Staging rectourinary fistulas to guide surgical treatment

[Rectourethral fistula treatment using the modified York Mason technique: Failure factors assessment]

OBJECTIVES

To assess surgical outcomes and failure factors in the management of rectourethral fistulas treated surgically with the modified York Mason technique based on our center's 25 years of experience.

METHODS

From 1997 to 2021, in a single center study, a total of 35 consecutive patients, underwent rectourethral fistula cure, using the modified York Mason technique. Preoperative patient data, surgical outcomes and failure factors were assessed.

RESULTS

Of the 35 patients, 28 were successfully managed without the need of further intervention (80%). Median age was 67 years (IQR 62-72) and median follow-up time was 71 months (IQR 30-123). There was no significant difference between the patients that had recurrence or not after the first York Mason.

CONCLUSIONS

The modified York Mason technique offers a high success rate for the cure of iatrogenic rectourethral fistulas. No predictive factor of failure, after a first cure of recto-uretral fistula by modified York-Mason technique was reported.

LEVEL OF EVIDENCE

3.

Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

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.

Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

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.

Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes

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.

Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas

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.

Transsphincteric repair of rectourethral fistulas: 15 years of experience with the York Mason approach

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.

Perineal approach for rectourethral fistulae after radical laparoscopic prostatectomy

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.

Intersphincteric approach for rectourethral fistulas following radical prostatectomy

BACKGROUND

Rectourethral fistula is a challenging complication of radical retropubic prostatectomy. Several treatments have been proposed, with varying outcomes. The available data are difficult to interpret, because patient and disease characteristics differ significantly among reports. Details of long-term follow-up and functional status are rarely provided. We describe a technique of rectourethral fistula repair via an intersphincteric route.

METHODS

Preoperative workup included proctoscopy and urethrocystography. All patients already had a stoma at the time of fistula repair. Mechanical cleansing of the bowel distal to the colostomy was routinely performed, and perioperative antibiotic prophylaxis was administered. Patients were placed in the lithotomy position. Under spinal anesthesia, a curvilinear anteanal incision was made, to expose the external sphincter. The anterior portion of the external sphincter was gently displaced along half of its circumference. The anterior rectal wall was sharply dissected free from the urethra, approximately up to 2 cm above the fistula level through the intersphincteric plane. The fistula was identified. The surrounding tissues were mobilized to obtain a tension-free repair of the urethral defect, using a single row of 4-0 polyglactin transverse, interrupted sutures. Transanally, a U-shaped full-thickness rectal flap was advanced and sutured with 3-0 monofilament interrupted sutures to cover the rectal opening, and care was taken to ensure that the two suture lines were in different planes. The catheter was left in place for 4 weeks. Patients were evaluated at 3-month follow-up for stoma closure.

RESULTS

We successfully treated five patients. Only one minor complication was observed (surgical site infection). Stomas were taken down uneventfully. After a median follow-up duration of 2 years (range 2-3 years), no patients had fistula recurrence or impaired continence.

CONCLUSIONS

Intersphincteric repair should be considered as an effective option in patients with iatrogenic rectourethral fistulas. This technique offers several advantages over alternative procedures that require more extensive approaches or invasive manipulation of the anal sphincters.

Acquired recto-uretral fistulas: etiopathogenesis, diagnosis and therapeutic options

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.

[Management of rectourethral fistulas with the York Mason procedure: surgical techniques and outcomes]

OBJECTIVE

To report our experience for the management of urethro-rectal fistula by the York Mason technique.

PATIENTS AND METHODS

We retrospectively analyzed the data of patients treated surgically for FUR by the technique of York Mason, between 2000 and 2012.

RESULTS

Seventeen patients were included in the study. All patients had a bowel diversion before surgery. We observed four recurrences of FUR (23.5%). Recurrences occurred in a radiation field for two patients and in a oncologic recurrence for 1 patient. The fourth recurrence was treated by a second procedure of York Mason successfully.

CONCLUSION

In our study, the York Mason technique was safe and reproducible for the treatment of FUR. The main factor of failure was a history of pelvic radiotherapy.

