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Brush E, Hernandez JA, Flusché AM, Oleck NC, Naga HI, Wickenheisser V, Hayden JP, Mantyh CR, Peterson AC, Erdmann D. The Uroplastic Approach to Complex Rectourethral Fistula Repair: Indications, Technique, Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2025; 13:e6662. [PMID: 40182296 PMCID: PMC11964384 DOI: 10.1097/gox.0000000000006662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 02/03/2025] [Indexed: 04/05/2025]
Abstract
Background Rectourethral fistulae are complex pathologies with significant morbidity that warrant multidisciplinary care. Although gracilis muscle interposition for fistula repair has been reported, specific indications and techniques for this mode of reconstruction remain unclear. Methods A retrospective quasi-experimental study was previously conducted to assess outcomes of rectourethral fistula management before and after the implementation of a multidisciplinary treatment algorithm. Patients with complex rectourethral fistulae and repair with gracilis muscle flap interposition were further investigated. Plastic surgery involvement for gracilis muscle interposition was indicated for (1) radiated rectourethral fistulae less than 3 cm and (2) nonradiated rectourethral fistulae more than 2 cm. Our preferred technique for gracilis muscle flap harvest, transposition, and inset is described in detail. Primary outcomes included healing of rectourethral fistulae and secondary reversal of urinary or fecal diversions. Results Twenty-three patients with complex rectourethral fistulae underwent gracilis muscle flap interposition between 2001 and 2022 before (n = 12) and after (n = 11) algorithmic implementation. The frequency of definitive rectourethral fistula healing improved in the postalgorithm group by 33%. There was no significant difference in fistula healing time or the rate of urinary or fecal diversions after algorithm implementation. The technique of gracilis muscle flap interposition is also described. Conclusions The gracilis muscle interposition flap is a valuable reconstructive option for complex rectourethral fistula repair. Implementation of a multidisciplinary treatment algorithm including plastic surgery involvement and refinement of the operative approach was associated with improved frequency of definitive healing of rectourethral fistulae.
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Affiliation(s)
- Erin Brush
- From the Duke University School of Medicine, Durham, NC
| | - J. Andres Hernandez
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | | | - Nicholas C. Oleck
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | - Hani I. Naga
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | | | - Joshua P. Hayden
- Division of Urology, Lahey Hospital and Medical Center, Urology, Burlington, MA
| | | | - Andrew C. Peterson
- Department of Surgery, Division of Urologic Surgery, Duke University, Durham, NC
| | - Detlev Erdmann
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
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Dafnis G. Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy. Urology 2024; 191:130-135. [PMID: 38834146 DOI: 10.1016/j.urology.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE To present our experience with a novel technique that combines the York-Mason transsphincteric approach with dartos muscle flap interposition to treat rectourethral fistulas. METHODS We extracted records from our prospectively kept database of 35 procedures conducted for treating rectourethral fistulas during 2002-2023; the York-Mason approach was combined with dartos muscle flap interposition in 5 cases, performed for treating rectourethral fistulas due to radical prostatectomy, all of which were referral cases. RESULTS All 5 patients were successfully treated and followed up for a median of 70.0 months without recurrence. Before the fistula repair, all had a diverting stoma. In all cases, the first voiding cystourethrogram revealed a healed fistula. The posterior and the scrotal incisions healed uneventfully. All patients reported normal voiding and no urinary incontinence. To date, the stoma has closed in 3 patients, all of whom had intact fecal continence and no postoperative anal stenosis. CONCLUSION The transsphincteric modified York-Mason approach combined with dartos muscle flap interposition resulted in complete healing of rectourethral fistulas.
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Affiliation(s)
- George Dafnis
- Colorectal Unit, Department of Surgery and Urology, Eskilstuna County Hospital, Eskilstuna, Sweden.
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Reichert M, Stepniewski A, Grade M, Felmerer G, Trojan L, Mohr MN. [Closure of a prostatocutaneous urinary fistula while preserving sexual function using a perineal approach with Gracilis flap interposition]. Aktuelle Urol 2023. [PMID: 38049104 DOI: 10.1055/a-2201-6302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
We present the case of a 36-year-old man suffering from perianal loss of urine through a cutaneous pore while urinating. Appropriate diagnostic investigation showed a urethrocutaneous fistula of the prostatic urethra of unclear aetiology. Because of the patient's young age and sexual activity, surgical treatment was challenging. The fistula was isolated via a perineal access and ligated close to the prostate without endangering the neurovascular bundles. In order to achieve a secure closure of the fistula, a Gracilis flap was placed as an interposition between the dorsal prostate and the percutaneous fistula outlet. To date, no case has been described of a successful, function-preserving surgical treatment of a prostatocutaneous urinary fistula.
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Affiliation(s)
- Mathias Reichert
- Urologie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen
| | - Adam Stepniewski
- Plastische und Ästhetische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen, Deutschland
| | - Marian Grade
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen, Deutschland
| | - Gunther Felmerer
- Plastische und Ästhetische Chirurgie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen, Deutschland
| | - Lutz Trojan
- Urologie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen
| | - Mirjam Naomi Mohr
- Urologie, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen
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Mouawad C, El Helou E, Dahboul H, Akel R, Chamaa B, Aoun R, Kassar S, Osseis M, Noun R, Chakhtoura G. Laparoscopic repair of acquired rectourethral fistula by vesical peritoneal flap. Asian J Endosc Surg 2023; 16:814-818. [PMID: 37421167 DOI: 10.1111/ases.13230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION A rectourethral fistula (RUF) is an infrequent complication that can be iatrogenic in most cases. Multiple surgical interventions were described for RUF repair including transsphincteric, transanal, transperineal, and transabdominal approaches. To this day, there is no consensus on a standardized surgery of choice for acquired RUF. MATERIALS AND SURGICAL TECHNIQUE Our patient was diagnosed with RUF 4 weeks after undergoing laparoscopic low anterior resection for midrectum adenocarcinoma, with failure of conservative treatment. A three-port transabdominal approach was used to dissect the rectoprostatic space and close the fistula orifice on the anterior rectal wall. With the technical impossibility to develop an omental flap, the peritoneum on the posterior vesical wall was carefully dissected to form a rectangular flap pedicled by its inferior aspect. The harvested peritoneal flap was then anchored between the prostate and the rectum. Follow-up imaging showed the absence of RUF, concurrently with total remission of RUF symptomatology. DISCUSSION Management of acquired RUF can be challenging, especially after failure of conservative treatment. Laparoscopic repair of acquired RUF by vesical peritoneal flap is a valid option for a minimally invasive approach for the treatment of RUF.
