Surgical management of rectourinary fistulae

Abstract

The rectourinary fistula presents a challenging clinical problem that is becoming increasingly common. Rectourinary fistulae most often arise from iatrogenic injuries during prostate surgery, but other causes include pelvic radiation, malignancy, and infection. Therapy must be individualized depending on the cause, comorbidities, patient desires, experience of the surgeon, and coexistent urinary or rectal pathologies. There is a lack of consensus regarding an algorithm to diagnose and treat these fistulae owing to their small numbers and rare incidence. Surgical approaches for definitive repair include the perineal, transanal, transanosphincteric, and combined abdominoperineal approaches. Depending on patient desires and coexistent conditions, a surgeon may perform adjunctive urethral, prostatic, and vesical procedures such as urethroplasty, prostatectomy, or bladder augmentation, with or without augmentation and closure of the vesical neck. We describe a case example of a rectovesical fistula acquired after radical prostatectomy that was repaired with a sliding transanal advancement flap, similar to a type of transanal fistula repair first described by Vose in 1941. The simplicity, minimal invasiveness, and low risk for potential serious complications has led us to recommend this as an initial operative intervention for rectovesical fistulae arising from benign causes. Based on our experience, we propose an evaluation and treatment algorithm based on cause and coexistent conditions. Rectourinary fistulae are rare events. The lack of large series and heterogeneous populations have hindered development of a consensus concerning the management of this debilitating condition. But these fistulae are becoming more common with earlier diagnosis of prostate cancer, which is amenable to treatment with radical prostatectomy, cryosurgery, radioactive seed implantation, external beam radiation, or combination radiotherapy. The causes of rectourinary fistulae can be categorized as benign or malignant. Benign causes include inflammatory bowel disease, diverticular disease, pelvic infections, trauma, and pelvic or urethral surgery. Malignant causes include direct invasion from bladder, urethral, and colon cancer. Generally, prostatic malignancies fail to directly invade the rectum. Iatrogenic injuries can also result from cancer therapies, indicating surgery, cryosurgery, and radiation in the form of brachytherapy or external beam radiation therapy. A comprehensive physical examination is essential for all patients. Emphasis should be placed on the neurologic, abdominal, genital, and pelvic examinations. Identification of previous incisions, medications, immunosuppression, nutritional status, history of relevant coexisting disorders such as diverticular disease, inflammatory bowel disease, pelvic malignancies, and operations is important. Before potential reconstructive flap rotations, limitations of the abdominal, perineal, or leg approaches should be assessed. The most common manifestations of enterovesical fistulas are irritative voiding and recurrent cystitis. Dysuria, pneumaturia, and fecaluria are other common urinary symptoms. GastrointesNo competing interests declared.