Management Of Rectourethral Fistula Research Articles

Minimally Invasive Management of Rectourethral Fistulae

ObjectiveTo report our experience and outcomes in minimally invasive management of rectourethral fistula (RUF). MethodsFrom 2004 to 2021, 15 patients who underwent minimally invasive RUF repair by a single surgeon at 2 international institutions were retrospectively reviewed. Baseline demographic characteristics, perioperative, and postoperative data were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Panel Assesment and Recommendations. Success was defined as complete resolution of fistula-related symptoms at 12-month follow-up along with confirmation of fistula closure by imaging or cystoscopy. Categorical variables were presented as frequencies and percentages whereas continuous variables were reported as median and quartiles. ResultsFifteen male patients with a median age of 71 (64-79.2) years were treated. Four cases (26.6%) occurred postsurgery, 8 cases (53.3%) occurred after energy treatments, and 3 cases (20%) after surgery combined with an energy treatment modality. A robotic and laparoscopic approach was performed in 9 (60%) and 6 (40%) patients, respectively. No intraoperative complications were reported. Median operative time was 264 (217.5-341) minutes, estimated blood loss was 175 (137.5-200) mL, and the length of hospital stay was 4 days. Nine postoperative complications were reported. All patients were followed-up for 12 months with no recurrence reported. All patients reached our criteria for successful RUF repair. ConclusionsMinimally invasive surgery could represent an efficient way to manage RUF in selected patients. More studies and treatment standardization are needed to assess the role of minimally invasive surgery in the management of RUF.

Rectourethral Fistula—Review of Current Practices, Developments, and Outcomes

Rectourethral fistula (RUF) is an uncommon pathology associated with a significant deterioration in quality of life. It can result from a variety of etiologies and frequently occurs in medically complex patients. Due to the involvement of both the urinary and fecal systems, there are a number of treatment considerations. The literature surrounding management of this condition is quite varied due to these factors. Recent literature on the field consists primarily of single institution case series, though there is a recently published multi-center cohort study with a relatively larger sample size. There is no clear surgical technique that appears to be superior. Transperineal repair is the most commonly described approach. In the properly selected patient, RUF repair results in success rates approaching 85–90%, though the definition of success is not standardized in the literature, and success rates are lower in patients post radiation or ablative therapy. This review highlights contemporary developments in the RUF literature, and provides an overview of important work-up and management considerations. Overall, there is no standardized protocol for management of RUF. Every case presents a unique challenge as a result of the RUF etiology, anatomical considerations, varying degrees of involvement of the genitourinary and gastrointestinal tracts, and patient comorbidities. Urologists must ultimately understand the disease process and utilize techniques that they feel most comfortable with.

Management of Rectourethral Fistula following a Gunshot Injury with Gracilis Flap: A Case Report

Management of Rectourethral Fistula following a Gunshot Injury with Gracilis Flap: A Case Report

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

BackgroundCongenital rectourethral fistula (RUF) is the most common form of anorectal malformations found in boys. The aim of this study is to review our experience with dissection and division of distal fistula using laparoscopic surgery in the management of RUF, especially rectourethral bulbar fistula. MethodsOne hundred and two consecutive boys with congenital RUF who underwent conventional or single-incision laparoscopic surgery between July 2008 and June 2015 were enrolled in the study. The dissection of the distal fistula was performed along submucosal layer to a level 0.5 cm proximal to the urethra. Rectal mucosa of the fistula was dissected to the distal most point and completely transected flush with the posterior urethra. The residual muscular cuff was ligated with Hem-o-Lock clip or 5-0 PDS suture. Voiding cystourethrography and pelvic magnetic resonance imaging were performed at 3 mo, 6 mo, and 1 y postoperatively. ResultsAll patients successfully underwent laparoscopic surgery without conversion. The mean age at the time of operation was 4.3 ± 2.9 mo. The operative times for the rectoprostatic fistula and rectobulbar fistula were similar (118.2 versus 119.4 min, P = 0.082). There was no significant difference in average operative time between conventional laparoscopic surgery group and single-incision laparoscopic surgery group (118.8 versus 119.1 min, P = 0.281). There was no injury to the urethra or vas deferens. The urethral catheter was removed on postoperative day 10. All patients were followed up. The median follow-up period was 3.3 ± 1.8 y. No recurrent fistula or urethral diverticulum was detected on voiding cystourethrography and pelvic MRI at 1 y. ConclusionsSubmucosal dissection and division of distal fistula using a laparoscopic approach is safe, feasible, and effective for congenital RUF, especially bulbar fistula, in boys.

Rectourethral fistula: A challenging management problem

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.

Rectourethral fistula reconstruction in elderly patients.

This article discusses etiologic considerations, evaluation, and contemporary approaches to managing rectourethral fistula (RUF) with particular emphasis on geriatric patients. With the advent of multimodal approaches to treating prostate cancer, such as radiation and ablative therapies, the incidence of RUF is increasing, especially in the geriatric population. Surgical repair and healing of RUF in patients with prior radiation is more challenging than in those without prior radiation or ablation because of fibrotic and ischemic changes in surrounding tissues. There is, at present, a lack of consensus over a standardized approach to RUF management because of the heterogeneity in presentation and limited, primarily retrospective, experience in the literature. Nonetheless, an evolving array of surgical approaches now exists for fistula excision and tissue interposition. Immediate recognition and management of RUF is paramount to prevent related complications. Patient selection and counseling are key to selecting the best approach for repair, whereas a multidisciplinary team, including colorectal and plastic surgery colleagues, may optimize outcomes.

