Correlation between congenital pelvic floor muscle development assessed by magnetic resonance imaging and postoperative defecation

OBJECTIVE

Children with congenital anorectal malformation (CAM) experience challenges with defecation. This study aims to assess defecation in preschool-age children with CAM and to evaluate the correlation between pelvic floor muscle developed assessed by magnetic resonance imaging (MRI) and postoperative defecation.

METHODS

We collected clinical data and MRI results from 89 male children with CAM. The bowel function scores for children with Perineal (cutaneous) fistula, Rectourethral fistula(Prostatic or Bulbar), and Rectovesical fistula were computed. MRI scans were subjected to image analysis of the striated muscle complex (SMC). The association between pelvic floor muscle score and bowel function score was examined using the Cochran-Armitage Trend Test.

RESULTS

We observed that 77.4% of the SMC scores by MRI for Perineal fistula were good. The Rectourethral fistula SMC score was 40.6% for moderate and 59.4% for poor. The SMC score for Rectovesical fistula was 100% for moderate. Furthermore, 77.4% of patients with Perineal fistula had bowel function scores (BFS) ≥ 17 points. Among those with Rectourethral fistula and Rectovesical fistula, 12.5% and 0 had BFS ≥ 17 points, respectively. An analysis of muscle development and bowel function in patients with Rectovesical fistula, Rectourethral fistula, and Perineal fistula revealed a correlation between SMC development and BFS. Subgroup analysis showed that the Perineal fistula had statistical significance; however, the Rectourethral fistula and Rectovesical fistula were not statistically significant.

CONCLUSION

A correlation exists between pelvic floor muscle development and postoperative defecation in children with Perineal fistula.

Mid-Perineal Scrotal Flap for the Repair of Urorectal Fistulas: A New Technique

Rectourethral fistula (RUF) is an infrequent but severe complication of the treatment of prostate cancer. Herein, we describe a new surgical approach used successfully in 3 patients that incorporates a partially de-epithelialized mid-perineal scrotal flap (MPSF), used as interposition flap, that can be used in almost every patient with RUF after radiotherapy, regardless of having or not a concomitant posterior urethra or bladder neck stricture or contracture that might require a simultaneous urethroplasty. The interposition flap includes well vascularized subcutaneous fat tissue by distal vascular branches of the internal pudendal vessels that reaches without tension the deep perineum up to the posterior bladder neck. The MPSF is a time efficient procedure that allows excellent access to the bulbar urethra and to the surgical plane between rectum and prostate and it does not require a separate incision for the flap harvesting procedure when required.

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra

OBJECTIVE

To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication.

METHODS

The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair.

RESULTS

Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229 min with an estimated blood loss (EBL) of 15 mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements.

CONCLUSION

Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

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.

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.

Adult residual rectourethral fistula and diverticulum presenting decades after imperforate anus repair: a case report

Background

This report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair.

Case presentation

A 44-year-old Latino male with history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum.

Conclusions

Although rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02921-3.

Transanal fistulectomy for postoperative persistent rectourethral fistula in patients with ARM: is simple resection enough?

Background

Postoperative rectourethral fistula (RUF) in patients with congenital anorectal malformation (ARM) remains a challenge for paediatric surgeons, among them persistent fistula is the most common. Various techniques have been proposed, only a few reports based on different causes are available, and there is no consensus so far. This study is to evaluate the application, advantages and limitations of transanal fistulectomy approach in repairing persistent RUF in ARM patients.

Methods

From January 2007 to July 2019, 78 ARM patients who received revisional surgery for RUF were reviewed, 34 persistent fistulas were identified. Examination under anaesthesia included patients with fistulas that were located within 3 cm from the anus verge, good appearance of the anus and sphincter function, and no urethral and rectoanal obstruction. Three patients were excluded because of complex urologic pathologic defects. In total, thirty-one patients underwent transanal fistulectomy to repair RUF.