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Affiliation(s)
- Christian Mouawad
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Elie El Helou
- Department of Urology, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Houssam Dahboul
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Rhea Akel
- Department of Radiology, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Bilal Chamaa
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Rany Aoun
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Serge Kassar
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Michael Osseis
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Roger Noun
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Ghassan Chakhtoura
- Department of Digestive Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon
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Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Postintervention Quasi-Experimental Study. Dis Colon Rectum 2023; 66:598-608. [PMID: 35507740 DOI: 10.1097/dcr.0000000000002467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rectourethral fistulas are a rare yet severe complication of prostate surgery, pelvic irradiation therapy, or both. Multiple surgical repairs exist with widely varying success rates. OBJECTIVE This study aimed to present our institutional multidisciplinary algorithm for rectourethral fistula repair and its outcomes. DESIGN This was a retrospective, pre- and postintervention, quasi-experimental design, comparing the frequency of fistula healing and reversal of urinary and fecal diversion before and after implementation of our algorithm. SETTING All patients who presented to the Duke University with rectourethral fistula between 2002 and 2019 were included. PATIENTS This study included 79 patients treated for rectourethral fistula: 36 prealgorithm and 43 postalgorithm. INTERVENTIONS Our multidisciplinary algorithm was implemented in 2012. Patients with fistulas <2 cm and without history of radiation therapy underwent York-Mason repair, whereas those with fistulas 2-3 cm or with prior irradiation underwent transperineal repair with gracilis flap interposition. Those with nonrepairable fistulas (>3 cm or fixed tissues) underwent pelvic exenteration. Before repair, the algorithm recommended all patients to undergo urinary and bowel diversion. MAIN OUTCOME MEASURES The 2 primary outcomes were rectourethral fistula healing, defined as both radiographic and clinical resolutions, and reversal of urinary and fecal diversions. RESULTS Frequency of fistula healing improved in the post- versus prealgorithm subgroups (93.1% vs 71.9%; p = 0.04). The relative risk of fistula healing pre- versus postintervention was 0.77 (0.61-0.98; p = 0.04) among the overall cohort. Eighteen patients (22.8%) underwent pelvic exenteration for nonrepairable fistulas and were not included in primary outcome measures. LIMITATIONS Limitations include the study's retrospective nature, possible selection bias because of algorithmic patient selection, and small sample size. CONCLUSIONS Implementation of a multidisciplinary institutional algorithm improved rectourethral fistula repair success with high rates of ostomy reversal. Proper patient selection and multidisciplinary involvement are paramount to this success. See Video Abstract at http://links.lww.com/DCR/B955 . RESULTADOS DE UN ABORDAJE ALGORTMICO Y MULTIDISCIPLINARIO PARA LA REPARACIN DE FSTULAS RECTOURETRALES UN ESTUDIO CUASIEXPERIMENTAL PREVIO Y POSTERIOR A LA INTERVENCIN ANTECEDENTES:Las fístulas rectouretrales son una complicación rara pero grave de la cirugía de próstata, la radiación pélvica o ambas. Existen múltiples reparaciones quirúrgicas con tasas de éxito muy variables.OBJETIVO:Presentar el algoritmo multidisciplinario de nuestra institución para la reparación de fístulas rectouretrales y sus resultados.DISEÑO:Este fue un diseño retrospectivo, previo y posterior a la intervención, cuasiexperimental, que comparó la frecuencia de curación de la fístula y la reversión de la derivación urinaria y fecal antes y después de la implementación de nuestro algoritmo.ESCENARIO:Se incluyeron todos los pacientes que acudieron a Duke con fístula rectouretral entre 2002 y 2019.PACIENTES:Setenta y nueve pacientes fueron tratados por fístula rectouretral; 36 pre-algoritmo y 43 post-algoritmo.INTERVENCIONES:Nuestro algoritmo multidisciplinario se implementó en 2012. Los pacientes con fístulas <2 cm y sin antecedentes de radiación se sometieron a reparación de York-Mason, mientras que aquellos con fístulas de 2-3 cm o radiación pélvica previa se sometieron a reparación transperineal con interposición de colgajo de gracilis. Aquellos con fístulas no reparables (> 3 cm o tejidos fijos) fueron sometidos a exenteración pélvica. Antes de la reparación, el algoritmo recomomendó que todos los pacientes se sometieran a una derivación urinaria y fecal.PRINCIPALES MEDIDAS DE RESULTADO:Los dos resultados primarios fueron la curación de la fístula rectouretral, definida como la resolución radiográfica y clínica, y la reversión de las derivaciones urinaria y fecale.RESULTADOS:La frecuencia de curación de la fístula mejoró en el subgrupo post-algoritmo vs. pre-algoritmo (93.1% vs. 71.9%, p = 0.04). El riesgo relativo de curación de la fístula antes de la intervención en comparación con después de la intervención fue de 0.77 (0.61-0.98, p = 0.04) entre la cohorte general. Dieciocho pacientes (22.8%) se sometieron a exenteración pélvica por fístulas no reparables y, por lo tanto, no se incluyeron en las medidas de resultado primarias.LIMITACIONES:Las limitaciones de este estudio incluyen su naturaleza retrospectiva, posible sesgo de selección debido a la selección algorítmica de pacientes y un tamaño de muestra pequeño.CONCLUSIONES:La implementación de un algoritmo institucional multidisciplinario mejoró el éxito en la reparación de la fístula rectouretral con altas tasas de reversión de la ostomía. La selección adecuada de pacientes y la participación multidisciplinaria son fundamentales para este éxito. Consulte Video Resumen en http://links.lww.com/DCR/B955 . (Traducción-Dr. Jorge Silva Velazco ).
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Reichert M, Schüler P, Stepniewski A, Felmerer G, Trojan L, von Knobloch HC. [Closure of persisting rectourethral fistula after suprasymphyseal adenoma enucleation of the prostate by combining the Bressel-Naujox and gracilis flap procedure]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:295-298. [PMID: 36066612 PMCID: PMC9998548 DOI: 10.1007/s00120-022-01924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/29/2022]
Abstract
When taking into consideration the basic principles of fistula surgery, numerous options are available for the surgical repair of rectourethral fistulas. However, there is no standard regarding which surgical method should be used under which circumstances-due to the heterogeneity of this disease. This case report describes the individual adaptation of a surgical technique that is used for the treatment of vesicovaginal fistulas to treat a rectourethral fistula in a patient who had already undergone an unsuccessful fistula closure attempt. Successful closure of the fistula was achieved on the basis of an established method using tissue interposition.
