Transperineal repair of complex rectourethral fistula using gracilis muscle flap interposition--can urinary and bowel functions be preserved?

Lower partial pubicectomy for postoperative complicated posterior urethral stricture

OBJECTIVE

To report the experience of partial inferior pubicectomy in the treatment of complex posterior urethral stricture after trauma.

METHODS

A total of 46 patients with post-traumatic posterior urethral stricture admitted to the Department of Urology of our Hospital from January 2013 to September 2021 were selected as the research objects and underwent urethroplasty (including nine patients who had failed previous perineal repair surgery and adopted partial inferior pubicectomy approach). Retrograde urethrograph (RUG) and urine flow measurement were performed at 1, 3, 12 and 18 months after operation, and follow-up was performed when necessary. The clinical data during treatment were statistically analyzed.

RESULTS

All 46 patients underwent urethroplasty successfully, of which nine were treated with partial pubicectomy, accounting for 19.57% of the total. The causes of the disease were motor vehicle accident in 4 cases, falling collision injury in 2 cases, and rolling injury of military exercise tank in 3 cases. Among the 9 patients, 2 were children (22.22%), aged 8 and 12 years, and 7 were adults (77.78%), aged 19-44 (28.42 ± 1.56) years. Among the 9 patients, 6 had erectile dysfunction, accounting for 66.67%. The length of posterior urinary tract stenosis was (5.12 ± 0.57) cm. The operation time was (290.34 ± 12.35) min from anesthesia induction to skin closure. Five patients received 2 U blood transfusion during operation and three patients received 3 U blood transfusion after operation. The average hospital stay was 12-16 (14.24 ± 1.25) days, and the follow-up was 12-24 (18.24 ± 1.35) months. After surgery, one patient developed HIP abscess, which was successfully treated conservatively. One patient had dysuria 1 month after operation and was successfully treated by transurethral dilatation. One case had postoperative infection and recovered after intravenous administration of potent antibiotics. Cystourethrography was performed 3 months after operation, and there was no difference between patients with wide, long or short anastomotic stretch defects. All patients met the criteria for surgical success.

CONCLUSION

Partial inferior pubicectomy is a good surgical procedure for the repair of complicated posterior urethral stricture after operation. It is safe and reliable, can better display the prostatic apex and surgical field, shorten the length of reconstructed urethra, and has good postoperative effect. It has no direct or long-term effect on the stability of pelvis or bladder. However, further studies in a larger cohort of patients with complex posterior urethral strictures after repair are needed to demonstrate the specific indications for partial pubicectomy.

Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review

BACKGROUND

First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review.

METHODS

A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure.

RESULTS

Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%).

CONCLUSION

Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer

BACKGROUND

Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment.

METHODS

This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications.

RESULTS

This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008).

CONCLUSIONS

Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Postintervention Quasi-Experimental Study

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 ).

Rectourethral Fistula Induced by Localised Prostate Cancer Treatment: Surgical and Functional Outcomes of Transperineal Repair with Gracilis Muscle Flap Interposition

BACKGROUND

Transperineal repair of rectourethral fistula (RUF) following prostate cancer treatment with gracilis muscle flap interposition (GMFI) leads to favourable outcomes, but published data are still lacking, notably concerning functional aspects.

OBJECTIVE

To assess surgical and functional outcomes of this treatment of RUF.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted in two referral hospitals including 21 patients who underwent RUF transperineal repair with GMFI between 2008 and 2020.

SURGICAL PROCEDURE

The standard vertical perineal approach is performed for fistula dissection. Bladder and rectal defects are closed separately. After dissection from its facia, the flap is harvested, preserving its pedicle; it is brought to the perineum and placed between the urethra and the rectum to fully cover the sutures.