Results

All cases were approached with transanal incision and fistulectomy to repair RUF. The average operative time was 91 ± 35 min. At a minimum six-month follow-up, 29 patients healed after the first attempt, the success closure rate was 93.5%. Two patients received redo transanal fistulectomy and healed. Two patients had postoperative complications: one patient had urethral stenosis and it was managed by dilation; one patient had urethral diverticulum but it did not require revisional surgery. No patient in this study was incontinent because of the surgery.

Conclusions

Transanal fistulectomy provides a simple, straightforward, and safe approach to repair persistent RUF in ARM patients, especially in those with a low-lying fistula, good anus appearance and sphincter function without obstruction in the rectum or urethra.

Trial registration: Retrospectively registered.

A novel combined enteroscopy and laparoscopy approach to prevent urethral complications in management of rectourethral fistula

BACKGROUND

For the last 20 years, laparoscopy management of anorectal malformations (ARM) has been challenged due to the development of postoperative urethral diverticulum or injury caused by the imprecise transection of rectourethral fistulae, particularly rectobulbar fistulae situated deep in the pelvis. We have developed a combined approach of enteroscopy and laparoscopy for intraluminal incision of a rectourethral fistula.

METHODS

We retrospectively reviewed 47 ARM patients who underwent surgical corrections using the combined approach between January 2019 and June 2020. Early postoperative and subsequent follow-up results were evaluated.

RESULTS

The median follow-up period was 12 months. The average age at surgery was 3.18 ± 0.64 months. The mean operative time of a single-incision laparoscopic-assisted anorectoplasty (SILAARP) was 1.19 ± 0.29 h. The time for intraluminal incision of the fistula was shortened from 14 to 2 min. No patients underwent a conversion. The average postoperative hospital stay, time to full feeds and placement of an anal tube were 10 days, 1 day, and 5 days, respectively. No urethral diverticulum, urinary injury, wound infection, rectal retraction, anal stenosis or rectal prolapse was encountered in the cohort.

CONCLUSIONS

The combined enteroscopy and laparoscopy approach offers precise management of rectourethral fistulae. It could effectively obviate urethral complications, eliminating the obstacles of laparoscopy application in the management of ARMs.

Rectourethral and rectovesical fistula as serious and rare complications after Hirschsprung disease operation: Experience in seven patients

AIM

To present the features and treatment of rectourethral fistula (RUF) and rectovesical fistula (RVF) after Hirschsprung disease (HD) operation.

METHODS

A retrospective analysis was performed on patients with RUF and RVF after HD operation, who received repair surgery from a single surgeon between January 2005 and December 2019. Bowel function was assessed using the Rintala score.

RESULTS

Seven patients were included. Six patients were referred to us after transanal endorectal pull-through (TEPT) in other centers; one RVF patient had fecal diversion at admission. Bladder-neck injury was detected during redo TEPT in our hospital in the remaining one patient and instant repair was given. 11 days later, RVF and sepsis were detected. Fecal and urine diversion was performed immediately. The fistula openings were prostatic urethra (3), membranous urethra (2), bladder triangle (1), and bladder-neck (1). Anastomotic stricture (4), bladder stone (3), hydronephrosis and ureterovesical junction obstruction (2), pelvic infection (2), distal colonic dilatation (1) and other fistulas (1) were identified before repair surgery. Fecal and urine diversion was performed before repair surgery in one RUF and one RVF patient respectively, to treat pelvic infection owing to fecal or urine leaks and accompanying problems. Five RUFs were repaired by transperineal approach, and two RVFs were repaired using the transabdominal and transanal approach respectively. Four patients with anastomotic stricture underwent redo TEPT with simultaneous fistula repair. Aside from one RUF patient, the fistula in all patients successfully resolved. Median follow up time was 81 months (range, 5-116 months). No recurrence was observed. Median bowel function score was 17.5 (range, 17-18).

CONCLUSION

The location of fistula, presence of anastomotic stricture and the association of urinary complications have significant impacts on the treatment strategy in such rare complications after TEPT for HD.

