The management of the complex recto-urethral fistula

Incidence of Rectal Injury After Radical Prostatectomy: A Systematic Review and Meta-analysis

Context

Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.

Objective

To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.

Evidence acquisition

A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.

Evidence synthesis

Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46-0.73) in contemporary series with significant across-study heterogeneity (I² = 100%, p < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66-2.38) and laparoscopic RP (1.25%; 95% CI 0.75-2.08) followed by perineal RP (0.19%; 95% CI 0-276.95) and robotic RP (0.08%; 95% CI 0.02-0.31). Age ≥60 yr (0.56%; 95% CI 0.37-06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99-9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92-18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.

Conclusions

RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.

Patient summary

Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.

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.

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.

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.

Transperineal repair of a persistent rectourethral fistula using a porcine dermal graft

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We describe a case of a persistent rectourethral fistula repaired through a transperineal approach.

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The fistula was excised, the rectum and the urethrovesical anastomosis were sutured.

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A porcine dermal graft was interposed between the rectum and the urinary tract.

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No fistula recurrence occurred at 1-year follow-up.

INTRODUCTION

Rectourethral fistula (RUF) is a rare major complication after radical prostatectomy (RP). Management of patients with persistent RUFs after primary repair is controversial and technically challenging.

PRESENTATION OF CASE

We describe the case of a patient with history of RUF secondary to rectal injury during laparoscopic RP and failed trans-abdominal repair. A further attempt to repair the persistent RUF was done through a perineal approach. The fistula was excised, the anterior rectal wall was closed in two layers and the defect at the level of the urethrovesical anastomosis (UVA) was repaired with an interrupted suture. A porcine dermal graft was interposed between the UVA and the rectum and was sutured to the rectal wall. There were neither clinical nor radiological evidences of fistula recurrence at one-year follow-up after transperineal surgical repair.

DISCUSSION

We used, for the first time, a porcine dermal collagen allograft as interposition tissue in a persistent RUF secondary to rectal injury during laparoscopic RP. The use of this allograft allows the potential advantage of less surgical invasivity if compared to gracilis muscle graft.

CONCLUSIONS

Transperineal repair of persistent RUFs with porcine dermal graft interposition is a safe and feasible surgical procedure.

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.

Reconstruction of radiation-induced injuries of the lower urinary tract

This article presents an overview of reconstruction of lower urinary tract injury caused by radiation therapy for prostate cancer. Discussions include cause, patient evaluation, reconstructive techniques, and outcomes following repair.

Transperineal repair with bulbocavernosus muscle interposition for recto-urethral fistula

AIM

The results of repair of recto-urethral fistulae (RUF) are presented using a bulbocavernosus muscle graft.

METHOD

Prospectively collected data were reviewed on 11 patients with RUF operated on between 2003 and 2011. Of these, six were treated by a bulbocavernosus flap. Two RUF had occurred after prostatectomy, three after prostatectomy and radiotherapy and one after perineal trauma; all had a urinary diversion.

RESULTS

Closure of the fistula was achieved in all patients and was maintained for the duration of the period of follow up (mean ± SD = 43.5 ± 24.7 months; range, 8-80 months) There were no complications.

CONCLUSION

This new technique for the repair of RUF is safe and effective, especially in patients with complex postradiation RUF.

Gracilis muscle interposition with primary rectal without urethral repair for moderate sized rectourethral fistula caused by brachytherapy for prostate cancer: a case report

INTRODUCTION

There is a 0.16% chance of a rectourethral fistula after prostate brachytherapy monotherapy using Palladium-103 or Iodine-125 implants. We present an unusual case report of a rectourethral fistula following brachyradiotherapy monotherapy for prostate adenocarcinoma. It was also associated with unusual management of the fistula.

CASE PRESENTATION

A 58-year-old Caucasian man underwent brachyradiotherapy monotherapy as definitive treatment for verified intracapsular prostate adenocarcinoma receiving 56 Iodine-125 implants using a transrectal ultrasound-guided technique. The patient started to complain of severe perineal pain and mild rectal bleeding 15Â months after brachyradiotherapy. A biopsy of mucosa of his anterior rectal wall was performed. A moderate sized rectourethral fistula was confirmed 23Â months after implantation of Iodine-125 seeds. Laparoscopic sigmoidostomy and suprapubic cystostomy were then performed. Long-term cortisone applications in combination with 30 sessions of hyperbaric oxygen therapy, and antibacterial therapies were initiated due to necrotic infection. A gracilis muscle interposition to create a partition between the patient's rectum and urethra in conjunction with primary rectal repair but without urethral repair were performed 6 months later. The 3cm rectal defect was repaired via a 3cm-long horizontal perineal incision. The 1.5cm urethral defect just below the prostate was not repaired. The patient underwent an optic internal urethrotomy 3Â months later for a 1.5cm-long urethral stricture. Several planned preventive urethral buginages were performed to avoid urethral stricture recurrence. At 12Â months postoperatively, there were no signs of a fistula and cancer recurrence. He now has a normal voiding and anal continence.