MEASUREMENTS

Fistula closure (clinical data and postoperative cystography), digestive stoma closure, and complications graded according to the Clavien-Dindo classification were reviewed. Functional results were assessed using the Urinary Symptom Profile (USP) questionnaire, anal incontinence St Mark's score, Patient Observer Scar Assessment Scale (POSAS) score, and a nonvalidated Likert scale questionnaire assessing issues with lower extremity functionality.

RESULTS AND LIMITATIONS

The median (interquartile range) follow-up was 27 (8-47) mo. Fistula closure was successful for 20 patients (95% success). Digestive stoma was closed in 10/12 shunted patients (83%). Two (9%) Clavien-Dindo grade ≥3b complications were reported (one urinoma in a kidney transplant patient and one thigh haematoma evacuation). Eighteen patients (86%) completed the postoperative questionnaire; 11/18 (61%) had significant urinary incontinence. The mean (standard deviation) USP dysuria score was 1/9 (1.2), mean St Mark's score was 5/24 (5), mean POSAS score was 19/70 (11), mean lower extremity functionality score was 2/20 (4), and mean procedure patient satisfaction score was 9/10 (2). The retrospective design and limited number of patients are the main limitations.

CONCLUSIONS

The present study found an excellent success rate and low morbidity for RUF transperineal repair with GMFI. Functional outcomes were satisfactory despite a high urinary incontinence rate.

PATIENT SUMMARY

We performed an analysis of the outcomes of perineal approach surgery with muscle interposition for closing abnormal communication between the bladder and the rectum after prostate cancer treatment. This surgical technique was found to be safe to perform and provides a high success rate, with patients being satisfied despite poor urinary continence outcomes. TAKE HOME  MESSAGE: Transperineal repair of rectourethral fistula with gracilis muscle flap interposition is a safe surgery with a high success rate. Urinary continence is a serious issue, but patients may be reassured as to the impact on digestive continence, lower extremity functionality, and scar aesthetics.

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.

Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair

INTRODUCTION

Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis.

METHOD

We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail.

RESULTS

Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula.

DISCUSSION

The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access.

CONCLUSION

Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

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.

Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series

INTRODUCTION

Iatrogenic recto-urogenital fistulae are refractory complications that rarely heal without surgical intervention. The ongoing local infection causes pain, discomfort and substantially impacts quality of life. Surgical repair requires adequate exposure and space to fill with healthy tissue, which is a major challenge in pelvic redo surgery. An abdominal approach to repair the fistula is associated with major morbidity and often fails to expose the deep pelvis. In our experience a novel transperineal minimally invasive approach a utilizing single incision laparoscopic surgery (SILS) technique could offer improved results.

PRESENTATION OF CASES

In the present study, three cases of patients with recto-urogenital fistulae after pelvic surgery are described. Two patients were diagnosed with a rectovesical fistula and one patient with a rectovaginal fistula. In all three cases, a minimally invasive perineal approach, using a SILS port, was used to perform surgical repair. The closure of the fistulae involved: a separate repair of the urethra/bladder or vaginal defect and the rectal defect, followed by interposition of vascularized tissue by either a pudendal thigh fasciocutaneous flap or omentoplasty.

DISCUSSION AND CONCLUSION

This study is the first to report on a minimally invasive perineal approach, utilizing a SILS technique for recto-urogenital fistulae repair after previous pelvic surgery. The current approach improves exposure, creates surgical space, optimizes view and allows the interposition of vascularized tissue, without causing substantial blood loss and avoiding major abdominal surgery.

Recurrent rectourethral fistula repair: A novel technique of gracilis muscle interposition

BACKGROUND

A perineal approach with gracilis muscle interposition (GMI) remains the most common in recurrent rectourethral fistulas (RUFs). The closure failures in10%-20% cases and urinary incontinence in 10%-80% cases referred to the disadvantages of the perineal approach owing to neurovascular damage. This article shows that the retraction of a survived muscle gracilis flap is one of the causes of fistula recurrence, and a simpler technique of the flap interposition is presented, requiring a less invasive perineal access.

