A PERINEAL APPROACH FOR REPAIR OF RECURRENT ANASTOMOTIC STRICTURES AND URETHRO-RECTAL-FISTULAS

Abstract

induced RUF. METHODS: We performed a retrospective review of all patients who underwent RUF repair between 1998-2008. Patient demographics, preoperative, operative, and postoperative data were recorded. Preoperative evaluation included an exam under anesthesia, cystoscopy, combined cystogram and retrograde urethrogram (RUG), and proctoscopy. RUF were repaired by an anterior transperineal approach with 1 or 2 gracilis muscle interposition flaps with or without a buccal graft. Postoperative evaluation included voiding cystourethrogram, cystoscopy, RUG, and selective barium contrast study and proctoscopy. RESULTS: 33 nonradiated and 33 radiated RUF were repaired (figure). Concurrent urethral strictures were present in 18% nonradiated and 27% radiated RUF. 12% radiated RUF presented with pelvic infection. 24% nonradiated and 3% radiated RUF had at least 1 prior failed repair. At a mean follow-up of 20 months, 100% nonradiated RUF were closed with 1 procedure. 85% radiated RUF were closed in a single stage while 12% required (1-5) additional procedures to achieve a 97% closure rate. 12% radiated RUF repairs required prolonged suprapubic cystotomy drainage for permanent closure. 1 radiated RUF required urinary diversion. Postoperatively, there were no strictures in the nonradiated group. There were 5 recurrent strictures in the radiated group, with 2 de-novo strictures. 91% nonradiated RUF had their bowel undiverted. Of those undiverted, 100% are without bowel complication. 39% radiated RUF still have bowel diversion. Urinary incontinence was noted in 12% patients in the nonradiated group and 30% patients in the radiated group. 6 patients had artificial urinary sphincter (AUS) insertion. 2/4 AUS inserted in radiated RUF were removed for erosion. CONCLUSIONS: Radiation RUF constitute the most challenging group of fistulas requiring the use of muscle interposition flaps and buccal mucosa grafts to consistently achieve successful closure.