THE TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Rectourethral fistula following SpaceOAR gel placement for prostate cancer radiotherapy: A rare complication

After undergoing a SpaceOAR® gel placement prior to planned radiotherapy for Gleason 4 + 4 prostate cancer, a 70-year-old male experienced severe right buttock pain and urine passing from his rectum. A colonoscopy and follow-up pelvic MRI demonstrated a large rectourethral fistula. The fistula was treated surgically with a robot-assisted radical prostatectomy, primary rectal repair, omental flap and diverting loop ileostomy. Pathology demonstrated extensive treatment effect with no residual prostate cancer. This is the first case study of a rectourethral fistula attributable to SpaceOAR® gel placement.

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.

Recurrent rectourethral fistula repair: A novel technique of gracilis muscle interposition

BACKGROUND

A perineal approach with gracilis muscle interposition (GMI) remains the most common in recurrent rectourethral fistulas (RUFs). The closure failures in10%-20% cases and urinary incontinence in 10%-80% cases referred to the disadvantages of the perineal approach owing to neurovascular damage. This article shows that the retraction of a survived muscle gracilis flap is one of the causes of fistula recurrence, and a simpler technique of the flap interposition is presented, requiring a less invasive perineal access.

METHODS

Three consecutive patients with RUF at the age of 5, 13 and 15 years who underwent multiple (3, 4 and 5) unsuccessful reconstructive attempts were referred to our clinic. The last procedure was performed with GMI. In all cases, these were acquired iatrogenic fistulas that occurred after operations for Hirschsprung's disease (2) or anorectal malformation (1), and subsequent dilatation of the anus. All patients had a colostomy several years ago. Reinterposition and distant anchoring of the survived graсilis flap were performed through the perineal approach, avoiding lateral and anterolateral dissection.

RESULTS

The early postoperative period was uneventful. In one patient, a stricture of the posterior urethra formed. Urethrotomy was performed in 3 months, with complete restoration of micturition. The colostomy was closed in all patients after 3-4 months. In the long term follow up within 4-8 years, no fistula recurrence was noted.

CONCLUSIONS

The suggested traction technique of GMI allowed: to minimize the perineal access size, hence minimizing the injury and the operating time; to place the anchoring suture outside of the inflammation zone, ensuring secure attachment; to provide precise flap positioning and intimate contact between the flap and the urethra.

LEVEL OF EVIDENCE

Level V.

Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas

BACKGROUND

Rectourethral fistulas (RUFs) are rare but devastating complications after surgery or radiation therapy to the urethra, prostate, or rectum. RUF repair is challenging, especially in irradiated patients.

OBJECTIVE

To evaluate the efficacy of the York Mason (YM) procedure with or without concomitant gracilis muscle interposition (graciloplasty) for RUF repair.

DESIGN, SETTING, AND PARTICIPANTS

Records of patients with an iatrogenic RUF who underwent the YM procedure between 2008 and 2018 in two university hospitals were reviewed. Data on etiology, diagnostic and operative procedures, urinary and fecal diversion, and postoperative follow-up were collected.

INTERVENTION

Twenty-eight patients underwent 33 YM procedures. Concomitant graciloplasty was performed in four (14%) primary repairs and two (7%) repairs for recurrent RUFs.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was successful RUF repair, defined as absence of symptoms and no leakage on control urethrocystography. The secondary endpoint was colostomy reversal rate.

RESULTS AND LIMITATIONS

Median follow-up was 24 mo. Ten patients (36%) were irradiated previously. The ultimate success rate was 75% after a maximum of three YM procedures. Success rates were 89% and 50% in patients with nonirradiated and irradiated fistulas, respectively. In irradiated patients, the success rates of the first YM procedure with and without graciloplasty were 100% and 29%, respectively. In recurrent cases, concomitant graciloplasty did not result in better outcomes. Colostomy reversal was possible in 15 patients after successful repair. In all patients, fecal continence was intact and no anal stenosis was reported. Limitations of the study include small sample size and the retrospective design.