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Affiliation(s)
- M Reichert
- Klinik für Urologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - P Schüler
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - A Stepniewski
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - G Felmerer
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - L Trojan
- Klinik für Urologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - H C von Knobloch
- Klinik für Urologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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7
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Complex Lower Genitourinary Fistula Repair. Urol Clin North Am 2022; 49:553-565. [DOI: 10.1016/j.ucl.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Singh P, Kumar S, Panaiyadiyan S, Singh P, Dogra P, Seth A. Repair of Rectourethral Fistula Using Gracilis Muscle Flap Interposition—a Tertiary Care Center Experience. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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9
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Ventura FL, Nguyen CM, Dang A, Baliss M, Sonstein LK. A Curious Case of Rectal Ejaculation. Cureus 2021; 13:e17330. [PMID: 34447650 PMCID: PMC8381446 DOI: 10.7759/cureus.17330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/24/2022] Open
Abstract
Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm. A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume. Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.
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Affiliation(s)
- Frank L Ventura
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Christopher M Nguyen
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Alexander Dang
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Michelle Baliss
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Lindsay K Sonstein
- Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
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10
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Juan Escudero JU, Villaba Ferrer F, Ramos de Campos M, Fabuel Deltoro M, Garcia Coret MJ, Sanchez Ballester F, Povo Martín I, Pallas Costa Y, Pardo Duarte P, García Ibañez J, Monzó Cataluña A, Rechi Sierra K, Juliá Romero C, Lopez Alcina E. Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access. Actas Urol Esp 2021; 45:398-405. [PMID: 34088440 DOI: 10.1016/j.acuroe.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/13/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. MATERIAL AND METHODS Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. RESULTS The mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. CONCLUSIONS The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.
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Affiliation(s)
- J U Juan Escudero
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| | - F Villaba Ferrer
- Servicio de Cirugía General, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - M Ramos de Campos
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - M Fabuel Deltoro
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - M J Garcia Coret
- Servicio de Cirugía General, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - F Sanchez Ballester
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - I Povo Martín
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Y Pallas Costa
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - P Pardo Duarte
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - J García Ibañez
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Monzó Cataluña
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - K Rechi Sierra
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - C Juliá Romero
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - E Lopez Alcina
- Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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Suhardja TS, Errington B, Khalessi A, Phan-Thien KC. Robotic transanal rectourethral fistula repair-a video vignette. Colorectal Dis 2021; 23:1275-1276. [PMID: 33527592 DOI: 10.1111/codi.15557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/31/2020] [Accepted: 01/27/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Thomas Surya Suhardja
- Department of Colorectal Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Belinda Errington
- Department of Surgery, Hurstville Private Hospital, Sydney, New South Wales, Australia
| | - Amirala Khalessi
- Department of Surgery, Hurstville Private Hospital, Sydney, New South Wales, Australia
| | - Kim-Chi Phan-Thien
- Department of Colorectal Surgery, St George Hospital, Sydney, New South Wales, Australia.,Department of Surgery, Hurstville Private Hospital, Sydney, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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12
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Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access. Actas Urol Esp 2021. [PMID: 33622527 DOI: 10.1016/j.acuro.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. MATERIAL AND METHODS Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. RESULTS The mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 minutes (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. CONCLUSIONS The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.
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13
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Mishra K, Mahran A, Abboud B, Bukavina L, Elshafei A, Ray A, Fernstrum A, Abboud R, Elgammal M, Zhao LC, Gupta S. Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes. Urology 2020; 147:299-305. [PMID: 32916190 DOI: 10.1016/j.urology.2020.08.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate. METHODS A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis. RESULTS Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification. CONCLUSION Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.
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Affiliation(s)
- Kirtishri Mishra
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Amr Mahran
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Laura Bukavina
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ahmed Elshafei
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Al Ray
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Austin Fernstrum
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Rayan Abboud
- Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Lee C Zhao
- New York University Health, New York, NY
| | - Shubham Gupta
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
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Bislenghi G, Verstraeten L, Verlinden I, Castiglione F, Debaets K, Van der Aa F, Fieuws S, Wolthuis A, D'Hoore A, Joniau S. Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients. Tech Coloproctol 2020; 24:927-933. [PMID: 32301002 DOI: 10.1007/s10151-020-02214-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF. METHODS This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed. RESULTS Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004). CONCLUSIONS Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.
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Affiliation(s)
- G Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - L Verstraeten
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - I Verlinden
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - F Castiglione
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - K Debaets
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - F Van der Aa
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - S Fieuws
- Interuniversity Center for Biostatistics and Statistical Bioinformatics, KU Leuven, University of Hasselt, Hasselt, Belgium
| | - A Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S Joniau
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas. Eur Urol Focus 2020; 6:762-769. [PMID: 31402242 DOI: 10.1016/j.euf.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/04/2019] [Accepted: 07/25/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rectourethral fistulas (RUFs) are rare but devastating complications after surgery or radiation therapy to the urethra, prostate, or rectum. RUF repair is challenging, especially in irradiated patients. OBJECTIVE To evaluate the efficacy of the York Mason (YM) procedure with or without concomitant gracilis muscle interposition (graciloplasty) for RUF repair. DESIGN, SETTING, AND PARTICIPANTS Records of patients with an iatrogenic RUF who underwent the YM procedure between 2008 and 2018 in two university hospitals were reviewed. Data on etiology, diagnostic and operative procedures, urinary and fecal diversion, and postoperative follow-up were collected. INTERVENTION Twenty-eight patients underwent 33 YM procedures. Concomitant graciloplasty was performed in four (14%) primary repairs and two (7%) repairs for recurrent RUFs. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was successful RUF repair, defined as absence of symptoms and no leakage on control urethrocystography. The secondary endpoint was colostomy reversal rate. RESULTS AND LIMITATIONS Median follow-up was 24 mo. Ten patients (36%) were irradiated previously. The ultimate success rate was 75% after a maximum of three YM procedures. Success rates were 89% and 50% in patients with nonirradiated and irradiated fistulas, respectively. In irradiated patients, the success rates of the first YM procedure with and without graciloplasty were 100% and 29%, respectively. In recurrent cases, concomitant graciloplasty did not result in better outcomes. Colostomy reversal was possible in 15 patients after successful repair. In all patients, fecal continence was intact and no anal stenosis was reported. Limitations of the study include small sample size and the retrospective design. CONCLUSIONS Combination of the YM procedure with graciloplasty resulted in higher success rates of RUF repair in patients with irradiated fistulas. Fecal continence was preserved, and colostomy reversal is feasible. PATIENT SUMMARY We analyzed the outcomes, complications, and colostomy reversal rate of the York Mason procedure for the repair of rectourethral fistulas (RUFs). We found that concomitant graciloplasty increases success rates in case of prior radiation therapy. Colostomy reversal is feasible after RUF repair.
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Keady C, Hechtl D, Joyce M. When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement. World J Gastrointest Surg 2020; 12:208-225. [PMID: 32551027 PMCID: PMC7289647 DOI: 10.4240/wjgs.v12.i5.208] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023] Open
Abstract
Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.
