Rectourethral fistulas after treatment for prostate carcinoma: Update and new management algorithm.

Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical Prostatectomy

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

A rectourethral fistula is a devastating complication of prostatectomy that is difficult to treat and may have significant implications for the patient with respect to quality of life after repair. Falavolti and colleagues have reviewed and published their results in employing the York Mason approach to repair of these fistulas [1]. As they so aptly describe, the surgical approach to rectourethral fistula varies and is often related to the etiology of the fistula. Fistulas that are the result of an iatrogenic injury at the time of prostatectomy are small and more easily managed than those caused by severe prostate and rectal necrosis secondary to radiation therapy for prostate cancer. Therefore the method of surgical repair varies. Hechenbleikner et al. [2] in a recent literature review on rectourethral fistula repair, identified four primary approaches to repairing these defects: transanal, transabdominal, trans-sphincteric, and transperineal. Now, we can clearly add the York Mason approach to that list. However, the overall results from the York Mason approach described are not as promising as those seen with more traditional repairs. The authors report only a 50 % success rate, which compares to a 90 % closure rate when using a transperineal approach [2]. The transperineal approach uses an interposition graft of either muscle, usually the gracilis muscle from the leg, or a buchal mucosal flap, which is not described with the York Mason technique. The transperineal or transanal approach also has the added benefit of not dividing the anal sphincter muscles, which may alter longterm fecal continence in patients. The authors of the present study have a large percentage of patients who have undergone more that two repairs before seeking their services, and this must be taken into account when reviewing the data they report with the York Mason approach. This York Mason technique may provide a clean nonviolated approach to the fistulous tissue after prior repairs have been attempted, and therefore perhaps this technique should be reserved for patients who have failed transanal or transperineal repairs. The addition of a flap such as the buchal mucosal flap to the York Mason approach may add further benefit and result in higher success rates. The factors that determine whether a patient with a rectourethral fistula will undergo a definitive local repair or an excision with either permanent fecal or urinary diversion include the degree of tissue destruction, the etiology of the fistula, and the continence of both systems. Small defects in patients who have maintained urinary control are still best served by the transperineal approach with gracilis or other muscle interposition. Those with significant tissue destruction and loss of continence may be best served with permanent urinary diversion and either fecal diversion, if they have poor sphincter function, or repair of the rectal defect. Those with severe radiation proctitis as a cause of fistula may require a proctectomy, but they may also be candidates for coloanal anastomosis. For those that have had failed traditional repairs and recurrence, and who wish to maintain urinary function, the York Mason approach may be the best bet for obtaining successful closure.

The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula

Men with Low Preoperative Sexual Function May Benefit from Nerve Sparing Radical Prostatectomy

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Acquired recto-urethral fistula in children: Long-term follow-up

Sexual Function, Fertility and Quality of Life after Modern Treatment of Anorectal Malformations

LIFE AFTER RADICAL PROSTATECTOMY: A LONGITUDINAL STUDY

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

Preface Currently, there are many wellestablished therapeutic options for early prostate cancer, and therefore, it is difficult for both urologists and patients to choose the optimal treatment. It is essential for urologists to counsel their patients according to reliable information about the advantages and disadvantages of each therapeutic option. We picked the topic for this issue, “Characteristics and management of erectile dysfunction after various treatments for prostate cancer,” because erectile dysfunction (ED) is one of the most frequent adverse events encountered in the management of prostate cancer. We invited six specialists to review each therapeutic option: radical prostatectomy, laparoscopic radical prostatectomy, robot-assisted laparoscopic radical prostatectomy, external beam radiotherapy, brachytherapy, and androgen deprivation therapy (ADT). Among these modalities, surgical interventions tend to induce a quick drop in erectile function with slow postoperative recovery. Early postoperative rehabilitation has been introduced, aiming at the early recovery of ED. On the contrary, radiation therapy tends to maintain the patient’s erectile function for a while after treatment but it gradually decreases. ADT may compromise not only the erectile function but also the libido level, and may result in significant deterioration of the patient’s quality of life. We hope these reviews will help urologists to counsel their patients with regards to decision-making in the management of early prostate cancer.

