Editor,

Moretto et al. are to be congratulated on their novel and innovative method of repair of post-radical prostatectomy recto-urethral fistulas, described in their paper: Use of biological mesh in trans-anal treatment for recurrent recto-urethral fistula [1]. A difficult condition to treat with frequent recurrence, their minimally invasive method should hold great promise.

However, the paper does raise a few queries about their technique and outcomes. As these fistulas are clean contaminated at best, and most likely infected at worst, it is surprising that the authors relied only upon 6 days of ciprofloxacin prophylaxis to prevent mesh infection. For instance, they do not mention whether any enteric preparation or mechanical bowel cleaning was employed beforehand. Enteric preparation of some sort is a standard recommendation for anorectal surgery [2].

The authors note no recurrence or complications over a median follow-up of nearly 3 years. However, the literature mentions a high rate of recurrences and infective complications (sepsis, suppuration, or abscesses) following the use of such devices in anorectal conditions [3, 4]. It is not unreasonable to expect some of these complications or recurrences when the plug is being used in a recto-urethral repair as well. Therefore, it becomes necessary to know whether any bacteriological studies were carried out during follow-up. Certainly, it might be worth considering whether a study with a greater number of patients and with longer follow-up might yield different outcomes.

In addition, the authors do not mention whether they inspected the urethra endoscopically for stricture or stone during the follow-up period. Indeed, during follow-up, did patients present with lower tract urinary symptoms that might indicate infective or urethral sequelae?