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Affiliation(s)
- Conor Keady
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Daniel Hechtl
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
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Medina LG, Rangel E, Fuchs I, Silva MC, Hernandez A, Cacciamani GE, Sotelo R. Rectourethral Fistula: Operative Technique and Outcomes. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00529-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Prabha V, Kadeli V. Repair of recto-urethral fistula with urethral augmentation by buccal mucosal graft and gracilis muscle flap interposition - our experience. Cent European J Urol 2018; 71:121-128. [PMID: 29732218 PMCID: PMC5926628 DOI: 10.5173/ceju.2018.1353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 09/16/2017] [Accepted: 11/13/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Recto-urethral fistula (RUF) is a relatively rare surgical condition, the treatment of which is quite challenging. There are many causes of RUF, but 60% of them are iatrogenic following open prostatectomies, radiotherapy, brachytherapy, urethral instrumentation etc. We present a series of six cases treated at our institution. Material and methods A retrospective study of all six patients with recto-urethral fistula treated at our centre between 2011 and 2016 was performed. The study included charting of information like age, etiology, clinical presentation, diagnostic modalities, treatment protocols, complications and recurrence. All the patients had simple direct fistulas with no previous history of repair. One patient had history of pelvic fracture following road traffic accident, one patient had a penetrating perineal injury following road traffic accident; two patients had history of Freyer's prostatectomy for benign prostatic hypertrophy; two patients had history of open radical prostatectomy performed at other centres. All patients were treated with an initial double diversion (suprapubic cystostomy and colostomy) followed by definitive surgical repair three months later. The surgical technique used was fistula excision, urethral augmentation by buccal mucosal graft, primary rectal defect repair and gracilis muscle flap interposition between the rectum and urethra. Results The patients were followed up ranging from after 6 to 48 months with a mean follow-up period of 27 months. There were minimal complications such as main wound site infections, seroma at the harvested site of gracilis muscle flap, urethral stricture. There was no report of recurrence. Conclusions From our experience, we conclude that this method of repair is a very efficient one without any recurrence and with minimal complications. The results were on par with all the other successful methods of recto-urethral fistula repair described in the literature.
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Affiliation(s)
- Vikram Prabha
- KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital & MRC, Department of Urology, Belgaum, India
| | - Vishal Kadeli
- KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital & MRC, Department of Urology, Belgaum, India.,Department of Urology, KLES Kidney Foundation, KLE University's JN Medical College, KLES Dr. Prabhakar Kore Hospital & MRC, Belgaum, India
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19
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Zachou A, Mteta KA, Thomas PJ. Matador injury case report: Spermatic cord fat pad (SCFP) interposition to support complex pelvic reconstruction-a novel technique. Urol Case Rep 2018; 18:87-88. [PMID: 29785382 PMCID: PMC5958927 DOI: 10.1016/j.eucr.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/23/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Kien A Mteta
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
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20
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Management of acquired rectourethral fistulas in adults. Asian J Urol 2018; 5:149-154. [PMID: 29988864 PMCID: PMC6032817 DOI: 10.1016/j.ajur.2018.01.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 06/14/2017] [Accepted: 10/30/2017] [Indexed: 02/05/2023] Open
Abstract
Rectourethral fistula is an uncommon but devastating condition resulting from surgery, radiation, trauma, inflammation, or occasionally anorectal anomaly. Because of involving the urinary and the digestive system, surgical repair can be challenging. More than 40 different surgical approaches were described in the literature. However, no standardized management exists due to the rarity and complexity of the problem. Spontaneous closure of fistula is rare and most cases need reconstructive procedures. Appropriate preoperative assessment is crucial for the decision of operation time and method. Gradually accumulating evidence indicates surgeons should take fistula size, tissue health and vascularity associated with radiation or infection, urethral stricture, and bladder neck sclerosis into consideration and make a proper treatment plan according to the features of various approaches. Accurate preoperative evaluation and proper approach selection would increase success rates. Multiple surgical team corporation, including colorectal, urological and plastic surgeons, would optimize the outcomes.
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Dafnis G. Transsphincteric repair of rectourethral fistulas: 15 years of experience with the York Mason approach. Int J Urol 2018; 25:290-296. [PMID: 29323430 DOI: 10.1111/iju.13518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/26/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the surgical and functional outcomes of our single institution's 15-year experience with surgically treated rectourethral fistulas using a modification of the York Mason technique. METHODS Prospectively recorded data between 2002 and 2016 of all patients who underwent transsphincteric repair of rectourethral fistula using a modified York Mason technique at Eskilstuna County Hospital, Eskilstuna, Sweden, were assessed. A total of 20 consecutive patients, including 17 referrals (85%) and three patients (15%) from our hospital have undergone the modified York Mason procedure. The surgical and functional outcomes were evaluated. RESULTS Of the 20 patients, 18 were repaired successfully (90%), and one was combined with a dartos muscle interposition flap. No fistula recurrence occurred in the 18 successful repairs during the median follow-up time of 84.7 months. Before fistula repair, 12 patients (60%) underwent a diverting stoma. The remaining eight patients (40%) underwent repair and synchronous diverting stoma. We did not find any significant differences between patients in which the repair was successful compared with patients with failed repair, but diabetes, smoking and preoperative irradiation were much more frequent in the failed group. Of the 18 patients who had a successful repair, 17 patients experienced normal voiding and no urinary incontinence. One patient was suffering from postprostatectomy incontinence before rectourethral fistula repair, and was successfully treated with Scott prosthesis. All the 13 patients in whom the stoma had been closed reported intact fecal continence and no anal stenosis postoperatively. CONCLUSIONS The transsphincteric modified York Mason approach offers excellent exposure and a high fistula closure rate without fecal and urinary incontinence.
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Affiliation(s)
- George Dafnis
- Colorectal Unit, Department of Surgery and Urology, Eskilstuna County Hospital, Eskilstuna, Sweden
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22
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Mao Q, Luo J, Fang J, Jiang H. Management of radiation-induced rectovesical fistula in a woman using ileum: A case report and review of the literature. Medicine (Baltimore) 2017; 96:e8553. [PMID: 29145262 PMCID: PMC5704807 DOI: 10.1097/md.0000000000008553] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Radiation-induced rectovesical fistulas (RVFs) require the most demanding treatment. We presented a rare case of postradiation RVF in a woman repaired with ileum. CASE PRESENTATION A 49-year-old women was referred to our department for fecaluria and dysuria after radiation for cervical cancer. The voiding cystourethrography demonstrated a large RVF. A segment of ileum was separated into 2 parts for the simultaneous reconstruction of bladder and rectum, which led to a permanently closed fistula. This approach is easily accessible via transabdominal approach, could be applied for large defect, and bladder augmentation could be performed simultaneously. CONCLUSION The repair of an RVF using ileum appears feasible and represents an attractive alternative for the management of RVFs.