120 Background: Urinary continence (UC) and sexual function (SF) may be impacted differently after robotic-assisted laparoscopic (RALRP) versus open (ORP) radical prostatectomy. We compared UC and SF among patients treated by RALRP and ORP at a high-volume hospital who were enrolled in a prospective, longitudinal quality-of-life (QOL) protocol. Methods: Between 2007 and 2012, 516 patients treated by active surveillance, brachytherapy, cryotherapy, RALRP, and ORP were enrolled in a QOL protocol at our institution. The focus of this study is 361 patients who were treated by RALRP (N=190) and ORP (N=171). Functional outcomes were assessed at baseline and at 1, 3, 6, 12, and 24 months using a validated QOL instrument (Giesler RB et al. Qual Life Res 2000). SF was assessed by adding the scores from questions on the quality and frequency of erections. UC was assessed by adding the scores from three questions about the frequency and quantity of incontinence and pad usage. Wilcoxon rank sum test and linear regression multivariable analysis were used to assess SF and UC at each time point. Results: Treatment groups were similar in age, PSA, clinical stage, Gleason grade, BMI, baseline UC and SF scores and baseline PDE-5 inhibitor use (all P > 0.05), but the RALRP patients were slightly older (60 vs 61 years, p=0.04) and had larger prostates (38 vs 44 grams, p=0.001). On multivariate analysis, UC was worse in the RALRP cohort at 1 month (12.0 vs 10.9, P = 0.02), 3 months (9.9 vs 8.5, P = 0.01), and 6 months (8.1 vs 6.8, P=0.01) but was similar at 12 and 24 months (all P > 0.2). SF was similar between both RALRP and ORP at all time points (all P > 0.3). At 24 months, UC for RALRP and ORP was 7.1 vs. 6.4, respectively which was not significant in multivariable analysis (P = 0.5). Likewise, SF for RALRP and ORP was 5.3 vs. 6.2 (multivariable P = 0.9). On repeated measures analysis there was no difference between the groups in UC or SF (P=0.4 and 0.5, respectively). Conclusions: Prospectively collected, patient reported QOL endpoints for SF are similar after RALRP and ORP at all time points in a high-volume hospital. Final UC is similar between both techniques, although RALRP patients may experience a slightly slower return to continence.

PD14-02 RECTOURETHRAL FISTULA REPAIR: EXPERIENCE OF VARIOUS APPROACHES OVER 30 YEARS

To describe the problems and management of rectourethral fistulas. Rectourethral fistula constitutes a rare entity that poses a challenging management problem. The condition is either congenital or acquired. The clinical findings suggestive of RUF include pneumaturia, faecaluria, and urine leakage per rectum. This study was based on English research literature, mainly by searching PubMed bibliographic database. Diagnosis of a rectourethral fistula is difficult and often based on history alone. In rare cases, non-operative management has been successful, but the majority of patients require surgical intervention. A wide variety of procedures have been described for RUF repair. Rectourethral fistula represents a complex management problem for any surgeon. Surgical treatment of RUF is technically demanding and requires collaboration with rectal surgeons.

Background: Rectourethral fistula is a rare complication of radical prostatectomy. Risk factors include history of pelvic irradiation, cryotherapy, intraoperative rectal injury or transurethral resection of the prostate. Diagnosis of rectourethral fistula requires a high index of suspicion, and complete work-up with endoscopy and imaging studies. The majority of patients require operative intervention, with approaches ranging from transabdominal, transrectal, transanal, and transperineal routes. Method: We report two patients with rectourethral fistula after radical prostatectomy. The first patient was a 59-year-old man who underwent an uncomplicated laparoscopic radical prostatectomy for early prostate cancer in another hospital. The second patient was a 64-year-old man who had local recurrence after cryotherapy for prostate cancer. He underwent salvage radical prostatectomy in a private hospital, which was complicated by intraoperative rectal injury. Results: In both patients, the rectourethral fistulae were successfully repaired with a transperineal approach in the prone jack-knife position. Conclusion: We found that the transperineal approach in the prone jack-knife position offered excellent exposure, allowed versatile surgical manoeuvres and produced successful repair with good continence outcomes.