MP29-06 RECONSTRUCTIVE SURGERY FOR URO-RECTAL AND PERINEAL FISTULAE

Abstract

You have accessJournal of UrologyTrauma/Reconstruction: Ureter, Bladder, External Genitalia and Urotrauma II1 Apr 2015MP29-06 RECONSTRUCTIVE SURGERY FOR URO-RECTAL AND PERINEAL FISTULAE Simon Bugeja, Anastasia Frost, Enrique Fes, Stella Ivaz, Daniela E. Andrich, and Anthony R. Mundy Simon BugejaSimon Bugeja More articles by this author , Anastasia FrostAnastasia Frost More articles by this author , Enrique FesEnrique Fes More articles by this author , Stella IvazStella Ivaz More articles by this author , Daniela E. AndrichDaniela E. Andrich More articles by this author , and Anthony R. MundyAnthony R. Mundy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.609AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES This study presents 66 cases of uro-rectal or uro-perineal fistulation managed by a transperineal (TP) approach with or without gracilis interposition flap, and additional abdominal exposure as necessary depending on the size and location of the fistula, presence of cavitation and involvement of adjacent structures such as the pubic symphysis. Surgical results as well as wound infection and radiological leak as predictors of outcome were evaluated. METHODS 43 TP (17 with gracilis flap) and 23 abdomino-perineal (AP) repairs of uro-rectal and/or uro-perineal fistulae were performed in 58 men. 13 were redo procedures. 31 patients had undergone radiotherapy, HIFU, cryotherapy, brachytherapy or a combination of these. All underwent fluoroscopic assessment on average 4 weeks post-op prior to urethral catheter removal. In 54 cases the perineal wound was closed over a corrugated drain. RESULTS 79.1% of primary TP repairs were successful with a slighly lower success rate when a gracilis flap was used (71% vs 85%) most likely reflected by a much higher proportion of irradiated patients in this group (65% vs 12%). AP approach was successful in 83% of cases, 74% of them having been irradiated. Overall success rate for the first reconstructive procedure was 80.3%. All recurrences occured in either irradiated patients, Crohn's disease or in non-primary procedures. Following salvage surgery, 92% of patients (53 of 58) were eventually reconstructed. 14 perineal wound infections were documented, 13 in patients having a perineal drain, 10 of whom developed recurrence (71%). Of the 13 recurrences, 11 (85%) developed a track onto the perineum at the drain site. In 8 of the 9 (88.9%) failed rectal fistula repairs, recurrence occured from the urinary side rather than the rectal side of the fistula. In 20 of 52 cases with a successful outcome (38.5%), urethrogram at 4 weeks demonstrated a leak from the urinary side. This was either into a contained cavity or blind-ending track and was managed conservatively. The catheter was removed on average 84.8 days after surgery. 18 patients remained asymptomatic. In 2, this cavity subsequently became infected, requiring further salvage surgery. CONCLUSIONS Recurrence after fistula repair is usually from the urinary tract. This most often presents as a recurrent track, not into the rectum, but onto the perineum to the drain site. Consequently we now avoid draining the perineal wound routinely. Radiological leaks from the urinary system into a blind ending track or cavity are common after this type of procedure and very often can be managed conservatively without compromising the final outcome. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e341 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Simon Bugeja More articles by this author Anastasia Frost More articles by this author Enrique Fes More articles by this author Stella Ivaz More articles by this author Daniela E. Andrich More articles by this author Anthony R. Mundy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...