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23
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Martins FE, Martins NM, Pinheiro LC, Ferraz L, Xambre L, Lopes TM. Management of iatrogenic urorectal fistulae in men with pelvic cancer. Can Urol Assoc J 2017; 11:E372-E378. [PMID: 29382460 DOI: 10.5489/cuaj.4427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Urorectal fistula (URF) is a devastating complication of pelvic cancer treatments and a surgical challenge for the reconstructive surgeon. We report a series of male patients with URF resulting from pelvic cancer treatments, specifically prostate (PCa), bladder (BCa), and rectal cancer (RCa), and explore the differences and impact on outcomes between purely surgical and non-surgical treatment modalities. METHODS Between October 2008 and June 2015, 15 male patients, aged 59-78 years (mean 67), with URF induced by pelvic cancer treatments were identified in our institutions. Patients with a history of diverticulitis, inflammatory bowel disease, or other benign conditions were excluded. We reviewed the patients' medical records for symptoms, diagnostic tests performed, type and etiology of the fistula, type of surgical reconstruction, followup, and outcomes. RESULTS Fourteen patients underwent surgical reconstruction. One patient developed metastatic disease before URF repair and, therefore, was excluded from this study. Mean followup (FU) was 32.7 months (14-79). All patients received diverting colostomy and temporary urinary diversion. An exclusively transperineal approach was used in nine (64.3%) patients and a combined abdominoperineal in five (35.7%). Overall successful URF closure was achieved in 12 (85.7%) patients, nine (64.3%) of whom at the first reconstructive attempt, two (14.3%) after two attempts (in our institution), and one (7.1%) after three attempts (two of which elsewhere). An interposition flap was used in seven (50%) patients. Surgical reconstruction failed ultimately in two (14.3%) patients who still have a colostomy and do not wish any further reconstruction. CONCLUSIONS Our study has several limitations, including its retrospective nature and the heterogeneity of our small patient cohort. Nonetheless, although surgical reconstruction of URF may be extremely difficult and complex in the non-surgical/energy ablation patients, its successful reconstruction is possible in most through a transperineal, or a more aggressive abdominoperineal, approach with tissue interposition in selected patients.
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Affiliation(s)
- Francisco E Martins
- Department of Urology, University of Lisbon, School of Medicine, Hospital Santa Maria (CHLN), Lisbon; Portugal.,Unidade Local de Saúde do Norte Alentejano (ULSNA), Portalegre; Portugal
| | - Natália M Martins
- Unidade Local de Saúde do Norte Alentejano (ULSNA), Portalegre; Portugal
| | - Luís Campos Pinheiro
- Department of Urology, Centro Hospitalar Lisboa Central/Hospital S. José (CHLC), Lisbon; Portugal
| | - Luís Ferraz
- Department of Urology, Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E), Vila Nova Gaia; Portugal
| | - Luís Xambre
- Department of Urology, Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E), Vila Nova Gaia; Portugal
| | - Tomé M Lopes
- Department of Urology, University of Lisbon, School of Medicine, Hospital Santa Maria (CHLN), Lisbon; Portugal
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Jai S, Ganpule A, Singh A, Vijaykumar M, Bopaiah V, Sabnis R, Desai M. Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula. F1000Res 2017; 5:2891. [PMID: 28299181 PMCID: PMC5310386 DOI: 10.12688/f1000research.10245.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 11/29/2022] Open
Abstract
High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni
et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the “first chance is the best chance”.
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Affiliation(s)
- Shrikant Jai
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Arvind Ganpule
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Abhishek Singh
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | | | - Vinod Bopaiah
- Staten Island University Hospital, Staten Island, USA
| | - Ravindra Sabnis
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Mahesh Desai
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
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Kaufman DA, Zinman LN, Buckley JC, Marcello P, Browne BM, Vanni AJ. Short- and Long-term Complications and Outcomes of Radiation and Surgically Induced Rectourethral Fistula Repair With Buccal Mucosa Graft and Muscle Interposition Flap. Urology 2016; 98:170-175. [DOI: 10.1016/j.urology.2016.06.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/20/2016] [Accepted: 06/23/2016] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW This article discusses etiologic considerations, evaluation, and contemporary approaches to managing rectourethral fistula (RUF) with particular emphasis on geriatric patients. RECENT FINDINGS With the advent of multimodal approaches to treating prostate cancer, such as radiation and ablative therapies, the incidence of RUF is increasing, especially in the geriatric population. Surgical repair and healing of RUF in patients with prior radiation is more challenging than in those without prior radiation or ablation because of fibrotic and ischemic changes in surrounding tissues. There is, at present, a lack of consensus over a standardized approach to RUF management because of the heterogeneity in presentation and limited, primarily retrospective, experience in the literature. Nonetheless, an evolving array of surgical approaches now exists for fistula excision and tissue interposition. SUMMARY Immediate recognition and management of RUF is paramount to prevent related complications. Patient selection and counseling are key to selecting the best approach for repair, whereas a multidisciplinary team, including colorectal and plastic surgery colleagues, may optimize outcomes.
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Minimally Invasive Transanal Repair of Rectourethral Fistulas. Eur Urol 2016; 71:133-138. [PMID: 27339834 DOI: 10.1016/j.eururo.2016.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/06/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Rectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk. OBJECTIVE To describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes. DESIGN, SETTING, AND PARTICIPANTS We retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5cm, sepsis, and/or faecaluria. SURGICAL PROCEDURE After fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks' anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure. MEASUREMENTS Fistula closure, postoperative complications, and recurrence. RESULTS AND LIMITATIONS Median follow-up was 21 (range, 12-74) mo. Median operative time was 58 (range, 50-70) min. Median hospital stay was 1.5 (range, 1-4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas. CONCLUSIONS MITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy. PATIENT SUMMARY We studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications.
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Guimerà-García J, Pieras-Ayala E, Burgués-Gasion JP, Ozonas-Moragues M, Tubau-Vidaña V, Piza-Reus P. Perineal approach for rectourethral fistulae after radical laparoscopic prostatectomy. Actas Urol Esp 2016; 40:119-23. [PMID: 26614434 DOI: 10.1016/j.acuro.2015.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe our experience with the perineal approach to treat rectourethral fistulae (RUF) after radical laparoscopic prostatectomy. MATERIALS AND METHODS We performed a retrospective study from 2012 to 2015 presenting 5 cases of RUF after radical laparoscopic prostatectomy. All cases required major abdominal surgery between the radical laparoscopic prostatectomy and the RUF treatment due to various complications. In no case was radiation therapy indicated prior to or after the repair. A perineal approach was performed in the 5 cases as the first option. One case required a second operation with a combined approach (abdominal and perineal) due to persistent fistulae. RESULTS After a minimum of 12 months of follow-up, 5 cases had resolved the RUF. Two patients presented urinary incontinence, and one patient had an anastomotic stricture that required internal urethrotomy. The other patients had no long-term complications. CONCLUSION The perineal approach provides a healthy surgical field in patients who undergo multiple operations, achieving high rates of resolution of the fistulae.