METHODS

Three consecutive patients with RUF at the age of 5, 13 and 15 years who underwent multiple (3, 4 and 5) unsuccessful reconstructive attempts were referred to our clinic. The last procedure was performed with GMI. In all cases, these were acquired iatrogenic fistulas that occurred after operations for Hirschsprung's disease (2) or anorectal malformation (1), and subsequent dilatation of the anus. All patients had a colostomy several years ago. Reinterposition and distant anchoring of the survived graсilis flap were performed through the perineal approach, avoiding lateral and anterolateral dissection.

RESULTS

The early postoperative period was uneventful. In one patient, a stricture of the posterior urethra formed. Urethrotomy was performed in 3 months, with complete restoration of micturition. The colostomy was closed in all patients after 3-4 months. In the long term follow up within 4-8 years, no fistula recurrence was noted.

CONCLUSIONS

The suggested traction technique of GMI allowed: to minimize the perineal access size, hence minimizing the injury and the operating time; to place the anchoring suture outside of the inflammation zone, ensuring secure attachment; to provide precise flap positioning and intimate contact between the flap and the urethra.

LEVEL OF EVIDENCE

Level V.

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.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

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.

[Fistula surgery]

Vesicovaginal fistulas are a rare problem in the western world but are frequent occurrences in developing countries. In Germany the most frequent cause is hysterectomy. Vesicovaginal fistulas can be treated by the transvaginal or transabdominal approach depending on the characteristics of the fistula and the patient. The incidence and complexity of urorectal fistulas increase with the number of cumulative sequences of prostate cancer treatment. Overall there is no clear consensus about the optimal surgical approach route. The surgical treatment of both vesicovaginal and urorectal fistulas is associated with high permanent fistula closure rates; however, for both entities if the fistula is discovered early enough, conservative treatment with a temporary catheter drainage can be tried, depending on the underlying cause. For both conditions fistula repair in irradiated patients shows a much lower success rate. A spontaneous closure of fistulas in radiogenic fistulas is also not to be expected.

Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas

AIM

Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients.

METHOD

The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination.

RESULTS

The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction.

CONCLUSION

GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.

Repair of recto-urethral fistula with urethral augmentation by buccal mucosal graft and gracilis muscle flap interposition - our experience

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.

Management of acquired rectourethral fistulas in adults

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.

Posterior Urethroplasty Complexity and Prognosis Can be Described by a Novel Method: Posterior Urethral Stenosis Score

OBJECTIVE

To develop a standardized PU-score (posterior urethral stenosis score), with the goal of using this scoring system as a preliminary predictor of surgical complexity and prognosis of posterior urethral stenosis.

PATIENTS AND METHODS

We retrospectively reviewed records of all patients who underwent posterior urethral surgery at our institution from 2013 to 2015. The PU-score is based on 5 components, namely etiology (1 or 2 points), location (1-3 points), length (1-3 points), urethral fistula (1 or 2 points), and posterior urethral false passage (1 point). We calculated the score of all patients and analyzed its association with surgical complexity, stenosis recurrence, intraoperative blood loss, erectile dysfunction, and urinary incontinence.

RESULTS

There were 144 patients who underwent low complexity urethral surgery (direct vision internal urethrotomy, anastomosis with or without crural separation) with a mean score of 5.1 points, whereas 143 underwent high complexity urethroplasty (anastomosis with inferior pubectomy or urethrorectal fistula repair, perineal or scrotum skin flap urethroplasty, bladder flap urethroplasty) with a mean score of 6.9 points. The increase of PU-score was predictive of higher surgical complexity (P = .000), higher recurrence (P = .002), more intraoperative blood loss (P = .000), and decrease of preoperative (P = .037) or postoperative erectile function (P = .047). However, no association was observed between PU-score and urinary incontinence (P = .213).

CONCLUSION

The PU-score is a novel and meaningful scoring system that describes the essential factors in determining the complexity and prognosis for posterior urethral stenosis.

