Abdominoperineal Repair Research Articles

Predictors of elaborated perineal or a combined abdominoperineal approach during repair for pelvic fracture urethral injury.

A step-based anastomotic urethroplasty is a standard technique for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). We aim to identify pre-operative factors, including results of conventional radiological imaging, for prediction of elaborated perineal or a combined abdominoperineal procedure. Retrospective observational study on 114 consecutive patients undergoing urethroplasty for PFUI between January 2020 and December 2022 was conducted. Surgical procedures were categorized according to the Webster classification into two groups: steps 1-2 (group 1) and steps 3-4 or a combined abdominoperineal repair (group 2). Pre-operative pattern results of RGU/VCUG were categorized regarding the relation between the proximal urethral stump with the pubic symphysis: posterior urethral stump below (pattern 1) or above (pattern 2) the lower margin of the pubic symphysis. Patient demographics were assessed. Univariate and multivariate logistic regression analyses were utilized. Overall, 102 patients were enrolled in the study for data analysis. On the multivariate logistic regression analysis, the presence of erectile dysfunction (OR 4.5; p = 0.014), prior combined treatment (endoscopic and urethroplasty) (OR 6.4; p = 0.018) and RGU/VCUG pattern 2 (OR 66; p < 0.001) significantly increased the likelihood of the need of step 3 or higher. The need of step 3 or higher during urethroplasty for PFUI can be predicted pre-operatively with conventional imaging (RGU/VCUG). Patients with proximal urethral stump above the lower margin of pubic symphysis were about 66 times more likely to need step 3 or higher during urethroplasty.

PD38-12 THE EFFECT OF RADIOTHERAPY ON THE OUTCOME OF THE REPAIR OF URORECTAL FISTULAE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2017PD38-12 THE EFFECT OF RADIOTHERAPY ON THE OUTCOME OF THE REPAIR OF URORECTAL FISTULAE Stella Ivaz, Simon Bugeja, Stacey Frost, Mariya Dragova, Daniela E Andrich, and Anthony R Mundy Stella IvazStella Ivaz More articles by this author , Simon BugejaSimon Bugeja More articles by this author , Stacey FrostStacey Frost More articles by this author , Mariya DragovaMariya Dragova 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.2017.02.1726AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urorectal fistulation is an uncommon consequence of a number of problems but particularly after the treatment of prostate or rectal cancer. Where there is little doubt that post-surgical fistulae can be repaired with satisfactory results, the impact of radiotherapy on the outcome of fistula repair is controversial. Herein we review our experience. METHODS We have repaired 127 urorectal fistulae in the last 10 years with a minimum of one year of follow-up. 24 patients have died or have been lost to follow-up leaving 41 patients who had an abdomino-perineal repair and 62 patients who had a transperineal repair - 103 patients in all. Of the 41 patients having an abdomino-perineal repair, 37 (90%) had had radiotherapy, or the combination of radiotherapy and surgery. Only 4 (10%) patients had a surgical cause of their fistula (NB these patients do not include patients with vesico-colic fistulae or other intra-abdominal fistulae). In the transperineal group 18 had had previous radiotherapy (29%) and the remaining 44 were purely post-surgical fistulae (71%). The principle implication for an abdomino-perineal repair is to deal with sepsis in the pre-sacral space or to deal with radiotherapy problems affecting the bladder or otherwise for omental wrapping of any repair. RESULTS After a tansperineal repair there were 5 failures in each of the two groups. All 10 failures underwent an abdomino-perineal repair subsequently with a satisfactory outcome in 4 out of 5 in each group. The overall success rate of transperineal repair, therefore, is in excess of 95%. After abdomino-perineal repair the success rate in both groups was in excess of 90% in both the surgical and the irradiation group. CONCLUSIONS 91% of patients with post-surgical fistulae can be treated by transperineal surgery with a 98% success rate. Only 31% of post-irradiation patients can be treated transperineally. The other 69% will require an abdomino-perineal repair and both approaches are only suitable in carefully selected patients, although the results are satisfactory in 95%. Although the overall success rate is satisfactory, the postoperative morbidity of post-irradiation patients undergoing abdomino-perineal surgery is high (62%), the recovery is protracted and the return to functional normality prolonged. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e744 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Stella Ivaz More articles by this author Simon Bugeja More articles by this author Stacey Frost More articles by this author Mariya Dragova 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 ...