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Affiliation(s)
- J Guimerà-García
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España.
| | - E Pieras-Ayala
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - J P Burgués-Gasion
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - M Ozonas-Moragues
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - V Tubau-Vidaña
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - P Piza-Reus
- Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, España
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Subhas G, Alva S, Longo WE. Re-operative surgery for genitourinary fistulae to the colorectum. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Selph JP, Madden-Fuentes R, Peterson AC, Webster GD, Lentz AC. Long-term Artificial Urinary Sphincter Outcomes Following a Prior Rectourethral Fistula Repair. Urology 2015; 86:608-12. [DOI: 10.1016/j.urology.2015.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
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Anderson KM, Gallegos M, Higuchi TT, Flynn BJ. Evaluation and Management of Rectourethral Fistulas After Prostate Cancer Treatment. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0297-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eswara JR, Raup VT, Heningburg AM, Brandes SB. Pelvic radiation is associated with urinary fistulae repair failure and need for permanent urinary diversion. Urology 2015; 85:932-6. [PMID: 25817118 DOI: 10.1016/j.urology.2014.11.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review our experience with nonmuscle flap repairs of enterourinary fistulae (EUF) and urinary cutaneous fistulae (UCF). EUF and UCF can be treated either with temporary urinary diversion allowing for healing by secondary intention or primary closure of the defect using an interposing omental, sliding, or muscle flap. Even after successful fistula repair, permanent urinary diversion can be required because of persistent urinary incontinence. MATERIALS AND METHODS We reviewed 86 patients who underwent treatment of EUF or UCF at Washington University between the years 1998 and 2013. Of these, 39 patients underwent fistula repair, whereas 47 patients underwent either surgical or nonsurgical urinary diversion. Outcomes measured included postoperative fistula closure, need for permanent urinary diversion, and urinary incontinence. RESULTS The mean age in our series was 59 years (21-87 years) at the time of surgery, with median follow-up of 20 months (1-137 months). Among patients who underwent surgical repair, radiation was associated with higher rates of repair failure (P = .0002), postsurgical incontinence (P <.0001), and the need for permanent urinary diversion (P = .0076). At the time of final follow-up, 32 of the 44 radiated patients had required permanent diversion (72%) compared with 3 of the 42 nonradiated patients (7%; P <.0001). CONCLUSION Patients who undergo pelvic radiation before EUF and UCF repairs are at higher risk for developing repair failure and postsurgical incontinence. Many patients eventually require permanent urinary diversion. Therefore, EUF and UCF repairs in radiated patients should be undertaken with caution, and patients should be counseled about the possibility of urinary diversion as primary therapy.
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Affiliation(s)
- Jairam R Eswara
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Valary T Raup
- Division of Urologic Surgery, Department of Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Avory M Heningburg
- Division of Urologic Surgery, Department of Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Steven B Brandes
- Division of Urologic Surgery, Department of Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
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Cerdán Santacruz C, Cerdán Miguel J. Acquired recto-uretral fistulas: etiopathogenesis, diagnosis and therapeutic options. Cir Esp 2014; 93:137-46. [PMID: 25467973 DOI: 10.1016/j.ciresp.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/05/2014] [Indexed: 01/26/2023]
Abstract
Rectouretral fistulas are a rare disease, but represent an important problem for the patient that suffers them and a challenge for the urologist and colorectal surgeon who has to manage them. A wide review has been performed focusing on etiopathogenic factors, diagnostic and therapeutic options including the analysis of different surgical techniques. PubMed, MEDLINE y EMBASE medical database were searched up to September 2014.
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Abstract
BACKGROUND Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis. OBJECTIVE To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm. DESIGN AND SETTING A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012. PATIENTS Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16. MAIN OUTCOME MEASURES The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence. RESULTS There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group. LIMITATIONS This study was limited by the small sample size and the retrospective nature of the review. CONCLUSIONS Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.
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Fujioka M, Hayashida K, Norooka S, Saijo H, Kuwabara K, Nonaka T, Hayashi M. Gluteal-fold adipofascial perforator flap transposition for rectourethral fistula reconstruction. JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415814527446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
If a rectourinary fistula does not close spontaneously, it requires surgical closure. We present our experience of rectourethral fistula reconstruction using a gluteal-fold perforator flap, resulting in a successful outcome. The patient was a 64-year-old man with prostate cancer who underwent radical prostatectomy. However, he developed rectourinary fistula, which required surgical closure. A dissection was undertaken to divide the fistula tract, and the rectal and urethral defect were closed. A 12.0×3.0 cm gluteal-fold adipofascial perforator flap was harvested and placed in the space between the rectum and urethra. The viability of lap was favourable, without infection or necrosis. The patient could walk the next day, and was discharged 2 weeks later without fecaluria or liquid stool. We conclude that the gluteal-fold adipofascial perforator flap offers excellent functional advantages in rectourethral fistula reconstruction with minimal morbidity at the donor site.
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Affiliation(s)
- Masaki Fujioka
- Nagasaki University, Nagasaki, Japan/Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kenji Hayashida
- National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Sin Norooka
- National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hiroto Saijo
- National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kaoru Kuwabara
- National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Mikio Hayashi
- Department of Urology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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Takano S, Boutros M, Wexner SD. Gracilis Muscle Transposition for Complex Perineal Fistulas and Sinuses: A Systematic Literature Review of Surgical Outcomes. J Am Coll Surg 2014; 219:313-23. [DOI: 10.1016/j.jamcollsurg.2014.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/15/2014] [Indexed: 02/07/2023]
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Polom W, Krajka K, Fudalewski T, Matuszewski M. Treatment of urethrorectal fistulas caused by radical prostatectomy - two surgical techniques. Cent European J Urol 2014; 67:93-7. [PMID: 24982792 PMCID: PMC4074714 DOI: 10.5173/ceju.2014.01.art21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 10/10/2013] [Accepted: 12/08/2013] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The repair of complex urethrorectal fistulas, which can be the result of treating prostate cancer with radical prostatectomy, is a big problem in urology and its final result is not always satisfactory. There are no universally accepted methods for repairing such fistulas. In our work we present a retrospective analysis of patients treated for urethrorectal fistulas after previous radical prostatectomy. The methods used were the initial excision and suture of the fistula, or a gracilis muscle flap interposition. MATERIAL AND METHODS In the years 2000-2012, four patients were treated because of urethrorectal fistulas after radical prostatectomy. In two patients, open radical prostatectomy had been performed. Two other patients had been operated laparoscopically. Two patients had a primary fistula repair. They were operated using anterior perineal access. Two others were treated with the use of a gracilis muscle flap. RESULTS During the follow up, there was no recurrence of fistulas. Medium follow up for the first two patients was 120 and 156 months, and follow up of two other patients was 16 and 23 months. Until now, there were no final postoperative complications. CONCLUSIONS Repair of the fistulas requires an individual approach to each case. Excision and suturing of the fistula gives a very good final result, especially when the primary reconstruction is performed. Repair of urethrorectal fistula using a gracilis muscle flap appears to be an excellent option in cases of complex recurrent fistulas. It is also associated with low morbidity in patients and a high success rate.