Experience with 32 Pelvic Fracture Urethral Defects Associated with Urethrorectal Fistulas: Transperineal Urethroplasty with Gracilis Muscle Interposition

PURPOSE

Pelvic fracture urethral defects associated with urethrorectal fistulas are rare and difficult to repair. The aim of this study was to evaluate the efficacy of transperineal urethroplasty with gracilis muscle interposition for the repair of pelvic fracture urethral defects associated with urethrorectal fistulas.

MATERIALS AND METHODS

We identified 32 patients who underwent transperineal urethroplasty with gracilis muscle interposition to repair pelvic fracture urethral defects associated with urethrorectal fistulas. Patient demographics as well as preoperative, operative and postoperative data were obtained.

RESULTS

Mean followup was 33 months (range 6 to 64). The overall success rate was 91% (29 of 32 cases). One-stage repair was successful in 17 of 18 patients (94%) using perineal anastomosis with separation of the corporeal body and in 12 of 14 (86%) using perineal anastomosis with inferior pubectomy and separation of the corporeal body. All 22 patients (100%) without a previous history of repair were successfully treated. However, only 7 of 10 patients (70%) with a previous history of failed urethroplasty and urethrorectal fistula repair were cured. Recurrent urethral strictures developed in 2 cases. One patient was treated successfully with optical internal urethrotomy and the other was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent urethrorectal fistulas associated with urethral strictures developed in an additional patient.

CONCLUSIONS

Transperineal urethroplasty with gracilis muscle interposition is a safe and effective surgical procedure for most pelvic fracture urethral defects associated with urethrorectal fistulas. Several other factors may affect its postoperative efficiency.

Rectourethral Fistula Management

Rectourethral fistula (RUF) is a rare condition that occurs, in most cases, as a consequence of prostate cancer treatments. Clinical suspicion and proper assessment prior to surgery are essential to adapt and successfully carry out an appropriate treatment plan. There are no randomized trials to guide clinical practice, and therefore, scientific evidence in this respect is limited. Expert recommendations seem to agree on the transperineal approach with flap interposition as the surgical treatment of choice in cases of complex fistulas, especially in those that have undergone prior radiation. Undoubtedly, the key to the successful treatment of the disease is the multidisciplinary and standardized management by physicians with experience in the field.

Minimally Invasive Transanal Repair of Rectourethral Fistulas

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.

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.

Algorithm-based multidisciplinary treatment approach for rectourethral fistula

PURPOSE

The purpose of this study is to report the outcomes of an algorithm-based multidisciplinary treatment approach to rectourethral fistula.

METHODS

This study is a retrospective review of a prospectively collected database at a tertiary center of all consecutive patients treated between 2003 and 2013.

RESULTS

Thirty males (mean age 63 years) were reviewed. Prostate cancer treatment was the most common fistula etiology (97%). Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47%). The rate of fecal diversion was 67%. During a mean follow-up of 72 months, healing rate was 90% and recurrence rate 0%. Spontaneous healing was achieved in 14 patients (47%): 8 (27%) without fecal diversion and 6 (20%) following fecal diversion. Thirteen patients (43%) required definitive intervention. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Only 2 patients (7%) required an abdominal approach (positive oncologic margins or non-functioning bladder). Fifteen out of the 20 patients (75%) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17%. Long-term urinary incontinence was noted in 11 patients (37%). Six patients (20%) required permanent urinary diversion or drainage catheters.

CONCLUSIONS

Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent.

York Mason procedure to repair iatrogenic rectourinary fistula: our experience

BACKGROUND

Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes.

METHODS

We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up.

RESULTS

In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula.

CONCLUSIONS

The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

[Surgical treatment of rectourinary fistulas: review of the literature]

BACKGROUND

A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation, or trauma. Retrospective studies and case reports have highlighted different approaches for surgical repair.

