Rectourethral fistula reconstruction in elderly patients

Management of acquired prostatic fistulas in adults

PURPOSE

Acquired prostatic fistula (PF) was defined as a connection between the prostatic urethra and the rectum, symphysis, peritoneum, or ending freely in the periprostatic area. This study aims to report our experience with PF presentation, diagnosis, and treatment.

METHODS

From January 2014 to February 2024, we retrospectively analyzed a prospectively maintained database from two urologic university hospitals to identify men with acquired PF. Diagnosis was based on post-intervention symptoms, including pneumaturia, fecaluria, rectal urine leakage, periprostatic inflammation or abscess, completed by radiological assessment using retrograde urethrogram, CT, or MRI. Standard cystoscopy and/or rectosigmoidoscopy assessed bladder and rectal integrity. Patients with post-prostatectomy fistulas were excluded.

RESULTS

Thirteen patients with a mean age of 66.54 ± 7.40 years were identified. The most commonly presenting symptoms were fecaluria/pneumaturia 54%, rectal urine leakage 31%, and recurrent urinary tract infection 31%. The mean time from the initial treatment to fistula development was 22.28 ± 20.53 months (0.1-59 months), and from diagnosis to repair was 3.5 ± 3 months (1-12 months). Cumulative closure rates (success rate) post-first and second attempts were 77% (10 patients) and 92% (12 patients), respectively; one patient declined definitive surgery, maintaining a persistent fistula after bladder drainage.

CONCLUSION

Clinical suspicion and detailed diagnosis are essential for formulating a tailored treatment plan for prostatic fistulas, which are successfully manageable in many patients. Complex cases benefit from a multidisciplinary approach, with individualized therapy based on etiology, severity, and recurrence of PF, facilitating effective closure.

Functional outcome and quality of life evaluation of graciloplasty for the treatment of complex recto-vaginal and recto-urethral fistulas

Recto-vaginal (RVF) and recto-urethral (RUF) fistulas are infrequent but disabling conditions that severely affect patients' quality of life. Considering the high recurrence rate after conservative approaches, the best surgical treatment is still challenging. The aim of this study was to evaluate the outcome of graciloplasty to treat patients with complex RVF or RUF, and to investigate its effect on the quality of life. Fourteen patients with RVF and RUF who underwent graciloplasty between 2003 and 2017 were retrospectively enrolled. The main outcome was the healing rate of fistulas. Postoperative patients satisfaction was evaluated administering the Clinical Patient Grading Assessment Scale (CPGAS), SF-36 questionnaires and Changes in Sexual Functioning (CSF) questionnaires. The Wexner score was calculated in case of preoperative faecal incontinence. RVF and RUF were iatrogenic in 11 patients and due to Crohn's disease in 3 cases. After 1 year of follow-up (IQR 10-14 months), the success rate of the procedure was 78%. Out of three patients with RVF due to Crohn's disease, two healed after the procedure. Six months after surgery, all eight SF-36 domains significantly improved except for "body pain"; CSF score significantly increased from 35.5 (IQR 31-38.7) to 44 (IQR 37.7-48.5); CPGAS score improved from a median value of 0 (IQR 0-0) to 4 (IQR 3.2-4). The Wexner score was calculated only in 5 patients with preoperative faecal incontinence and it significantly decreased from a median value of 12 (IQR 11-14) to 5 (IQR 4-5). Graciloplasty could be considered as a first option treatment for complex or recurrent RVF and RUF. It shows a good healing rate even in case of unfavourable factors like Crohn's disease.

Outcomes and Quality of Life Among Men After Anal Sphincter-Sparing Transperineal Rectourethral Fistula Repair

OBJECTIVE

To describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair.

METHODS

Patients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire).

RESULTS

Twenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion.

CONCLUSION

RUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients.

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.