Urorectal fistulae following the treatment of prostate cancer

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? It is known that urorectal fistulae is a serious but rare complication of the treatment of carcinoma of the prostate. This study adds a distinction between post-surgical fistulate and post-irradiation fistulae. Essentially most post-surgical fistulae are simple and relatively easily dealt with: the expectation is that the patient will return to normality; whereas post-irradiation fistulate are by their nature complex and much more difficult to treat with a much more uncertain long-term outcome. Complexity is discussed and defined. • To evaluate the management of urorectal fistulae (URF) in light of new technology in prostate cancer treatment, which has changed the nature of these URF and, therefore, the approach to treatment. • Between 2004 and 2009 we repaired URF after treatment for prostate cancer in 40 patients with a minimum of 1-year follow-up since their last intervention. • In 23 patients (post-surgical group) the URF resulted from open, laparoscopic or robotic radical prostatectomy. In the other 17 patients (post-irradiation group) the URF resulted from either external beam radiation (EBRT) or brachytherapy (BT), or both, salvage cryotherapy or salvage high-intensity focused ultrasound (sHIFU). • In the 23 patients in the post-surgical group a transperineal repair was performed. In the post-irradiation group a transperineal repair was performed in three of the 17 patients. A transabdominal or abdominoperineal repair was performed in the remaining 14 patients, combined with salvage radical prostatectomy in those eight patients in whom a discrete prostate still existed, and in whom this was possible. • The URF were cured in all patients. • A bladder-neck contracture (BNC) developed in two patients, one of whom is being managed by interval dilatation and the other of whom had a revision of his vesico-urethral anastomosis. Sphincter weakness incontinence required further treatment in eight patients by implantation of an artificial urinary sphincter. • A specific category of complex URF with cavitation was identified, which is particularly common after sHIFU following the combination of previous EBRT and BT, but which may result from the sequential application of any 'new technology'. • URF of any degree of complexity can be managed without the need for a transanorectal sphincter-splitting approach or a covering colostomy and without the need for an interposition flap when the circumstances are appropriate and the surgeon is sufficiently experienced. URF with cavitation and in the post-irradiation group are an exception and do require an interposition flap. • The role of salvage radical prostatectomy in patients with a URF who still have a prostate, needs to be defined. • We suggest that cavitation, BNC and extensive ischaemia due to the serial application of external energy sources confer 'complexity'. Post-surgical URF are simple except for those with cavitation or a BNC. Most post-irradiation URF are complex even in the absence of cavitation or a BNC.

Long-Term Follow-Up of Simultaneous Abdominoperineal Repair of Enterorectocele and Internal Mucosal Prolapse

Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage. Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery. Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression. Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.

Perineal Anastomotic Urethroplasty for Managing Post-Traumatic Urethral Strictures in Children: The Long-Term Outcome

OBJECTIVE To evaluate the long-term results of one-stage perineal anastomotic urethroplasty for post-traumatic paediatric urethral strictures. PATIENTS AND METHODS Thirty-five boys who had a perineal anastomotic urethroplasty for post-traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6-132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto-urethrography. RESULTS The mean (range) age of the patients was 11.9 (6-18) years. The estimated radiographic stricture length before surgery was 2.6 (1-5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow-up. CONCLUSIONS The overall success of a one-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino-perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

Pouch-Vaginal Fistula After Ileal Pouch-Anal Anastomosis: Treatment and Outcomes

Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution. Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy. Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision. The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Perineal anastomotic urethroplasty for managing post‐traumatic urethral strictures in children: the long‐term outcome