CONCLUSION

Severe rectal pain, bleeding, and local anterior necrotic proctitis are predictors of a rectourethral fistula. Urinary and fecal diversion is the first-step operation. Gracilis muscle interposition in conjunction with primary rectal repair but without urethral reconstruction is one of the reconstructive surgery options for moderate 2cm to 3cm rectourethral fistulas. Internal urethrotomy is a procedure for postoperative urethral strictures of 1.5cm in length.

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.

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.

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.

Iatrogenic recto-urethral fistula: perineal repair and buccal mucosa interposition

OBJECTIVE

To present a new and promising technique for repairing recto-urethral fistulae (RUF) using a perineal approach and buccal mucosa graft interposition, as RUF are rare but severe complications of rectal or urinary tract surgery, radiation treatment, trauma or inflammation, and the repair of recurrent or persistent RUF is particularly difficult when previous surgical attempts have failed, resulting in high recurrence rates.

PATIENTS AND METHODS

Between 2004 and 2006, five men (aged 61-67 years) with iatrogenic RUF had the perineal fistula closed using a buccal mucosa graft interposition. The RUF had developed after laparoscopic or retropubic radical prostatectomy in four patients and after radical cystectomy and ileal neobladder in the fifth. Four of the patients had had at least one failed RUF repair before their referral to our institution.

RESULTS

Four of the five RUF were repaired successfully using the perineal approach and buccal mucosa graft interposition. Failure occurred in one patient who had developed a RUF after laparoscopic radical prostatectomy followed by two unsuccessful attempts at closure. The failure was most probably due to a previously undetected postoperative perineal haematoma with infection.

CONCLUSION

Our perineal approach for repairing RUF, combined with buccal mucosa graft interposition, is a simple technique fulfilling all the requirements for successful fistula closure, especially in repeat surgery.

Complication after abdominoperineal resection of the rectum

Treatment of rectal cancer commonly involves pre-operative short-term external beam radiotherapy along with curative surgery. We describe a case that was treated with the standard multi-modality treatment but developed some very unusual complications.

Combined treatment of iatrogenic rectourethral fistula with endoscopic fibrin glue application and clipping

Rectourethral fistula (RUF) formation is a rare complication of prostatic surgery and other pelvic surgical procedures. The results of operations to correct RUF are not always satisfying, with a particular risk of recurrent breakdown or stricture formation at the site of the urethral closure. We present a case of a small RUF treated videoendoscopically with fibrin-glue application combined with endoscopic clipping.

Recto-urethral fistula following brachytherapy for localized prostate cancer

OBJECTIVE

The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development.

METHOD

A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded.

RESULTS

Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified.

CONCLUSION

The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.

Management of radiotherapy induced rectourethral fistula

PURPOSE

An increasing number of men are being treated with BT or a combination of external beam radiation therapy and BT for localized prostate cancer. Although uncommon, the most severe complication following these procedures is RUF. We reviewed our recent experience with RUF following radiotherapy for prostate cancer to clarify treatment in these patients.

MATERIALS AND METHODS

We recently treated 22 men with RUF following primary radiotherapy for adenocarcinoma of the prostate in 21 and adjuvant external beam radiation therapy following radical prostatectomy in 1. Time from the last radiation treatment to fistula presentation was 6 months to 20 years.

RESULTS

Four patients underwent proctectomy with permanent fecal and urinary diversion. RUF repair in 5 patients was performed with preservation of fecal or urinary function. Six patients were candidates for reconstruction with preservation of urinary and rectal function, including 5 who underwent proctectomy, staged colo-anal pull-through and BMG repair of the urethral defect. The additional patient underwent primary closure of the rectum, BMG repair of the urethra and gracilis muscle interposition. Successful fistula closure was achieved in the 9 patients who underwent urethral reconstruction. All 8 candidates for rectal reconstruction showed radiological and clinical bowel integrity postoperatively with 2 awaiting final diverting stoma closure.

CONCLUSIONS

With the increasing use of prostate BT the number of patients with severe rectal injury will likely continue to increase. Radiotherapy induced RUF carries significant morbidity and most patients are treated initially with fecal and urinary diversion. In properly selected patients good outcomes can be expected following repair using BMG for the urethral defect along with colo-anal pull-through or primary rectal repair and gracilis muscle interposition.