OBJECTIVE

The aim of this study was to review our experience with surgical management of RUF.

DATA SOURCES

MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms RUFs urethrorectal fistulas, and prostatourethral-rectal fistulas.

STUDY SELECTION

All studies were retrospective and in English. Of the records identified, 31 series were included.

RESULTS

Four hundred sixty-five patients were identified. Most patients underwent one of four categories of repair: transanal (4.7%), transabdominal (14.1%), transsphincteric (26.6%), and transperineal (57.6%). Tissue interposition flaps, predominantly gracilis muscle, were used in 56% of repairs. The fistula was successfully closed in 93.9% of patients.

CONCLUSIONS

Regardless of complexity, RUFs have an initial closure rate of 93.9%.

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.

Gluteal-fold adipofascial perforator flap transposition for rectourethral fistula reconstruction

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.

Rectourethral fistula: systemic review of and experiences with various surgical treatment methods

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.

Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula

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.

Novel treatment of a rectourethroperineal fistula after perineal prostatectomy using autologous fat transplantation

We describe a novel approach for treatment of a rectourethroperineal fistula after perineal prostatectomy using autologous fat transplantation. Unlike other procedures, this technique does not include a wide dissection in scar tissue, thereby reducing the risk of injury to important neurovascular structures. Donor site morbidity is minimal and more advanced techniques can still be used in case of recurrence.

Functional and quality-of-life outcomes in patients undergoing transperineal repair with gracilis muscle interposition for complex rectourethral fistula

OBJECTIVE

To evaluate the results and quality of life outcomes of transperineal repair using gracilis muscle interposition in patients who were candidates for attempted preservation of bowel and bladder function. There is currently no widely accepted procedure for the treatment of complex RUF, such as those complicated by radiotherapy, previous attempts at repair, or large in size.

METHODS

Thirteen patients who underwent transperineal repair with gracilis muscle interposition for complex RUF were identified. Records were reviewed for fistula etiology, prior repair, intraoperative findings, hospital course, complications, diversion reversal, and outcome. Follow-up data were gathered from clinic visits and questionnaires.

RESULTS

Preoperative diagnoses included: prostate cancer (PCA) (12) and imperforate anus (1). Treatment for PCA included radical prostatectomy (4); brachytherapy (BT) (3); external beam radiation therapy (EBRT) + BT (3); cryoablation (1); and EBRT + cryoablation (1). Five patients underwent prior unsuccessful repair. There were no intraoperative complications. Postoperative complications included fecal incontinence (3) and bladder neck contracture (1). Nine patients (75%) reported some degree of urinary incontinence, with 2 patients reporting this as significant, defined as incontinence "most of the time." Suprapubic catheters were removed after 6 weeks, and median stomal reversal was at 17.5 weeks (12-28). One patient developed a recurrent RUF. All patients completed quality-of-life questionnaires assessing urinary and fecal outcome. Fecal outcome measures were generally better than urinary, but both were reasonable given the complexity of the situation.

CONCLUSIONS

Transperineal repair with gracilis muscle interposition is an effective treatment for selected patients with complex RUF. Our experience demonstrates low morbidity, high success rates, and reasonable bowel and bladder function postoperatively.

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.

Management of surgical and radiation induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft

PURPOSE

Rectourethral fistulas are a rare but devastating complication of pelvic surgery and radiation. We review, analyze and describe the management and outcomes of nonradiated and radiation/ablation induced rectourethral fistulas during a consecutive 12-year period.

MATERIALS AND METHODS

We performed a retrospective review of patients undergoing rectourethral fistula repair between January 1, 1998 and December 31, 2009. Patient demographics as well as preoperative, operative and postoperative data were obtained. All rectourethral fistulas were repaired using an anterior transperineal approach with a muscle interposition flap and selective use of a buccal mucosal graft urethral patch onlay.