CONCLUSIONS

Combination of the YM procedure with graciloplasty resulted in higher success rates of RUF repair in patients with irradiated fistulas. Fecal continence was preserved, and colostomy reversal is feasible.

PATIENT SUMMARY

We analyzed the outcomes, complications, and colostomy reversal rate of the York Mason procedure for the repair of rectourethral fistulas (RUFs). We found that concomitant graciloplasty increases success rates in case of prior radiation therapy. Colostomy reversal is feasible after RUF repair.

A call to ARMs: Accurate identification of the anatomy of the rectourethral fistula in anorectal malformations

Recto-urethral fistulae are the most common finding in males born with an anorectal malformation (ARM). A high pressure distal colostogram is an important tool in visualizing the fistula, although the precise level at which the fistula communicates with the urethra may be difficult to interpret and is not reported in a uniform manner. This anatomy affects the surgical plan; determining the likelihood that the rectum is reachable via a posterior sagittal incision or better approached through the abdomen via laparoscopy or laparotomy helps counsel families and stratifies diagnoses for outcomes work. Herein we present a figure used at our Center to assist with correlating findings on the distal colostogram with the anatomic level of the recto-urethral fistula in males with anorectal malformations.

Anatomical alterations following the 'PSARP' procedure: Correlating MRI findings with continence scores

PURPOSE

To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome.

PATIENTS AND METHODS

Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification).

RESULTS

The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B.

CONCLUSION

Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients.

LEVEL OF EVIDENCE

This is a case control study (level III evidence).

Management of complex and redo cases of pelvic fracture urethral injuries

Objectives

Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios.

Methods

Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995–2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included.

Results

Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia.

Conclusion

The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

Management of acquired rectourethral fistulas in adults. Asian J Urol. 2018;5:149-154. [PMID: 29988864 PMCID: PMC6032817 DOI: 10.1016/j.ajur.2018.01.003]

Rectourethral fistula is an uncommon but devastating condition resulting from surgery, radiation, trauma, inflammation, or occasionally anorectal anomaly. Because of involving the urinary and the digestive system, surgical repair can be challenging. More than 40 different surgical approaches were described in the literature. However, no standardized management exists due to the rarity and complexity of the problem. Spontaneous closure of fistula is rare and most cases need reconstructive procedures. Appropriate preoperative assessment is crucial for the decision of operation time and method. Gradually accumulating evidence indicates surgeons should take fistula size, tissue health and vascularity associated with radiation or infection, urethral stricture, and bladder neck sclerosis into consideration and make a proper treatment plan according to the features of various approaches. Accurate preoperative evaluation and proper approach selection would increase success rates. Multiple surgical team corporation, including colorectal, urological and plastic surgeons, would optimize the outcomes.

Is measuring the residual rectourethral fistula during laparoscopically assisted anorectal pull-through for male high/intermediate type imperforate anus beneficial? Mid-term follow-up

BACKGROUND/PURPOSE

We evaluated routine intraoperative residual rectourethral fistula measurement (IRRFM) in 20 consecutive male imperforate anus with recto-bulbar (RB; n=12) or recto-prostatic (RP; n=8) fistula during laparoscopically assisted anorectal pull-through (LAARP) for preventing incomplete fistula excision (IFE) on mid-term follow-up.

METHODS

Twenty consecutive LAARP performed at a mean age of 10months (range: 3-30) followed-up for a mean of 4.8years (range: 1.5-9) were reviewed. IRRFM involves using a calibrated catheter and a cystoscope to measure the distance between where dissection was ceased at the rectal end and the urethral orifice (Figure). Dissection and IRRFM were repeated until the fistula was <5mm, then tied, and divided. Magnetic resonance imaging (MRI) and pelvic ultrasonography were used to exclude IFE and cyst formation.

RESULTS

Residual fistula was 4-18mm on initial IRRFM. Unless measured, dissection cannot proceed to <5mm safely with poentical for urethral injury or IFE. With experience, initial IRRFM were shorter, especially in RP (Table 1). Before the IRRFM era, our incidence of cysts was 2/11 (18%), but here we found no evidence of cyst formation on MRI, no dysuria, and no urinary tract infections.