To evaluate the long-term results of one-stage perineal anastomotic urethroplasty for post-traumatic paediatric urethral strictures. Thirty-five boys who had a perineal anastomotic urethroplasty for post-traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6-132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto-urethrography. The mean (range) age of the patients was 11.9 (6-18) years. The estimated radiographic stricture length before surgery was 2.6 (1-5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow-up. The overall success of a one-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino-perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

Perineal Repair of Pelvic Fracture Urethral Distraction Defects: Experience in 120 Patients During the Last 10 Years

We report the long-term success of a 1-stage perineal anastomotic repair in patients with pelvic fracture urethral distraction defects. A retrospective analysis of 120 patients undergoing perineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect in a single stage using our progressive approach between May 1991 and May 2001 was performed. Patients with posterior urethral stricture due to other etiologies, or those who underwent substitution urethroplasty or abdominoperineal repair were excluded from this review. Preoperative evaluation of the urethral defect included simultaneous retrograde urethrogram and voiding cystourethrogram. Postoperative retrograde urethrogram was performed at 3 weeks, 3 months, 12 to 18 months and as indicated thereafter. Mean patient age was 32 (range 6 to 82) years. The estimated preoperative radiographic length of the distraction defect was 3.1 cm (range 0.5 to 10). Mean followup was 64 (range 9 to 128) months, mean hospital stay was 1.8 days and duration of urethral stenting was 3.4 weeks. Perineal anastomotic repair was successful in 103 of 109 (95%) adults, in 8 of 11 (73%) prepubescent boys and in 25 of 29 (86%) undergoing secondary repairs. All treatment failures were at the anastomosis and occurred within the first postoperative year. Successful management of failed repairs was accomplished endoscopically in 3 of 7 and by repeat perineal anastomotic repair in 2 of 2, resulting in a final success rate of 97% in adults, 91% in prepubescent boys and 97% in secondary repairs. The overall success of our progressive 1-stage perineal anastomotic repair of pelvic fracture urethral distraction defect continues to be excellent with the majority of failures occurring in prepubescent boys and secondary repairs.

Combined abdominoperineal repair of enterocele and rectocele.

Combined abdominoperineal repair of enterocele and rectocele.

Abdomino–Perineal Repair of Recurrent and Complex Bladder Neck–Prostatic Urethra Contractures

Objective: To evaluate the effectiveness of abdomino–perineal repair in treating complex and recurrent bladder neck–prostatic urethra contractures.Methods: The study included 6 patients retrospectively. Their ages ranged from 66 to 75 years (67.83±8.13, mean + SD). All presented with a long history of voiding difficulty and urinary incontinence. Prior to definitive treatment all the patients had been subjected to multiple unsuccessful transurethral resections of bladder neck–prostatic urethra contractures. They were all subjected to diagnostic work–up including retrograde and voiding urethrogram, urethroscopy and urodynamics. Finally all the patients underwent abdomino–perineal excision of the stenotic area and end to end anastomosis. All of them received simultaneously an artificial urinary sphincter insertion for concurrent sphincteric deficiency and three were subjected simultaneously to clam type ileocystoplasty for intractable detrusor instability. The follow–up ranged from 8 to 56 months (24.42±19.64, mean + SD).Results: The actual surgical time ranged from 3.5 to 5.5 h (4.1+0.4, mean + SD). Five patients void satisfactorily remaining unobstructed through the entire follow–up period, while one has to empty his augmented bladder by means of clean intermittent self catheterization. Five patients are continent and one significantly improved. Major complications due to infection–erosion of the prosthetic material were encountered in one patient.Conclusions: Abdomino–perineal repair is an effective surgical procedure for the management of recurrent and complex bladder neck–prostatic urethra contractures, although it is time consuming and requires in the majority of cases combined techniques in order to achieve optimal results.