RESULTS

A total of 74 patients with rectourethral fistulas underwent repair with an anterior perineal approach and muscle interposition flap (68 gracilis muscle interposition flaps, 6 other muscle interposition flaps). We compared 35 nonradiated and 39 radiated/ablation induced rectourethral fistulas. Concurrent urethral strictures were present in 11% of nonradiated and 28% of radiated/ablation rectourethral fistulas. At a mean followup of 20 months 100% of nonradiated rectourethral fistulas were closed with 1 procedure while 84% of radiated/ablation rectourethral fistulas were closed in a single stage. Of the patients with nonradiated rectourethral fistulas 97% had the bowel undiverted. Of those undiverted cases 100% were without bowel complication. Of the patients with radiated/ablation rectourethral fistulas 31% required permanent fecal diversion.

CONCLUSIONS

Successful rectourethral fistula closure can be achieved for nonradiated (100%) and radiation/ablation (84%) rectourethral fistulas using a standard anterior perineal approach with an interposition muscle flap and selective use of buccal mucosal graft, providing a standard for rectourethral fistula repair. Even the most complex radiation/ablation rectourethral fistula can be repaired avoiding permanent urinary and fecal diversion.

Urorectal fistulae following the treatment of prostate cancer

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? It is known that urorectal fistulae is a serious but rare complication of the treatment of carcinoma of the prostate. This study adds a distinction between post-surgical fistulate and post-irradiation fistulae. Essentially most post-surgical fistulae are simple and relatively easily dealt with: the expectation is that the patient will return to normality; whereas post-irradiation fistulate are by their nature complex and much more difficult to treat with a much more uncertain long-term outcome. Complexity is discussed and defined.

OBJECTIVE

• To evaluate the management of urorectal fistulae (URF) in light of new technology in prostate cancer treatment, which has changed the nature of these URF and, therefore, the approach to treatment.

PATIENTS AND METHODS

• Between 2004 and 2009 we repaired URF after treatment for prostate cancer in 40 patients with a minimum of 1-year follow-up since their last intervention. • In 23 patients (post-surgical group) the URF resulted from open, laparoscopic or robotic radical prostatectomy. In the other 17 patients (post-irradiation group) the URF resulted from either external beam radiation (EBRT) or brachytherapy (BT), or both, salvage cryotherapy or salvage high-intensity focused ultrasound (sHIFU). • In the 23 patients in the post-surgical group a transperineal repair was performed. In the post-irradiation group a transperineal repair was performed in three of the 17 patients. A transabdominal or abdominoperineal repair was performed in the remaining 14 patients, combined with salvage radical prostatectomy in those eight patients in whom a discrete prostate still existed, and in whom this was possible.

RESULTS

• The URF were cured in all patients. • A bladder-neck contracture (BNC) developed in two patients, one of whom is being managed by interval dilatation and the other of whom had a revision of his vesico-urethral anastomosis. Sphincter weakness incontinence required further treatment in eight patients by implantation of an artificial urinary sphincter. • A specific category of complex URF with cavitation was identified, which is particularly common after sHIFU following the combination of previous EBRT and BT, but which may result from the sequential application of any 'new technology'.

CONCLUSIONS

• URF of any degree of complexity can be managed without the need for a transanorectal sphincter-splitting approach or a covering colostomy and without the need for an interposition flap when the circumstances are appropriate and the surgeon is sufficiently experienced. URF with cavitation and in the post-irradiation group are an exception and do require an interposition flap. • The role of salvage radical prostatectomy in patients with a URF who still have a prostate, needs to be defined. • We suggest that cavitation, BNC and extensive ischaemia due to the serial application of external energy sources confer 'complexity'. Post-surgical URF are simple except for those with cavitation or a BNC. Most post-irradiation URF are complex even in the absence of cavitation or a BNC.