CONCLUSIONS

Mid-term review demonstrates that IFE can be prevented successfully by IRRFM during LAARP.

LEVEL OF EVIDENCE

Case Series with no Comparison Group, Level IV.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

Laparoscopic dissection and division of distal fistula in boys with rectourethral fistula

BACKGROUND

Congenital rectourethral fistula (RUF) is the most common form of anorectal malformations found in boys. The aim of this study is to review our experience with dissection and division of distal fistula using laparoscopic surgery in the management of RUF, especially rectourethral bulbar fistula.

METHODS

One hundred and two consecutive boys with congenital RUF who underwent conventional or single-incision laparoscopic surgery between July 2008 and June 2015 were enrolled in the study. The dissection of the distal fistula was performed along submucosal layer to a level 0.5 cm proximal to the urethra. Rectal mucosa of the fistula was dissected to the distal most point and completely transected flush with the posterior urethra. The residual muscular cuff was ligated with Hem-o-Lock clip or 5-0 PDS suture. Voiding cystourethrography and pelvic magnetic resonance imaging were performed at 3 mo, 6 mo, and 1 y postoperatively.

RESULTS

All patients successfully underwent laparoscopic surgery without conversion. The mean age at the time of operation was 4.3 ± 2.9 mo. The operative times for the rectoprostatic fistula and rectobulbar fistula were similar (118.2 versus 119.4 min, P = 0.082). There was no significant difference in average operative time between conventional laparoscopic surgery group and single-incision laparoscopic surgery group (118.8 versus 119.1 min, P = 0.281). There was no injury to the urethra or vas deferens. The urethral catheter was removed on postoperative day 10. All patients were followed up. The median follow-up period was 3.3 ± 1.8 y. No recurrent fistula or urethral diverticulum was detected on voiding cystourethrography and pelvic MRI at 1 y.

CONCLUSIONS

Submucosal dissection and division of distal fistula using a laparoscopic approach is safe, feasible, and effective for congenital RUF, especially bulbar fistula, in boys.

Rectourethral Fistula Management

Rectourethral fistula (RUF) is a rare condition that occurs, in most cases, as a consequence of prostate cancer treatments. Clinical suspicion and proper assessment prior to surgery are essential to adapt and successfully carry out an appropriate treatment plan. There are no randomized trials to guide clinical practice, and therefore, scientific evidence in this respect is limited. Expert recommendations seem to agree on the transperineal approach with flap interposition as the surgical treatment of choice in cases of complex fistulas, especially in those that have undergone prior radiation. Undoubtedly, the key to the successful treatment of the disease is the multidisciplinary and standardized management by physicians with experience in the field.

A delayed-onset rectourethral fistula after intersphincteric resection for very low rectal cancer: a case report and literature review

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

Intersphincteric approach for rectourethral fistulas following radical prostatectomy

BACKGROUND

Rectourethral fistula is a challenging complication of radical retropubic prostatectomy. Several treatments have been proposed, with varying outcomes. The available data are difficult to interpret, because patient and disease characteristics differ significantly among reports. Details of long-term follow-up and functional status are rarely provided. We describe a technique of rectourethral fistula repair via an intersphincteric route.

METHODS

Preoperative workup included proctoscopy and urethrocystography. All patients already had a stoma at the time of fistula repair. Mechanical cleansing of the bowel distal to the colostomy was routinely performed, and perioperative antibiotic prophylaxis was administered. Patients were placed in the lithotomy position. Under spinal anesthesia, a curvilinear anteanal incision was made, to expose the external sphincter. The anterior portion of the external sphincter was gently displaced along half of its circumference. The anterior rectal wall was sharply dissected free from the urethra, approximately up to 2 cm above the fistula level through the intersphincteric plane. The fistula was identified. The surrounding tissues were mobilized to obtain a tension-free repair of the urethral defect, using a single row of 4-0 polyglactin transverse, interrupted sutures. Transanally, a U-shaped full-thickness rectal flap was advanced and sutured with 3-0 monofilament interrupted sutures to cover the rectal opening, and care was taken to ensure that the two suture lines were in different planes. The catheter was left in place for 4 weeks. Patients were evaluated at 3-month follow-up for stoma closure.

