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

Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula

OBJECTIVE

To evaluate the effect of a new strategy of transperineal anastomotic urethroplasty (TAU) with proximal transection in treating pelvic fracture urethral injury (PFUI) associated with urethrorectal fistula (URF).

PATIENTS AND METHODS

A retrospective review of all patients treated by TAU with proximal transection and fistula repair for PFUI associated with URF was performed between August 2013 and July 2022. Information on demographics, peri-operative variables, and postoperative follow-up outcomes was collected. Successful surgery was defined as restoration of a uniform urethral calibre using flexible cystoscopy (third postoperative month) without strictures or leakage, with no further interventions required. Functional outcomes, including erectile function (assessed using the five-item International Index of Erectile Function) and urinary continence, were assessed.

RESULTS

Forty patients diagnosed with PFUI associated with URF and treated by TAU with proximal transection and rectal fistula repair were enrolled. Six patients (15.0%) had a history of failed urethral reconstruction. The mean stenosis length and fistula diameter were 2.9 cm and 1.2 cm, respectively. All patients underwent faecal diversion before urethroplasty. After a median (range) follow-up of 45 (3-115) months, the final success rate was 90.0% (36/40). Postoperative complications included haematoma in three patients, epididymo-orchitis in three, wound infection in one, wound bleeding in one, delayed wound healing in three, and wound numbness in three. The overall incidence of postoperative erectile dysfunction reached 75.0%, with a median (range) score of 9 (0-19). Normal continence was achieved in 31 patients (77.5%). Occasional incontinence without the need for urinal pads occurred in eight patients, whereas one patient required urinal pads.

CONCLUSIONS

Transperineal anastomotic urethroplasty with proximal transection is a precise and effective surgical strategy for treating PFUI associated with URF. This strategy ensures a high success rate and improves surgical efficiency.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature

AIM

Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF.

METHOD

PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data.

RESULTS

Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I²  = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I²  = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I²  = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I²  = 61%).

CONCLUSION

The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.

A neo-rectal bladder by uretero-rectal anastomosis: a case report

Urinary diversion has always been a great challenge for urologists. There are many reasons and various methods for urinary diversion in clinical practice. In this report, who was diagnosed with a pelvic fracture complicated by enterostomy, urethral stricture, and bilateral inferior ureteral stricture. We performed laparoscopic bilateral ureterorectal reimplantation for this patient. Postoperatively, the patient recovered well and was able to perform volitional emptying. Bilateral DJ stents were removed under ureteroscopy at 6 weeks postoperatively. Six months after operation, no hydronephrosis was found in both kidneys. No increase of blood urea nitrogen (BUN) and creatinine were observed in renal function examination. It is clearly stated that in the present report a modified version of Heitz-Boyer-Houvelac uretero-rectostomy technique was carried out, as the technically demanding surgical step of retrorectal pull-through of the sigmoid colon was unneccesary given that the patient already had enterostomy. This surgery was performed laparoscopically and that the most relevant benefit for the patient was to avoid incontinent urinary diversion or possibly a more complex surgical procedure.

Transperineal anastomotic urethroplasty for the treatment of pelvic fracture urethral distraction defects: a progressive surgical strategy

PURPOSE

The aim was to reduce the difficulty of transperineal anastomotic urethroplasty for pelvic fracture urethral distraction defect (PFUDD) and make it easy to master through an effective strategy.

PATIENTS AND METHODS

Between January 2010 and December 2019, 1637 patients with PFUDDs were treated by transperineal anastomotic urethroplasty. The surgical strategy we used was the progressive transperineal anastomotic urethroplasty. First, after full mobilization of the distal bulbomembranous urethra, the stenotic urethra was transected directly at the proximal margin of the stenotic urethra to expose the proximal disrupted urethral end. Second, if the urethral stenosis location of some complicated cases was too deep to fully mobilize, the position of urethral transection was selected at the distal margin of the stenotic urethra. Then, the distal and proximal disrupted urethras were then trimmed and anastomosed without tension. A successful urethroplasty was defined as reestablishment of a uniform urethral caliber and no further interventions were needed.

RESULTS

Follow-up was obtained in 1475 patients. The success rate was 92.4% (1363/1475). Among the 112 failed patients, 10 patients received endoscopic urethrotomy, 99 underwent a secondary or third anastomotic urethroplasty and 3 successfully treated with perineal skin flap urethroplasty. After final successful urethroplasty, 125 patients (8.5%) had different degrees of urinary incontinence and 15 (1.6%) developed de novo erectile dysfunction (1.6%).

CONCLUSION

The progressive transperineal anastomotic urethroplasty strategy was effective for treating PFUDD cases, improving surgical efficacy and reducing complications. It may contribute to standardizing the transperineal anastomotic urethroplasty and making it easy to master.