure , a 7 cm  4 cm size fistula repair product ( g13181 ) ( http://www.cookmedical.com/sur/datasheet.do?id = 5643 ) was used . it is cost effective as effective healing takes place and thereby recurrence and retreatment cost is avoided . upto our knowledge , our case is the first of ruf repair with surgisis noted in the literature . the technique adds one more option of reinforcement to the armamentarium of reconstructive surgeon involved in repair of rectourethral fistula . it adds to the advantage of avoiding morbidity associated with harvesting other tissue flaps ( e.g. , gracilis ) . further larger series is necessary to confirm the efficacy of porcine small intestinal submucosa in the repair of rectourethral fistula .
rectourethral fistula is an uncommon but devastating condition . 
 traumatic rectourethral fistula is still uncommon and repair of traumatic rectourethral fistula involves a complex procedure . 
 most of the urologists would prefer to repair the fistula through perineal route especially when urethral reconstruction is also required . 
 the repaired ends of the fistula are separated with various interposition flaps and grafts in order to prevent recurrence . 
 gracilis interposition muscle flap is commonly used . 
 we describe the first case of traumatic rectourethral fistula repair in a 45-year - old man using interposition of a porcine small intestinal submucosal ( biodesign ( surgisis ) graft .