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

Use of bulbospongiosus muscle for repair of traumatic posterior urethral stenosis combined with urethrorectal fistulas

OBJECTIVE

To evaluate the efficacy and functional outcomes of bulbospongiosus muscle (BSM) flap interposition in the repair of urethral stenosis combined with urethrorectal fistula (USURF) or anterior rectal wall weakness (USRW).

PATIENTS AND METHODS

Between January 2016 and December 2023, 36 patients underwent transperineal posterior urethroplasty with BSM flap interposition. 36 patients with traumatic posterior urethral stenosis who underwent perineal urethroplasty without interposition of the BSM as the control group, matched by propensity score analysis during the same period. Pre- and intra-operative clinical data were collected. Functional outcomes, including voiding, erectile, and ejaculatory function, were compared between the two groups.

RESULTS

A total of 36 males were included, of whom 19 (52.8%) had USURF and 17 (47.2%) had USRW. The mean follow-up time was 31.3 ± 17.7 months. The overall success rate was 94.4%. The median operating time was 3.0 (2.0, 3.0) h. The mean stricture length was 4.2 ± 1.2 cm. The mean postoperative maximum urinary flow rate was 24.2 ± 12.9 mL/s. Postoperative functional outcomes did not significantly differ between BSM interposition and BSM non-interposition group as assessed by Incontinence Questionnaire Male Lower Urinary Tract Symptoms (5.0 vs 3.0; P = 0.399), the International Index of Erectile Function 5 (3.0 vs 6.5; P = 0.183), Erection Hardness Score (P = 0.801), the Male Sexual Health Questionnaire 4 (1.0 vs 1.0; P = 1.00), European Quality of Life-5 Dimensions (0.9 ± 0.1 vs 0.9 ± 0.1; P = 0.139), EQ-VAS scores (75.9 ± 20.0 vs 79.9 ± 18.7; P = 0.428), urine dribbling (2.0 vs 1.5, P = 0.727), ejaculation volume (2.0 vs 2.0, P = 0.631) and ejaculation intensity (3.0 vs 4.0, P = 0.645).

CONCLUSIONS

Transperineal BSM flap interposition combined with anastomosis urethroplasty and urethrorectal fistula repair is a safe and effective treatment. BSM can strengthen the anterior rectal wall and separate the urethral anastomosis from the repaired rectal fistula, which should improve the success rate of fistula repair.

Rectourethral fistulas after treatment for prostate carcinoma: Update and new management algorithm

Rectourethral fistula (RUF) is associated with poor quality of life related to urinary functional symptoms (pneumaturia, fecaluria, urine passing through the rectum) or urinary tract infections (upper or lower, often recurrent). Most are iatrogenic, occurring after surgery such as radical prostatectomy, where their prevalence ranges from 0.03 in various series. RUF can also occur after radiation therapy administered for prostate cancer. Management of RUF is complex and depends on whether the patient has had previous radiation therapy or not. Different surgical techniques have been evaluated, but currently there is no consensus as to the best approach. The York-Mason technique is preferred for simple RUF in patients without prior irradiation, while for more complex cases, with antecedent irradiation, transperineal approaches with muscular flap interposition are often recommended. Evaluation of quality of life is crucial, because management of RUF can have severe consequences on urinary continence and sexual function. Despite successful anatomical repair, patients often continue to suffer from functional sequalae that affect their quality of life. Although progress has been achieved in the treatment of RUF, a coherent and efficient management algorithm is necessary to standardize the practical aspects and improve the outcomes. This update summarizes the different strategies that are available for management of RUF and underscores the importance of an individualized approach.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes

OBJECTIVE

To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair.

METHODS

We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively).

RESULTS

RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation.

CONCLUSION

Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.

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.

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.