Rectourethral fistula stenting: a technique for better fistula visualization and efficient repair

In this study, the authors present a technical tip for better and easier visualization of rectourethral fistula both during dissection and fistula closure. In this technique, a small-caliber ureteral catheter is used for catheterization of the fistulous tract under direct urethroscopic guidance. Five cases were treated using this technique. All cases had either brachytherapy as a monotherapy or combined brachytherapy and external beam radiotherapy. All cases had the fistula completely healed except for one failed case that had a 2-cm fistula.

Posterior sagittal pararectal approach with rectal mobilization for repair of rectourethral fistula: an alternative approach

OBJECTIVES

To present this clinical series to report our initial experience with our technique as an alternative approach for treatment of rectourethral fistulas (RUFs). RUFS are a devastating complication of the urinary tract. The most appropriate approach remains controversial.

METHODS

From March 2002 to August 2007, 8 patients with RUF were referred to our institution. The etiology of the RUF was a fractured pelvis in 2, radical prostatectomy in 1, transurethral resection of the prostate in 1, anterior bowel resection in 1, and a pull-through operation in 3. Of the 8 patients, 5 had undergone urinary diversion and 3 had undergone a previous repair that had failed. They were evaluated and treated using the posterior sagittal approach with rectal mobilization. The fistulas were excised, and both the urethra and rectum were repaired. The inferior half of the gluteus maximus muscle was used as barrier in 5 of the 8 patients. The operative and immediate and late postoperative complications were recorded. The clinical outcome was defined as success when the patients experienced no fecaluria or pneumaturia.

RESULTS

All 8 patients, with a mean age of 38.7 years, were completely cured of their RUF. The mean operative time was 290 minutes, and the mean blood loss was 637.5 mL. The median hospital stay was 18 days. Early postoperative complications included wound infection in 1 and deep vein thrombosis in 1 patient. One patient developed a late complication of urinary incontinence.

CONCLUSIONS

Our approach is safe, provides excellent exposure, and allows for dissection under direct vision. The gluteus maximus flap is a good, nearby flap that can be used with minimal host morbidity.

Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas

BACKGROUND

Urethrorectal fistulas (URF) in patients with complex posterior urethral strictures are rare and difficult to repair surgically. There is no widely accepted standard approach described in the published literature.

OBJECTIVE

The aim of this study was to describe the outcomes of various operative approaches for the repair of URFs in patients with complex posterior urethral strictures.

DESIGN, SETTING, AND PARTICIPANTS

From January 1985 to December 2007, 31 patients (age: 6-61 yr; mean: 28.4) with URFs secondary to posterior urethral strictures were treated using a perineal or combined abdominal transpubic-perineal approach.

INTERVENTIONS

A simple perineal approach was used in 4 patients; a transperineal inferior pubectomy approach was used in 18 patients; and a combined transpubic-perineal approach was used in 9 patients. A bulbospongiosus muscle and subcutaneous dartos pedicle flaps were interposed between the repaired rectum and urethra in 22 patients. The combined transpubic-perineal approach used either a gracilis muscle flap (one patient) or a rectus muscle flap (eight patients).

MEASUREMENTS

Suprapubic catheterisation was used for bladder drainage, and a urethral silicone stent was left indwelling for 4 wk.

RESULTS AND LIMITATIONS

One-stage repair was successful in 4 patients (100%) using the perineal approach, in 16 of 18 patients (88.9%) using the transperineal-inferior pubectomy approach, and in 7 of 9 patients (77.8%) using the transpubic-perineal approach. Recurrent urethral strictures developed in two cases; one patient required regular dilation, and the other patient was treated successfully with tubed perineoscrotal flap urethroplasty. Recurrent URFs developed in two additional patients.

CONCLUSIONS

Surgical approaches for the treatment of URFs associated with complex urethral strictures should be based on a number of considerations including the location of the URF, its aetiology, the length of the urethral strictures, and a history of previous unsuccessful repairs. These results demonstrate that the transperineal-inferior pubic approach may be appropriate as a first-line procedure.