Surgical Treatment of Iatrogenic Rectourinary Fistula-York-Mason Technique-a Case Report

Introduction. Recto-urinary fistulas resulting from trauma or surgery are a serious and debilitating complication. They represent a challenge not only because of the difficulty on choosing the best technique to solve them but also because of the risk of recurrence. Spontaneous cure is rare. Materials and Methods. We describe the case of a 61-years-old man that on the 9th postoperative day of a laparoscopic radical prostatectomy (LRP) started with fecaluria and liquid faeces. Recto-urinary fistula was confirmed at the 10th postoperative day by CT scan and contrast enema. Discussion. We chose the York-Mason technique, because it is simple to perform, effective and has minimal morbidity. This is a posterior, transrectal, and transsphincteric approach, carried out on healthy tissues without previous scarring phenomena. Results. The postoperative period progressed without complications, and the patient discharged on the 4th day. The closure of the fistula was confirmed radiologically by retrograde cystography after 4 weeks allowing the removal of drainage catheter. The reconstruction of intestinal transit was carried out 2 months later. Conclusion. The York-Mason technique, a transrectal and transsphincteric approach with minimal morbidity, proved to be effective on the resolution of the recto-urinary fistula, a rare complication of the radical prostatectomy.

York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience

OBJECTIVE

To review the use of the York-Mason transanal, transrectal procedure, used in properly selected patients over a 40-year period, for repairing recto-urinary fistulae.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all patients who underwent acquired recto-urethral or rectovesical fistula repair at our institution. A total of 51 patients have undergone York-Mason recto-urinary fistula repair at our institution during this time.

RESULTS

Since our last report in 2003, we have performed this procedure an additional 27 times. We continue to have good results, with 25 of these patients having resolution of their fistulae after one procedure. Failures in the updated cohort were radiation-induced fistulae. We continue to find no evidence of faecal incontinence or stenosis after this procedure.

CONCLUSIONS

Over a period of 40 years, the York-Mason posterior, transanal, transrectal correction of iatrogenic recto-urinary fistula has been highly successful, reliable and safe, when used for fistulae occurring after prostate surgery. Preliminary faecal diversion can often be avoided in selected patients.

Outcome of a modified York Mason technique in men with iatrogenic urethrorectal fistula after radical prostatectomy

BACKGROUND

Urethrorectal fistula formation is a rare but devastating complication after radical prostatectomy. Reconstructive surgery is usually required, and one surgical option is the York Mason procedure.

OBJECTIVE

We present our experience with a modified York Mason technique for the surgical management of urethrorectal fistula.

DESIGN

Retrospective review of medical records.

SETTING

Tertiary care university medical center.

PATIENTS

Consecutive male patients with urethrorectal fistula due to radical prostatectomy who underwent York Mason repair between 1998 and 2009.

INTERVENTION

All patients initially received both a urinary and a bowel diversion as the first step of the treatment. The second step consisted of a modification of the York Mason technique in which the approach began with a parasacrococcygeal incision extending from the coccyx to the anal verge.

MAIN OUTCOME MEASURES

All patients were seen 3, 6, and 12 months after surgery and yearly thereafter to assess the resolution of clinical functional disorders and the Wexner fecal incontinence score.

RESULTS

The study included 10 men with a mean age of 63.7 (range, 50-80) years who had urethrorectal fistula after open retropubic prostatectomy (n = 6) or after laparoscopic prostatectomy (n = 4). Confined prostate cancer (pT2) was found in 7 patients and extracapsular extension of the tumor (pT3) in 3 patients. Urethrorectal fistula was discovered because of fecaluria in 6 patients and pneumaturia in 6. The mean time from surgery to York Mason repair was 15 (range, 4-42) months. Five patients had each previously undergone 1 unsuccessful repair procedure. The mean operative time was 81 (range, 60-130) minutes and the mean hospital stay was 6 days. No fecal incontinence or anal stenosis developed after York Mason repair. No recurrence of urethrorectal fistula occurred during a mean follow-up of 24 (range, 18-38) months.

LIMITATIONS

Lack of objective fecal continence data.

CONCLUSIONS

: York Mason repair appears to be a safe and effective approach for management of urethrorectal fistula. The rates of fistula closure and symptom resolution are encouraging, and patients show rapid postoperative recovery with minimal morbidity. Thus, York Mason repair should always be considered for treatment of urethrorectal fistula after radical prostatectomy.

Urinary tract injures: recognition and management

Iatrogenic injury to the urinary tract during colorectal surgery can be a source of significant morbidity. Although most cases of ureteral injury occur in patients without significant risk factors, the incidence of urinary tract injuries increases in patients with prior pelvic operations, inflammatory bowel disease, infection, and in patients with extensive neoplasms causing distortion of normal surgical planes. The most commonly injured locations are the ureter, bladder, and urethra. Mechanisms of injury include ligation, transection, devascularization, and energy induced. Early identification of urinary tract injuries is paramount in minimizing morbidity and preservation of renal function. Anatomic considerations for preventing injuries, diagnostic techniques for localizing and staging injuries, as well as reconstructive techniques and principles of repair are discussed.

