Transperineal repair with bulbocavernosus muscle interposition for recto-urethral fistula

Post-traumatic rectourethral fistula in an adolescent managed via a transperineal approach using a local gluteal tissue interposition flap: a case report

Background

Rectourethral fistula is a rare disease with a wide variety of etiologies and clinical presentations. A definitive surgical procedure for rectourethral fistula repair has not been established.

Case presentation

A 13-year-old boy sustained a penetrating injury to the perineum, and developed a symptomatic rectourethral fistula thereafter. Conservative management through urinary diversion and transanal repair was unsuccessful. Fecal diversion with loop colostomy was performed, and three months later, a fistula repair was performed via a transperineal approach with interposition of a local gluteal tissue flap. There were no postoperative complications, and magnetic resonance imaging studies confirmed the successful closure of the fistula. The urinary and fecal diversions were reverted 1 and 6 months after the fistula repair, respectively, and postoperative excretory system complications did not occur.

Conclusions

The transperineal approach with interposition of a local gluteal tissue flap provides a viable surgical option for adolescent patients with rectourethral fistulas who are unresponsive to conservative management.

Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients

BACKGROUND

Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF.

METHODS

This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed.

RESULTS

Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004).

CONCLUSIONS

Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.

Use of biological mesh in trans-anal treatment for recurrent recto-urethral fistula

PURPOSE

To report the author's experience on a mini-invasive technique using bioprosthetic plug and a rectal wall flap advancement in the treatment of recurrent recto-urethral fistula.

MATERIALS AND METHODS

Between 2013 and 2015, seven patients with recurrent recto-urethral fistula were referred to the Pederzoli Hospital, Peschiera del Garda, Verona, Italy. Intraoperatively all patients were found to have a rectal wall lesion and were treated with urinary and fecal diversion. For the persistence of the fistula, all the patients underwent a mini-invasive treatment consisting on placement of a bioprosthetic plug in the fistula covered by an endorectal advancement flap through a trans-anal and trans-urethral combined technique.

RESULTS

Median operative time was 48 min with a median blood loss of 30 ml. Median hospital stay was 3 days (IQR 1-3). No case of fistula recurrence or plug migration was described. None of the patients experienced fecal or urinary incontinence. All patients obtained complete fistula healing.

CONCLUSIONS

Recurrent recto-urethral fistula is a challenging postsurgical complication for surgeons and urologists, and its best treatment is still unknown. Our method seems to be feasible and effective for the treatment of complex recto-urethral fistula.

[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%.

Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients

BACKGROUND

Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis.

OBJECTIVE

To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm.

DESIGN AND SETTING

A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012.

PATIENTS

Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16.

MAIN OUTCOME MEASURES

The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence.

RESULTS

There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group.

LIMITATIONS

This study was limited by the small sample size and the retrospective nature of the review.

CONCLUSIONS

Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.