[Fistulas of the urogenital tract after radiotherapy]

Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases

PURPOSE

Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies.

METHODS

A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula.

RESULTS

A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1).

CONCLUSION

Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.

[High urinary diversion after irradiation to the lesser pelvis]

As useful and necessary as radiotherapy may be, it is associated with irreversible long-term adverse effects including loss of bladder function. In the majority of cases the small bowel, sigmoid rectum and ureter are also affected. The extent of injury depends on the irradiated area, the applied dose and the quality of application. Three factors are essential when choosing a urinary diversion: the length of functional ureter, the position of the bowel outside of the irradiated area and the type of diversion. A continent diversion is best performed through a ascending-transverse or transverse-descending colon pouch. The efferent segment is diverted through the umbilicus. The simplest technique for an incontinent diversion is a conduit using the ascending colon or the right colon flexure. If the length of the ureter does not suffice for such a conduit, the ideal solution is a transverse conduit, as this conduit can be attached to both renal pelves, while simultaneously allowing free choice of the lateral location of the stoma. In case of an exenteration, a double stoma on one side of the body should be avoided in order to prevent maintenance issues.