RESULTS

We successfully treated five patients. Only one minor complication was observed (surgical site infection). Stomas were taken down uneventfully. After a median follow-up duration of 2 years (range 2-3 years), no patients had fistula recurrence or impaired continence.

CONCLUSIONS

Intersphincteric repair should be considered as an effective option in patients with iatrogenic rectourethral fistulas. This technique offers several advantages over alternative procedures that require more extensive approaches or invasive manipulation of the anal sphincters.

Management of anorectal malformation without ligation of fistula: an approach preventing posterior urethral diverticula

OBJECTIVE

The posterior urethral diverticulum is a common urologic complication requiring reoperations in anorectal malformation cases (ARM). We present a series of 24 cases of male ARM managed without ligation of fistula.

MATERIAL AND METHODS

A prospective study was conducted between July 2010 and June 2012 including male neonates with ARM, where rectobladder neck and rectoprostatic fistula were approached by the abdominal route. The fistulous tract was dissected to the distal-most possible length and was excised flush with the urethra without its ligation. A per-urethral catheter was placed in situ. A record was made of any features of urinary leak and a micturating cystourethrogram was performed at the 1-year of follow-up.

RESULTS

Twenty-four cases of ARM, 16 with rectobladder neck fistula and eight cases with rectoprostatic fistula were included. Of these, 12 had single-stage primary abdominoperineal pull-through and 10 were managed by primary posterior sagittal anorectoplasty. Two cases with colostomy during the neonatal period were managed by laparoscopic assisted anorectoplasty at 6 months. None of the cases had a urinary leak during the postoperative period. All had a normal micturating cystourethrogram at 1 year.

CONCLUSIONS

The approach of dividing fistula without ligation may prevent posterior urethral diverticula, but larger long-term follow-up studies are needed.

Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4-29 years of follow-up: a single-institution, cross-sectional study

BACKGROUND/PURPOSE

Posterior sagittal anorectoplasty (PSARP) has become the standard surgical treatment for males rectourethral fistula (RUF) at most surgical centers worldwide. We aimed to define the long-term bowel functional outcomes following PSARP for RUF at our institution between 1983 and 2006, with comparison to age- and gender-matched controls.

METHODS

Patients were invited to answer a detailed, previously validated Bowel Function Score (BFS) questionnaire by post. Respondents were matched by age and gender to three controls from the general population who had answered identical questionnaires. Case records were reviewed retrospectively for operative details. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids.

RESULTS

Of 34 (79%) respondents (median age 19 (range, 4-29) years), 74% had voluntary bowel movements (VBMs), 24% were reliant on anterograde continence enema (ACE) washouts, and 1 patient had a colostomy. Impairment of bowel function was significantly higher in all aspects of fecal control among patients than controls (p<0.001). A statistically significant decline in fecal accidents and soiling was observed with age (p ≤ 0.03). Thirty-one percent of patients with VBMs had constipation managed with diet or laxatives (vs 2% of controls, p=0.0002). Of patients with VBMs followed up for > 12 years (n=20), 50% were completely continent (vs 73% of controls; p=NS). Overall, 76% of respondents were socially continent with or without artificial means in the form of ACE washouts. By BFS score, 39% had a good functional outcome, 27% had a moderate outcome, 9% had a clearly poor score and 24% were living with an ACE.

CONCLUSIONS

Our results suggest that in the long-term, functional symptoms remain highly prevalent among patients treated for RUF with PSARP. However, the majority can be expected to achieve social continence, although for some this will require intervention with ACE bowel management. Approximately one third may report VBMs and complete continence.

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.