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Affiliation(s)
- Wojciech Polom
- Department of Urology, Medical University of Gdańsk, Gdańsk, Poland
| | - Kazimierz Krajka
- Department of Urology, Medical University of Gdańsk, Gdańsk, Poland
| | - Tomasz Fudalewski
- Karol Marcinkowski University of Medical Sciences, Św. Marii Magdaleny, Poznań, Poland
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Choi JH, Jeon BG, Choi SG, Han EC, Ha HK, Oh HK, Choe EK, Moon SH, Ryoo SB, Park KJ. Rectourethral fistula: systemic review of and experiences with various surgical treatment methods. Ann Coloproctol 2014; 30:35-41. [PMID: 24639969 PMCID: PMC3953168 DOI: 10.3393/ac.2014.30.1.35] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 11/04/2013] [Indexed: 10/27/2022] Open
Abstract
PURPOSE A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF. METHODS The outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed. RESULTS The causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion. CONCLUSION Depending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.
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Affiliation(s)
- Ji Hye Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Geon Jeon
- Department of Surgery, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sang-Gi Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eon Chul Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heon-Kyun Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Department of Surgery, MyongJi Hospital, Seoul, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Kyung Choe
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Sang Hui Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Ali A, Tewari A. Radical Surgery. Prostate Cancer 2014. [DOI: 10.1002/9781118347379.ch8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Beddy D, Poskus T, Umbreit E, Larson DW, Elliott DS, Dozois EJ. Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula. Colorectal Dis 2013; 15:1515-1520. [PMID: 23841640 DOI: 10.1111/codi.12350] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 05/20/2013] [Indexed: 02/08/2023]
Abstract
AIM Most patients presenting with rectourethral fistula acquire it as a complication of radiotherapy for prostate cancer, as a result of injury to the rectum during prostatectomy, through trauma or from Crohn's disease. This study examined whether choice of operation and results of surgery for rectourethral fistula are influenced by prior radiotherapy. METHOD Male patients undergoing surgery for rectourethral fistula were identified from a prospectively maintained database. Data regarding aetiology, surgical treatment and outcomes were analysed. RESULTS Fifty patients (median age = 65.5 years) were identified. Radiation was received by 29 patients for prostate or rectal cancer, and 21 patients developed a fistula following prostatectomy, Crohn's disease or pelvic fracture (without radiation). Prior to definitive surgery, 30 patients underwent fecal diversion and 37 underwent urinary diversion. In total, 57 repairs were performed (44 patients had one repair, five patients had two and one patient had three). Definitive surgery was approached predominantly abdominally in radiated patients (90.6 vs 9.3%, P < 0.001) and perineally in nonradiated patients (80 vs 20%, P < 0.001). Successful primary fistula repair was more frequent in the nonradiated group compared with the radiated group (80.9 vs 0%, P < 0.001). Permanent colostomy and urinary diversion were more often required in radiated patients than in nonradiated patients (colostomy: 83 vs 0%, P < 0.001; urorostomy: 100 vs 19%, P < 0.001). CONCLUSION Few patients with radiation-induced rectourethral fistula avoid permanent colostomy and urostomy. In contrast, most patients with nonradiation-related fistulae undergo successful perineal repair without permanent faecal and urinary diversion.
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Affiliation(s)
- D Beddy
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Linder BJ, Umbreit EC, Larson D, Dozois EJ, Thapa P, Elliott DS. Effect of Prior Radiotherapy and Ablative Therapy on Surgical Outcomes for the Treatment of Rectourethral Fistulas. J Urol 2013; 190:1287-91. [DOI: 10.1016/j.juro.2013.03.077] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Affiliation(s)
| | | | - David Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Eric J. Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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Nfonsam VN, Mateka JJ, Prather AD, Marcet JE. Short-term outcomes of the surgical management of acquired rectourethral fistulas: does technique matter? Res Rep Urol 2013; 5:47-51. [PMID: 24400234 PMCID: PMC3826856 DOI: 10.2147/rru.s28002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acquired rectourethral fistulas are uncommon and challenging to repair. Most arise as a complication of prostate cancer treatment. Several procedures have been described to repair rectourethral fistulas with varying outcomes. We review the etiology, management, and outcomes of patients with rectourethral fistulas at our institution. MATERIALS AND METHODS A retrospective review of patients undergoing repair of rectourethral fistulas was undertaken. Data were collected on patient demographics, fistula etiology, operative procedure, fecal and urinary diversion, and clinical outcome. Patients with urinary and/or fecal diversion underwent radiographic evaluation to confirm closure of the fistula prior to reversal of the diversion. RESULTS Fistula repair was performed on 22 patients from 1999 to 2009. All the patients were male of an average age of 69 years (range: 39-82 years). All patients, except one, had prostate cancer. Fistula formation was associated with radiotherapy in 54.4% of patients, brachytherapy in 36.4% of patients, and with external beam radiation therapy in 18.2% of patients. Other causes included prostatectomy (seven patients, 31.8%), cryotherapy (two patients, 9.1%), and perianal abscess (one patient, 4.5%). Procedures performed for fistula repair included transanal repair (eleven patients, 50%), transperineal repair (five patients, 22.7%), transabdominal repair (three patients, 13.6%), and York-Mason repair (three patients, 13.6%). Fourteen patients (63.6%) had urinary diversion. Fecal diversion was performed in 16 (72.7%) patients. Five (22.7%) patients had had previous attempts at fistula repair. Of the 22 patients treated, repair was successful in 20 patients (91%). The average follow-up time was 6 months (range: 3-13 months). CONCLUSION The success rate of treatment of rectourethral fistulas is high, regardless of the procedure type. Patients with previous repair attempts tend to have less favorable outcomes. With high success rates, less invasive procedures should be attempted first.