Abdomino Perineal Repair of Pulsion Enterocele

To review the techniques, results and complications of the combined abdomino perineal repair and mersilene mesh sacrocolpopexy. From March 1988 to December 1993; 45 cases of pulsion enterocele were treated by a combination of the Zacharin type abdomino perineal repair and mersilene mesh sacrocolpopexy. Forty cases were followed from between 1 month and 18 months (mean 5.95 months). The notes were reviewed retrospectively. There were 3 recurrences (7.5%). Complications were not insignificant: wound infection in 3, urinary tract infection in 6, bowel dysfunction in 8, ventral hernia, vaginal stricture necessitating surgical release, and brachial nerve plexus injury occurred once. In one patient a peritoneal cyst developed necessitating laparoscopic aspiration. The combined abdomino perineal and sacrocolpopexy procedure offers the restoration of normal anatomy and the relief of the symptoms of prolapse in 92.5% of patients. The complication rate is significant and it should be undertaken as a secondary procedure.

The importance of accurate assessment and conservative management of the open bladder neck in patients with post-pelvic fracture membranous urethral distraction defects.

To review the pre-operative assessment of bladder neck competence and assess the success of non-operative management of the bladder neck in patients with pelvic fracture membranous urethral distraction defects. A series of four patients with long-standing post-pelvic fracture urethral distraction defects and open bladder necks demonstrated on pre-operative investigation are presented. All four patients were managed by perineal urethroplasty without surgery to the bladder neck. All patients were continent post-operatively despite the injury having ablated the distal sphincter mechanism. We believe that the majority of patients can be managed successfully by a non-operative approach to the bladder neck, sparing them the unnecessary operative morbidity of an abdomino-perineal repair, which should be reserved for those with obviously scarred or distorted bladder necks.

High imperforate anus—Quantitative results of long-term fecal continence

In a 22-year period, 120 patients were admitted for treatment of a high imperforate anus. Sixty-one patients were available for long-term assessment following a pull-through procedure. These patients were evaluated by written questionnaire and personal interview. Both a qualitative and quantitative fecal continence score were established to provide a system for long-term follow-up that was both reproducible and easy to use. These results were grouped according to the length of time following repair and type of repair performed. Three follow-up time periods were used: 2.5 to 9 years; 10 to 16 years; and 17 to 24 years. During this study, three different procedures were used: sacroperineal (SP), sacroabdominoperineal (SAP), and abdominoperineal (AP). Grouping all three procedures together, the percentage of patients with "good" fecal continence increased in time from 33% to 58% to 64%. Patients undergoing an SP repair uniformly had good results by 10 or more years following repair. In contrast, all patients undergoing an SAP or AP repair had only fair quantitative results 10 to 16 years following repair. Females generally had much better results than males but females also tended to have a lower rectal pouch than males. A comparison of this survey with the results of Swenson, Kiesewetter, Stephens, and Rehbein supports the following conclusions: the anatomic level of rectal pouch at birth predicts fecal continence better than the sex of the patient or type of procedure used; patients in whom the full thickness, terminal rectal wall is used in performing the pull-through procedure have the best fecal continence results.(ABSTRACT TRUNCATED AT 250 WORDS)

Imperforate anus in the adult.

The case report of a 28-year-old man with high imperforate anus and rectourethral fistula (Ladd Type III) is presented. The preoperative findings and operative details are described. The satisfactory result obtained in spite of the patient’s age and the presence of associated vertebral anomalies should encourage attempts at abdominoperineal repair in similar cases. Details of pelvic dissection in an adult with imperforate anus are described, with emphasis upon the problems of greater vascularity and increased depth and narrowness of the pelvis. An alternative method of repair for high imperforate anus, utilizing the sacro-abdominoperineal approach to alleviate some of these difficulties, is suggested. The possibility of using an endorectal procedure in such a case should also be entertained.