The Gonzalez hernia revisited: use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae

INTRODUCTION

During the development of the posterior sagittal approach to anorectal malformations a vital technical challenge was a precise midline dissection, which if off, allowed for the ischiorectal fat pad to bulge into the wound. This occurrence became affectionately known as a "Gonzalez hernia", after a trainee of Dr Pena's (and a co-author of this paper). We describe here an innovative use of the ischiorectal fat pad to aid in the repair of acquired rectovaginal and rectourethral fistulae.

METHODS

Patients with recurrent vaginal or urethral fistulae were selected for review. The ischiorectal fat pad was deliberately mobilized (via a posterior sagittal or transanal approach) and used to buttress the repair of the posterior vagina or urethra.

RESULTS

The ischiorectal fat pad technique was used in 9 patients. All had an acquired fistula (6 rectovaginal fistula, 3 rectourethral fistulas). We used the posterior sagittal approach in 7 and in 2 the transanal approach. Six patients had had at least two prior attempts at fistula repair. Six patients had a stoma, and 3 did not. There were no recurrences in greater than six month follow-up.

DISCUSSION

The ischiorectal fat pad is easily visualized and mobilized, either via a posterior sagittal or transanal approach, providing excellent coverage with native, well-vascularized tissue, in an area that is difficult to heal. It is an excellent option for recurrent rectovaginal and rectovaginal fistulae and may have other additional creative applications.

Prenatal diagnosis of enterolithiasis at 18 weeks: multiple foci of intraluminal calcified meconium within echogenic bowel

Enterolithiasis is an uncommon finding of a dilated hyperechogenic bowel with multiple ball-like echogenic structures at a routine prenatal check-up using ultrasonography. We here report a case of prenatally diagnosed enterolithiasis at 18 weeks of gestation, showing multiple hyperechogenic foci rolling within the bowel fluid after peristalsis. The size of the dilated bowel gradually increased during pregnancy. Magnetic resonance image demonstrated the dilated lower bowel with blind-ending rectum. A postnatal contrast medium study with retrograde urethrography revealed a middle imperforate anus and a rectourethral fistula. A careful examination, even before 20 weeks of gestation, is extremely useful in demonstrating intraluminal coarse calcifications within an echogenic bowel.

[Augmented-pressure colostogram in the radiological assessment of anorectal malformations]

OBJECTIVES

To present our experience in detecting the existence of a possible associated fistula between the pouch colon and the urogenital tract in patients with anorectal malformations by carrying out an augmented-pressure colostogram, and its subsequent correlation between radiological and surgical findings.

MATERIAL AND METHODS

A 17-year retrospective revision of 43 patients with anorectal malformations was performed. 34 of them were referred to the Radiology Department in order to carry out an augmented-pressure distal colostogram prior to surgery.

RESULTS

A fistula was demonstrated in 26 of the 34 patients who had an augmented-pressure distal colostogram done. In the remaining 8 patients, this technique failed to demonstrate a fistula. The radiological findings were confirmed during the surgery in each case.

CONCLUSIONS

The augmented-pressure distal colostogram is a simple and accurate study to delineate the altered anatomy of anorectal malformations, to define the distance between pouch colon and perineum, and to identify the localization of any associated fistulous communication. It is the most dependable test for a surgeon in order to choose the type of surgical approach, which depends on the presence or absence of an associated fistula.

Rectourethral fistula secondary to a bowel management system

A 67-year-old Caucasian male was admitted under the vascular team with critical lower limb ischaemia. Bypass surgery was performed and he was admitted to the intensive care unit post-operatively. The patient experienced a turbulent post-operative recovery complicated by pneumonia, poor respiratory wean and faecal incontinence. A bowel management system was inserted but after 18 days it was reported faecal matter was bypassing his catheter. A CT scan demonstrated an area of necrosis where the bowel management system had been sited which formed a rectourethral fistula. Bowel management systems are frequently used in intensive care unit settings where a high proportion of patients suffer from faecal incontinence. If used correctly they can reduce skin contamination, infection and maintain patient hygiene. However, appropriate assessment and investigations should be addressed before inserting such devices. This case report highlights serious adverse effects of these devices and describes the first documented case of these devices causing a rectourethral fistula.

Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas

AIM: To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas (RVFs) and rectourethral fistulas (RUFs).

METHODS: Between May 2009 and March 2012, 11 female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled. Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage. Efficacy was assessed in terms of the success rate and surgical complications. SF-36 quality of life (QOL) scores and Wexner fecal incontinence scores were compared before and after surgery.

RESULTS: The fistulas healed in 14 patients after gracilis muscle transposition; the initial healing rate was 73.7%. Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5 patients: 4 healed and 1 failed, and postoperative fecal diversions were performed for the patient whose treatment failed. At a median follow-up of 17 mo, the overall healing rate was 94.7%. Postoperative complications occurred in 4 cases. Significant improvement was observed in the quality outcomes framework scores (P < 0.001) and Wexner fecal incontinence scores (P = 0.002) after the successful healing of complex RVFs or RUFs. There was no significant difference in SF-36 QOL scores between the initial healing group and irrigation-suction-assisted healing group.

CONCLUSION: Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs. QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.

Traumatic rectourethral fistula repair: A potential application of porcine small intestinal submucosa

Rectourethral fistula is an uncommon but devastating condition. Traumatic rectourethral fistula is still uncommon and repair of traumatic rectourethral fistula involves a complex procedure. Most of the urologists would prefer to repair the fistula through perineal route especially when urethral reconstruction is also required. The repaired ends of the fistula are separated with various interposition flaps and grafts in order to prevent recurrence. Gracilis interposition muscle flap is commonly used. We describe the first case of traumatic rectourethral fistula repair in a 45-year-old man using interposition of a porcine small intestinal submucosal (Biodesign™ (Surgisis^®) graft.

Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: an easier and more physiologic approach

AIM

To present surgical technique and results of combined laparoscopic and modified posterior sagittal approach (PSAP) saving the external sphincter in the management of rectourethral fistula.

METHODS

The operation was started by a laparoscopic approach to dissect around the rectal pouch and separate the rectal pouch from the upper urethra. The PSAP saving the external sphincter was added to completely separate the rectal pouch from the urethra. The fistula was divided and closed. The rectal pouch was then pulled through a tunnel created at the center of the external sphincter and an anoplasty was performed.

RESULTS

From September 2011 to September 2012, 19 patients were operated on using the same technique. Mean age of patients was 4.0 ± 1.8 months. Rectourethral fistula was located in the prostatic urethra in 15 patients and in the bulbar urethra in 4 patients. The mean operative time was 82 ± 13 min. There were no intraoperative complications. Postoperative perforation of the posterior wall of the rectum happened in one patient and required a second laparoscopic operation. Follow-up after closure of colostomy from 1 month to 7 months revealed all patients were able to pass stool spontaneously. All patients could urinate easily. No urethral fistula or diverticulum was detected on voiding cysto-urethrography.

CONCLUSIONS

Combined laparoscopic and PSAP saving the external sphincter is the easier and more physiologic approach to manage rectourethral fistula with fewer complications.

Treatment of a recurrent rectourethral fistula by using transanal rectal flap advancement and fibrin glue: a case report

Rectourethral fistulas (RUFs) in adults are rare and could result from complicated trauma, and prostatic or rectal surgery. RUFs have been treated initially by using primary repair and omental interposition with or without a colostomy during surgery. Recurrent RUFs require complex surgery, such as a low rectal resection and coloanal anastomosis, an interposition flap of the datos muscle or gracilis muscle, and others. Recently, transanal rectal flap advancement and fibrin glue injection have provided an effective occlusion of RUFs. However, no reports about this technique exist for cases of recurrent RUFs. We report a case of a recurrent RUF successfully repaired by using transanal rectal flap advancement combined with fibrin glue injection into the fistula tract. The postoperative course was uneventful without complications. At the 1-year follow-up, no complications such as urethral stricture or recurrence existed, and voiding was normal without anal incontinence.