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Affiliation(s)
- Valentine N Nfonsam
- Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - James Jl Mateka
- Department of Surgery, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Andrew D Prather
- Department of Surgery, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jorge E Marcet
- Department of Surgery, College of Medicine, University of South Florida, Tampa, FL, USA
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Abdou AH, Troja A, Raab HR, Antolovic D. Feasibility of Gracilis Muscle Flap Interposition for Management of Recurrent Rectovesical/Rectourethral Fistulas: A Single Centre Expertise. Visc Med 2013. [DOI: 10.1159/000354775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background: </i></b>Recurrent rectovesical fistulas are a serious burden for the affected patient. Depending on the size and location of the fistula, the underlying disease as well as the preceding therapies, a definitive surgical treatment of the fistula should be the main goal. We analysed the technique of the transposition of the gracilis muscle as a therapeutical option. <b><i>Methods: </i></b>We analysed data from 3 male patients who were diagnosed with a recurrent rectovesical fistula and were treated by the transposition of the gracilis muscle in the surgical department of Klinikum Oldenburg. <b><i>Results: </i></b>All 3 patients suffered from prostate cancer and were already treated by a different surgical approach while one patient had a second recurrence. Complications arose in two cases in the form of fistula recurrence. <b><i>Conclusion: </i></b>Our study has shown that the interposition of the gracilis muscle provides an option to treat rectovesical fistulas.
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Evaluation and Management of Rectourethral Fistula Following Radiation Treatment for Prostate Cancer. CURRENT BLADDER DYSFUNCTION REPORTS 2012. [DOI: 10.1007/s11884-012-0154-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Blumetti J, Chaudhry V, Prasad L, Abcarian H. Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer. Colorectal Dis 2012; 14:1238-41. [PMID: 22229958 DOI: 10.1111/j.1463-1318.2012.02932.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AIM Anastomotic leakage is a feared complication of colorectal surgery and can be devastating in low pelvic anastomosis. With the advent of nonoperative treatments for leakage, the question of management of persistent low colorectal and coloanal anastomosis arises. A review of patients who have undergone transanal repair of anastomotic leakage is presented. METHOD A review of all anastomoses performed in the Division of Colorectal surgery at two institutions, from January 2000 to June 2008, was performed. Anastomotic leakage was defined as the finding at reoperation of a dehiscence, or radiographic findings of extravasation from the anastomosis, or the identification of intra-abdominal abscess formation at the site of the anastomosis, enterocutaneous fistula or rectovaginal fistula. Patients who underwent transanal repair of the leakage were identified. RESULTS There were 663 low anterior resections performed during the study period. Of these, 36 experienced leakage of a low colorectal or coloanal anastomosis. Of these 36 patients, five underwent transanal repair of the anastomotic leak. All had had a low anterior resection for rectal cancer (coloanal=4; low colorectal anastomosis=1). Four had had prior chemoradiation and ileostomy defunctioning at the initial operation. The fifth had an ileostomy created to treat a leak. Six transanal repairs were performed, including endorectal advancement flap (n=3), dermal flap (n=1), direct suture repair (n=1) and debridement of an infected cavity (n=1). At the time of the present assessment, four patients had undergone reversal of ileostomy after radiographic evidence of complete healing and the fifth patient has a persistent leak. CONCLUSION Transanal repair of a persistent low colorectal or coloanal anastomotic leakage is feasible in selected cases, even when chemoradiation has been performed.
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Affiliation(s)
- J Blumetti
- Division of Colon and Rectal Surgery, Stroger Hospital of Cook County, Chicago, IL 60612, USA.
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Complications after radical prostatectomy: anastomotic stricture and rectourethral fistula. Curr Opin Urol 2012; 21:461-4. [PMID: 21934623 DOI: 10.1097/mou.0b013e32834b7e1b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW With the discovery of prostate-specific antigen and routine prostate cancer screening, came a renewed interest in the radical prostatectomy. As a result of early detection, the majority of prostate cancer is of low risk placing more emphasis on the social consequences of the surgery such as urinary incontinence, anastomotic contracture, erectile dysfunction and rectourethral fistula (RUF) formation. This review is specifically focused on the current approaches to anastomotic stricture and RUF following radical prostatectomy. RECENT FINDINGS A subset of anastomotic contractures following radical prostatectomy are recurrent and refractory to standard endoscopic therapy. Previous enthusiasm for permanent urethral stents has been dissipated by long-term results showing high revision and complication rates. In an attempt to avoid permanent urethral stents, new adjunctive agents are being used in combination with urethrotomy to achieve a stable, bladder neck anastomosis. There has been a major shift in the cause of RUF from primarily surgical to approximately 50% resulting from radiation/ablation therapy. Surgically induced RUF typically are small, located in bladder neck/trigonal region and can be primarily closed. Radiation/ablation induced fistula are large (>2 cm), involve the prostatic urethra and are fibrotic often requiring a combination of onlay grafting and interposition muscle flap for closure. The anterior, perineal sphincter-sparing approach is the optimal approach for closure of all RUF (simple or complex). SUMMARY Recent advancements in these two challenging patient populations have allowed reconstructive urologists to remain committed to rehabilitating the lower urinary tract avoiding palliative maneuvers and often-unnecessary urinary and fecal diversion.
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Amar AHY, Kim SH, Cho JS, Kang SH. Urethro-anastomotic fistula caused by manual digital dilatation of low rectal anastomotic stricture successfully managed by prostatectomy: a case report. Colorectal Dis 2011; 13:e418-9. [PMID: 21819520 DOI: 10.1111/j.1463-1318.2011.02746.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- A H Y Amar
- Colorectal Division, Department of Surgery, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
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Nerli R, Amarkhed SS, Hiremath MB. Vascularized tunica vaginalis interposition flap for the treatment of recto-urethral fistulas. Indian J Urol 2011; 25:467-9. [PMID: 19955669 PMCID: PMC2808648 DOI: 10.4103/0970-1591.57914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Recto-urethral fistula is a rare complication of pelvic surgery, trauma, or inflammation. The many techniques for repairing these fistulas vary in their success rates. We describe the use of vascularised tunica vaginalis flap interposition in the repair of a recto-urethral fistula. Materials and Methods: Three children who had developed rectourethral fistula following surgery for anorectal anomaly/Hirschsprungs disease underwent repair through the perineal approach and interposition of vascularised tunica vaginalis flap in between the rectum and the urethra. Results: Three patients, all males aged 6 to 14 years old, presented with passage of urine per rectum following surgery. Following repair of the recto-urethral fistula, there was no recurrence of fistula in the follow-up period ranging from 1 to 6 years. Conclusions: Vascularised tunica vaginalis flap interposition is a straight-forward technique that can result in successful fistula repair.
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Affiliation(s)
- Rajendra Nerli
- Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital & MRC, Nehru Nagar, Belgaum 590 010, India
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