Management of iatrogenic recto-urethral fistula by transanal rectal flap advancement

A New Technique to Repair Vesicorectal Fistula: Overlapping Rectal Muscle Plasty by Transanal Endoscopic Surgery

OBJECTIVE

To evaluate clinical results of a novel surgical technique, we developed to repair vesicorectal fistula (VRF) occurring after prostatectomy, hospital records of the patients, who underwent the new surgical treatment, were assessed.

METHODS

The novel surgical technique is called "overlapping rectal muscle plasty," which is performed under transanal endoscopic microsurgery (TEM). During the new procedure, a complete fistulectomy was first performed, and then the proper muscle layer of the rectum was folded, overlapped, and sutured to create a thick wall between the rectum and urinary bladder. This operation was carried out in 15 patients with VRF following radical prostatectomy.

RESULTS

The operation was safely performed in all patients with an average time of 127.2 min. Fistula was corrected in 13 patients (86.7%), who were then freed from both urinary and intestinal diversions.

CONCLUSIONS

Overlapping rectal muscle plasty by TEM is a safe procedure. The success rate seems to be acceptable in selected patients. This new repair method may be considered as a minimally invasive option in the surgical treatment of VRF after prostatectomy.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

[Fistula surgery]

Vesicovaginal fistulas are a rare problem in the western world but are frequent occurrences in developing countries. In Germany the most frequent cause is hysterectomy. Vesicovaginal fistulas can be treated by the transvaginal or transabdominal approach depending on the characteristics of the fistula and the patient. The incidence and complexity of urorectal fistulas increase with the number of cumulative sequences of prostate cancer treatment. Overall there is no clear consensus about the optimal surgical approach route. The surgical treatment of both vesicovaginal and urorectal fistulas is associated with high permanent fistula closure rates; however, for both entities if the fistula is discovered early enough, conservative treatment with a temporary catheter drainage can be tried, depending on the underlying cause. For both conditions fistula repair in irradiated patients shows a much lower success rate. A spontaneous closure of fistulas in radiogenic fistulas is also not to be expected.

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.

Repair of transperineal recto-urethral fistula using a fibrin sealant haemostatic patch

AIM

Recto-urethral fistula (RUF) is a rare complication of radical prostatectomy. We report a transperineal approach using a fibrin sealant haemostatic patch.

METHOD

Five consecutive patients who developed RUF following radical prostatectomy had a direct transperineal repair with a haemostatic patch (TachoSil®) and were assessed at a median follow-up of 35.5 (21-45) months.

RESULTS

There were no early postoperative complications. The average length of hospital stay was 5 (4-7) days. One patient developed recurrence 4 weeks after removal of the urethral catheter. Following healing in four patients the stoma was reversed at a median interval of 3 months, and 9.5 (7-10) months following the prostatic surgery. In the four patients with successful closure there was no case of recurrence or anorectal or urinary dysfunction at a median follow-up of 35.5 (21-45) months.

CONCLUSION

Direct transperineal repair of RUF reinforced with a fibrin haemostatic patch of TachoSil is safe and effective.

Transanal Minimally Invasive Surgery (TAMIS) to Treat Vesicorectal Fistula: A New Approach

PURPOSE

Vesicorectal fistula is one of the most devastating postoperative complications after radical prostatectomy. Definitive treatment is difficult due to morbidity and recurrence. Despite many options, there is not an unanimous accepted approach. This article aimed to report a new minimally invasive approach as an option to reconstructive surgery.

MATERIALS AND METHODS

We report on Transanal Minimally Invasive Surgery (TAMIS) with miniLap devices for instrumentation in a 65 year old patient presenting with vesicorectal fistula after radical prostatectomy. We used Alexis® device for transanal access and 3, 5 and 11 mm triangulated ports for the procedure. The surgical steps were as follows: cystoscopy and implant of guide wire through fistula; patient at jack-knife position; transanal access; Identification of the fistula; dissection; vesical wall closure; injection of fibrin glue in defect; rectal wall closure.

RESULTS

The operative time was 240 minutes, with 120 minutes for reconstruction. No perioperative complications or conversion were observed. Hospital stay was two days and catheters were removed at four weeks. No recurrence was observed.

CONCLUSIONS

This approach has low morbidity and is feasible. The main difficulties consisted in maintaining luminal dilation, instrumental manipulation and suturing.

Treatment of urethrorectal fistulas caused by radical prostatectomy - two surgical techniques

INTRODUCTION

The repair of complex urethrorectal fistulas, which can be the result of treating prostate cancer with radical prostatectomy, is a big problem in urology and its final result is not always satisfactory. There are no universally accepted methods for repairing such fistulas. In our work we present a retrospective analysis of patients treated for urethrorectal fistulas after previous radical prostatectomy. The methods used were the initial excision and suture of the fistula, or a gracilis muscle flap interposition.

MATERIAL AND METHODS

In the years 2000-2012, four patients were treated because of urethrorectal fistulas after radical prostatectomy. In two patients, open radical prostatectomy had been performed. Two other patients had been operated laparoscopically. Two patients had a primary fistula repair. They were operated using anterior perineal access. Two others were treated with the use of a gracilis muscle flap.