Rectourinary fistula after radical prostatectomy: review of the literature for incidence, etiology, and management

Although rectourinary fistula (RUF) after radical prostatectomy (RP) is rare, it is an important issue impairing the quality of life of patients. If the RUF does not spontaneously close after colostomy, surgical closure should be considered. However, there is no standard approach and no consensus in the literature. A National Center for Biotechnology Information (NVBI) PubMed search for relevant articles published between 1995 and December 2010 was performed using the medical subject headings “radical prostatectomy” and “fistula.” Articles relevant to the treatment of RUF were retained. RUF developed in 0.6% to 9% of patients after RP. Most cases required colostomy, but more than 50% of them needed surgical fistula closure thereafter. The York-Mason technique is the most common approach, and closure using a broad-based flap of rectal mucosa is recommended after excision of the RUF. New techniques using a sealant or glue are developing, but further successful reports are needed.

[Treatment of a rectourethral fistula after radical prostatectomy by York Mason posterior trans-sphincter exposure]

INTRODUCTION

Recto-urethral fistula is an uncommon complication after radical prostatectomy, occurring in less than 2% of patients. Our aim is to review our experience for repairing these fistulas with the posterior trans-sphincter approach of York Mason.

PATIENTS AND METHOD

Retrospective review. All patients who underwent repair of postoperative recto-urethral fistula in our unit were included. The procedure described by York Mason was performed in all cases.

RESULTS

During the last 6 years, 5 patients with recto-urethral fistulas after radical prostatectomy were repaired by using this method. Symptoms, including faecaluria and/or passing of urine via the anus, appeared between the postoperative day 4 and 7 weeks after surgery, and confirmation was obtained by cystography. Initial faecal diversion with sigmoid loop colostomy was performed in 3 cases, whereas in the other 2 patients a loop ileostomy was performed at the time of surgical repair. The posterior trans- sphincter approach and fistula repair was performed between 5 and 10 months after diagnosis. Morbidity included wound infection in 2 cases and skin dehiscence in another 2 patients. Successful fistula closure was achieved in all cases with complete faecal continence. No recurrence has been observed after a mean follow-up of 22 (4-40) months.

CONCLUSIONS

The posterior trans-sphincter approach of York Mason is effective for the repair of recto-urethral fistulas after radical prostatectomy with minor morbidity and no impairment of continence.

Rectal injury during laparoscopic radical prostatectomy: detection and management

Among 294 patients who underwent laparoscopic radical prostatectomy (LRP), five (1.7%) developed complications such as rectal injury (RI) and rectourethral fistula (RUF). In four patients, the RI was immediately repaired by placing two layers of uninterrupted sutures without fecal diversion. The RI in two of these four patients were diagnosed using a transrectally inserted Hegar uterine dilator (26 mm). The remaining patients, who presented with RUF as the primary manifestation, were conservatively managed, and the fistulas closed spontaneously. Most of the RI detected during the operation were managed with primary fistula closure without fecal diversion. In some cases of postoperative RUF, spontaneous closure may occur while the patient is waiting for surgical repair.

Modified York-Mason technique for repair of iatrogenic rectourinary fistula: the montsouris experience

PURPOSE

Rectourinary fistula is a devastating complication of rectal and genitourinary surgery. Spontaneous closure is rarely successful and failure in conservative management calls for surgical intervention. We present our experience with rectourinary fistula repair using a modified York-Mason technique.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of all 12 patients who underwent modified York-Mason repair at our institution between 1998 and 2008. Rectourinary fistula developed in 10 patients after radical prostatectomy and in 2 following high intensity focused ultrasound. Six patients were initially treated with fecal diversion. Our approach begins with a transanal incision at the 2 o'clock position representing a modification of the classically described midline incision extending from the coccyx to the anal verge. Key aspects of the York-Mason procedure are maintained. However, we do not close the urethra after fistula excision, and instead perform a multilayer, nonoverlapping closure of the anterior rectal wall only.

RESULTS

With a median followup of 22 months we observed the complete resolution of rectourinary fistula in all 12 patients. Three patients required multiple York-Mason procedures to achieve resolution of symptoms. All patients reported intact fecal continence. Median operative time and estimated blood loss were 63 minutes and 100 ml, respectively. Median hospital stay was 4 days.

CONCLUSIONS

Our modified York-Mason technique is safe and effective for the repair of small, iatrogenic rectourinary fistula. We report 75%, 92% and 100% rectourinary fistula resolution after 1, 2 and 3 York-Mason procedures, respectively, with 100% fecal continence. This technique can be performed multiple times without a significant increase in operative time, estimated blood loss or fecal incontinence.