Patient-Reported and Physiologic Outcomes Following Pelvic Exenteration for Non-Repairable Radiated Rectourethral Fistula

The Uroplastic Approach to Complex Rectourethral Fistula Repair: Indications, Technique, Results

Background

Rectourethral fistulae are complex pathologies with significant morbidity that warrant multidisciplinary care. Although gracilis muscle interposition for fistula repair has been reported, specific indications and techniques for this mode of reconstruction remain unclear.

Methods

A retrospective quasi-experimental study was previously conducted to assess outcomes of rectourethral fistula management before and after the implementation of a multidisciplinary treatment algorithm. Patients with complex rectourethral fistulae and repair with gracilis muscle flap interposition were further investigated. Plastic surgery involvement for gracilis muscle interposition was indicated for (1) radiated rectourethral fistulae less than 3 cm and (2) nonradiated rectourethral fistulae more than 2 cm. Our preferred technique for gracilis muscle flap harvest, transposition, and inset is described in detail. Primary outcomes included healing of rectourethral fistulae and secondary reversal of urinary or fecal diversions.

Results

Twenty-three patients with complex rectourethral fistulae underwent gracilis muscle flap interposition between 2001 and 2022 before (n = 12) and after (n = 11) algorithmic implementation. The frequency of definitive rectourethral fistula healing improved in the postalgorithm group by 33%. There was no significant difference in fistula healing time or the rate of urinary or fecal diversions after algorithm implementation. The technique of gracilis muscle flap interposition is also described.

Conclusions

The gracilis muscle interposition flap is a valuable reconstructive option for complex rectourethral fistula repair. Implementation of a multidisciplinary treatment algorithm including plastic surgery involvement and refinement of the operative approach was associated with improved frequency of definitive healing of rectourethral fistulae.

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.

Patient-Reported Outcomes in Chinese Patients with Locally Advanced or Recurrent Colorectal Cancer After Pelvic Exenteration

BACKGROUND

Pelvic exenteration (PE) is often the only curative treatment option for selected locally advanced and locally recurrent colorectal cancer associated with significant morbidity. Open and laparoscopic approaches were accepted for this procedure.

OBJECTIVE

This study aimed to examine the Chinese patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after PE.

METHODS

A total of 122 enrolled participants were asked to complete PROs at baseline and 1, 3, 6, 9 and 12 months after PE. PROs included seven symptoms from the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). The HRQoL was assessed using the Functional Assessment of Cancer Therapy-Colorectal (FACT-C).

RESULTS

The overall postoperative complication rate was 41.0%. Patients experienced lower physical and functional well-being and FACT-C 1 month after surgery, then gradually recovered. The FACT-C score returned to baseline 9 months after surgery. Social and emotional well-being did not show signs of recovery until 6 months after the surgical procedure, and did not fully return to baseline until 12 months post-surgery. Symptom rates of insomnia, anxiety, discouragement, and sadness (composite score >0) did not improve significantly from baseline until 12 months after surgery.

CONCLUSIONS

PE is a feasible treatment choice for locally advanced primary and recurrent colorectal cancer. Social, psychological, and emotional recovery in the Chinese population after PE tends to be slower compared with the physical condition.

Patient reported outcome measures (PRO) in colorectal surgery

Patient reported outcomes refer to, "Any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else" (US Food and Drug Administration, 2009) [1]. These outcomes can include anything that matters to patients including quality of life, pain, number of bowel movements. Patient reported outcome measures refer to tools or instruments that help to measure these outcomes. These measures can be done using validated tools, those that have undergone rigorous testing and psychometric validation, and non-validated tools such as may exist in a practice to rate practice or physician/staff care quality. For this paper, we will discuss the role of patient reported outcomes measures in colon and rectal surgery.

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.

Impact of Prostate Cancer-related Genitourinary Radiation Injury on Mental Health Diagnosis and Treatment: Assessment of 55,425 Men

OBJECTIVE

To investigate the association of low-grade radiation injury (LGRI) and high-grade radiation injury (HGRI) following prostate cancer treatment with mental health diagnoses and therapy.

METHODS

A retrospective study of men diagnosed with prostate cancer who were treated with radiotherapy. Men were followed to assess for LGRI or HGRI using IBM MarketScan. Cohorts included: no injury (no-RI), LGRI, HGRI, and controls. Mental health diagnoses and related treatment (medication/therapy) were identified using ICD-10 codes, CPT codes, and national drug codes. A multivariable Cox proportional hazards model from time of radiation to first instance of mental health diagnosis was modeled against injury group, age, and comorbidities.

RESULTS

Between 2011 and 2020 we identified 55,425 men who received radiotherapy for prostate cancer. 22,879 (41.3%) experienced a LGRI while 4128 (7.4%) experienced a HGRI. Prior to radiation therapy, mental health diagnoses were equally distributed across cohorts (P > .05). Every marker of mental health showed a step-wise increase in incidence from no-RI to LGRI to HGRI except for alcohol abuse. Use of mental health medications and therapy visits were slightly more likely in the LGRI and HGRI groups prior to radiation, however, this difference was greatly increased postradiation therapy. LGRI (HR 1.38; P < .001) and HGRI (HR 2.1; P < .001) were independently associated with an increased likelihood of mental health diagnoses.

CONCLUSION

LGRI and HGRI following prostate cancer radiotherapy are associated with increased risk of mental health diagnosis, medication use, and therapy need compared to men who do not develop injuries. The most common mental health diagnoses were depression and anxiety.

Pelvic exenteration for chronic fistulating pelvic sepsis after multimodal treatment of pelvic malignancy

BACKGROUND

Chronic fistulating pelvic sepsis is an uncommon complication of multimodal treatment of visceral pelvic tumours. Radical multi-visceral resection is reserved for patients with persistent, debilitating symptoms despite less invasive treatments and for which there is minimal published data. This study aimed to report the rates of morbidity and long-term sepsis control after pelvic exenteration for chronic fistulating pelvic sepsis.

METHODS

This retrospective cohort study was conducted at a high-volume pelvic exenteration referral centre. Patients who underwent pelvic exenteration for chronic fistulating pelvic sepsis between September 1994 and January 2023 after previous treatment for pelvic malignancy were included. Data relating to postoperative morbidity, mortality and the rate of recurrent pelvic sepsis or fistulae were retrospectively collected.

RESULTS

19 patients who underwent radical resection for chronic fistulating pelvic sepsis after previous pelvic cancer treatment were included. 11 patients were male (58 %) and median age was 62 years (range 42-79). Previously treated rectal (8 patients, 42 %), prostate (5, 26 %) and cervical cancer (5, 26 %) were most common. 18 patients (95 %) had previously received high-dose pelvic radiotherapy, and 14 (74 %) had required surgical resection. Total pelvic exenteration was performed in 47 % of patients, total cystectomy in 68 % and major pubic bone resection in 37 %. There was no intraoperative or postoperative mortality. Major complication rate was 32 %. 12-month readmission rate was 42 %. At last follow up, 74 % had no signs or symptoms of persisting pelvic sepsis.

CONCLUSIONS

Pelvic exenteration for refractory pelvic sepsis following treatment of malignancy is safe and effective in selected patients.