RESULTS

During the follow up, there was no recurrence of fistulas. Medium follow up for the first two patients was 120 and 156 months, and follow up of two other patients was 16 and 23 months. Until now, there were no final postoperative complications.

CONCLUSIONS

Repair of the fistulas requires an individual approach to each case. Excision and suturing of the fistula gives a very good final result, especially when the primary reconstruction is performed. Repair of urethrorectal fistula using a gracilis muscle flap appears to be an excellent option in cases of complex recurrent fistulas. It is also associated with low morbidity in patients and a high success rate.

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.

Short-term outcomes of the surgical management of acquired rectourethral fistulas: does technique matter?

BACKGROUND

Acquired rectourethral fistulas are uncommon and challenging to repair. Most arise as a complication of prostate cancer treatment. Several procedures have been described to repair rectourethral fistulas with varying outcomes. We review the etiology, management, and outcomes of patients with rectourethral fistulas at our institution.

MATERIALS AND METHODS

A retrospective review of patients undergoing repair of rectourethral fistulas was undertaken. Data were collected on patient demographics, fistula etiology, operative procedure, fecal and urinary diversion, and clinical outcome. Patients with urinary and/or fecal diversion underwent radiographic evaluation to confirm closure of the fistula prior to reversal of the diversion.

RESULTS

Fistula repair was performed on 22 patients from 1999 to 2009. All the patients were male of an average age of 69 years (range: 39-82 years). All patients, except one, had prostate cancer. Fistula formation was associated with radiotherapy in 54.4% of patients, brachytherapy in 36.4% of patients, and with external beam radiation therapy in 18.2% of patients. Other causes included prostatectomy (seven patients, 31.8%), cryotherapy (two patients, 9.1%), and perianal abscess (one patient, 4.5%). Procedures performed for fistula repair included transanal repair (eleven patients, 50%), transperineal repair (five patients, 22.7%), transabdominal repair (three patients, 13.6%), and York-Mason repair (three patients, 13.6%). Fourteen patients (63.6%) had urinary diversion. Fecal diversion was performed in 16 (72.7%) patients. Five (22.7%) patients had had previous attempts at fistula repair. Of the 22 patients treated, repair was successful in 20 patients (91%). The average follow-up time was 6 months (range: 3-13 months).

CONCLUSION

The success rate of treatment of rectourethral fistulas is high, regardless of the procedure type. Patients with previous repair attempts tend to have less favorable outcomes. With high success rates, less invasive procedures should be attempted first.

Rectourethral fistula following laparoscopic radical prostatectomy

PURPOSE

To review the outcome of rectourethral fistula sustained during laparoscopic radical prostatectomy.

METHODS

A retrospective chart review of all cases managed at a tertiary referral center. Data abstracted included demographics, presenting symptoms, additional interventions, healing, and long-term functional outcome.

RESULTS

Between 2004 and 2009, 10 patients were treated for rectourethral fistula following laparoscopic radical prostatectomy. Mean age was 60 years. Two patients were converted to open prostatectomy for primary repair of the rectal laceration without fecal diversion. The remaining 8 patients (80%) had unrecognized injury at the time of prostatectomy and presented postoperatively. Mean time from radical prostatectomy to presentation with fistula symptoms was 9.5 days. Seven patients (70%) required 1 or more operations to treat or control the symptoms of the rectourethral fistula (median 2.3, mean 2, range 1-4 operations). Three patients (30%) required colostomy within 1 month of radical prostatectomy due to severity of symptoms. Spontaneous healing of the fistula was noted in 6 patients (60%) following diversion (urinary ± fecal diversion), and a minority of patients (30%) required an operation to close the fistula. One patient (10%) required cystectomy for positive margins. During a mean follow-up of 27 months, no recurrent fistula was observed in any of the patients. All patients had normal anal continence, but the majority of patients were incontinent of urine.

CONCLUSIONS

Patients who develop a rectourethral fistula following laparoscopic radical prostatectomy often require additional operations for symptoms control and/or healing of the fistula. Urinary continence is affected in the majority of patients.

Rectourinary fistula after radical prostatectomy: review of the literature for incidence, etiology, and management

Although rectourinary fistula (RUF) after radical prostatectomy (RP) is rare, it is an important issue impairing the quality of life of patients. If the RUF does not spontaneously close after colostomy, surgical closure should be considered. However, there is no standard approach and no consensus in the literature. A National Center for Biotechnology Information (NVBI) PubMed search for relevant articles published between 1995 and December 2010 was performed using the medical subject headings “radical prostatectomy” and “fistula.” Articles relevant to the treatment of RUF were retained. RUF developed in 0.6% to 9% of patients after RP. Most cases required colostomy, but more than 50% of them needed surgical fistula closure thereafter. The York-Mason technique is the most common approach, and closure using a broad-based flap of rectal mucosa is recommended after excision of the RUF. New techniques using a sealant or glue are developing, but further successful reports are needed.