Pelvic radiation is associated with urinary fistulae repair failure and need for permanent urinary diversion

Minimally invasive delivery of ethanol for the treatment of urinary bladder fistulas

Urinary bladder fistula formation is a complication of significant morbidity and mortality following pelvic surgery or radiotherapy. Surgical treatment is the definitive management, but it may be contraindicated in patients with significant comorbidities. The alternative approach is to divert urine away from the fistula with stents and catheters, and allow time for healing. The case illustrated herein describes the use of alcohol to accelerate the fibrotic healing of a urinary bladder fistula, based on the premise that sclerosing agents have been effective in the treatment of pancreatic fistulas and renal cysts.

Adverse Features of Rectourethral Fistula Requiring Extirpative Surgery and Permanent Dual Diversion: Our Experience and Recommendations

Introduction: To report a series of men with a rectourethral fistula (RUF) resulting from pelvic cancer treatments and explore their therapeutic differences and impact on the functional outcomes and quality of life highlighting the adverse features that should determine permanent urinary or dual diversion. Methods: A retrospective database search was performed in four centers to identify patients with RUF resulting from pelvic cancer treatment. Medical records were analyzed for the demographics, comorbidities, diagnostic evaluation, fistula characteristics, surgical approaches and outcomes. The endpoints analyzed included a successful fistula closure following a repair and the impact of the potential adverse features on outcomes. Results: Twenty-three patients, aged 57–79 years (median 68), underwent an RUF reconstruction. The median follow-up (FU) was 54 months (range 18–115). The patients were divided into two groups according to the etiology: radiation/energy-ablation treatments with or without surgery (G1, n = 10) and surgery only (G2, n = 13). All of the patients underwent a temporary diverting colostomy and suprapubic cystostomy. Overall, a successful RUF closure was achieved in 18 (78%) patients. An interposition flap was used in six (60%) patients and one (7.7%) patient in groups G1 and G2, respectively (p = 0.019). The RUF was managed successfully in all 13 patients in group G2 as opposed to 5/10 (50%) in group G1 (p = 0.008). The patients in the radiation/energy-ablation group were more likely to require permanent dual diversion (50% vs. 0%, p < 0.0075). Conclusion: Radiation/energy-ablation therapies are associated with a more severe RUF and more complex reconstructions. Most of these patients require an abdominoperineal approach and flap interposition. The failure of an RUF repair with the need for permanent dual diversion, eventually combined with extirpative surgery, is higher after previous radiation/energy-ablation treatment. Therefore, permanent dual diversion as the primary treatment should always be included in the decision-making process as reconstruction may be futile in specific settings.

Early closure of fistula using neo-adjuvant intra-arterial chemotherapy in locally advanced anal cancer

BACKGROUND

Locally advanced anal cancer patients, especially with T4 disease and fistula, have a dismal prognosis. Neo-adjuvant intra-arterial chemotherapy before standard chemoradiation has been shown to be promising in this setting.

AIMS

We are reporting results from a larger patient population.

METHODS

From 2005 to 2015, 25 consecutive patients with locally advanced anal cancer, 18 of them fistulised, received intra-arterial chemotherapy.

RESULTS

Twenty-two of 25 patients (88%) had T4N0-3 disease and 3 (12%) T3N3. An objective tumour response was observed in 24 of 25 patients (96%): 24 partial responses and 1 with stable disease. Fistulas' complete closure was observed in 15 of 18 patients (83.3%). Following intra-arterial chemotherapy, 23 patients underwent chemoradiation. Twenty-one of 25 patients (84%) had a complete remission 6 months after treatment completion. Amongst 22 patients followed for 3 or more years, 18 of them (81%) are colostomy free at 3 years. Five-year overall survival is 75%. Most frequent grade 3-4 toxicity of IAC was neutropenia (25%).

CONCLUSIONS

Neo-adjuvant intra-arterial chemotherapy combined to chemoradiation resulted in a high rate of fistulas closure and long-term control of locally advanced anal cancer. This interesting approach in the treatment of fistulised anal cancer, needs a prospective study before being considered a new standard strategy.