Evaluation and Management of Rectourethral Fistulas After Prostate Cancer Treatment

Most men newly diagnosed with prostate cancer will undergo local treatment with prostatectomy, radiation, or tissue ablation. A small percentage of these men will develop a rectourethral fistula, a complicated disease that requires a multidisciplinary approach to management. Diagnosis is typically made with a careful history and physical exam with endoscopy and select imaging recommended in all patients. Fistulas resulting from prostatectomy, radiation, or tissue ablative technology are approached differently due to local tissue changes following therapy. Post-radiation and thermal ablation fistulas have a lower fistula closure rate due to the deleterious effect of the primary treatment on local tissue. It is imperative that the patient understands the complexity of treatment and sets reasonable goals for treatment.

Management of Recurrent Rectourethral Fistula by York Mason Posterior Transrectal Transsphincteric Approach.

Rectourethral fistula (RUF) may develop after ureterovesical and rectal intervention or radiation therapy (RT) rarely, but it is associated with significant morbidity and mortality. The patient will typically present with pneumaturia, faecaluria, and urinary drainage from the rectum. Diagnosis can be easily done with digital rectal examination, cystography, and urethrocystoscopy. Conservative supportive management of RUF does not appear to be successful in most patients, and management with surgical intervention remains the best treatment option. Several surgical techniques have been described including transabdominal, transanal, transperineal, combined abdominoperineal, anterior and posterior transsphincteric, transsacral, laparoscopic, robotic, and endoscopic minimally invasive approaches. There have been very few data about treatment of recurrent RUF. We would like to report the management of recurrent RUF following transurethral resection of prostate and RT for prostate carcinoma in an immunosuppressed, 75-year-old patient by York Mason posterior transrectal transsphincteric approach.

Bilateral Puborectalis Interposition Repair of Rectourethral Fistula

Rectourethral fistula is a rare but significant complication that often requires operative intervention. A new perineal approach using the medial aspect of the puborectalis muscles as a double-breasted rotational interposition flap to repair the rectourethral fistula is hereby described. With the patient in a modified Lloyd-Davies position, a vertical midline incision from the base of the scrotum to 2 cm anterior to the anal verge is made. The dissection continues along the anterior rectal wall through the Denonvilliers fascia until the rectourethral fistula is reached. The dissection through the fused Denonvilliers fascia continues a further 1 to 2 cm above the fistula. The openings in the rectum and the urethra are then closed vertically (urethra) and horizontally (rectum) with interrupted 3/0 and 4/0 polyglactin sutures. The puborectalis muscles are then mobilized as a 1-cm strip bilaterally and released posteriorly at the level of the anorectum. The 2 strips of the puborectalis muscles are then rotated medially and superiorly along its anterior attachments, forming a double -breasted overlapping flap overlying the fistula openings. The flaps are anchored into the superior and contralateral aspect of the surgical field with the use of 2/0 polyglactin sutures. From November 2011 to December 2012, 4 patients underwent this procedure. No perioperative complications, including those related to the harvesting of the puborectalis muscles, were identified. Subsequent radiological studies confirmed the success of the procedure. After a median follow-up of 8 (6-18) months, 3 patients had their colostomy reversed and remained continent, whereas the last patient had a permanent ileostomy. None of the patients reported any urinary leakage through the perineum. The double-breasted puborectalis interposition flap is an alternative transperineal procedure in the management of rectourethral fistula. It avoids a laparotomy and is rectum sparing.

Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: An easier and more physiologic approach

AimTo present surgical technique and results of combined laparoscopic and modified posterior sagittal approach (PSAP) saving the external sphincter in the management of rectourethral fistula. MethodsThe operation was started by a laparoscopic approach to dissect around the rectal pouch and separate the rectal pouch from the upper urethra. The PSAP saving the external sphincter was added to completely separate the rectal pouch from the urethra. The fistula was divided and closed. The rectal pouch was then pulled through a tunnel created at the center of the external sphincter and an anoplasty was performed. ResultsFrom September 2011 to September 2012, 19 patients were operated on using the same technique. Mean age of patients was 4.0±1.8months. Rectourethral fistula was located in the prostatic urethra in 15 patients and in the bulbar urethra in 4 patients. The mean operative time was 82±13min. There were no intraoperative complications. Postoperative perforation of the posterior wall of the rectum happened in one patient and required a second laparoscopic operation. Follow-up after closure of colostomy from 1month to 7months revealed all patients were able to pass stool spontaneously. All patients could urinate easily. No urethral fistula or diverticulum was detected on voiding cysto-urethrography. ConclusionsCombined laparoscopic and PSAP saving the external sphincter is the easier and more physiologic approach to manage rectourethral fistula with fewer complications.

Evaluation and Management of Rectourethral Fistula Following Radiation Treatment for Prostate Cancer

Rectourethral Fistula (RUF) is an unusual entity with severe consequences to patients. Radiation induced RUF is an infrequent complication following prostate cancer treatment. Evaluation and management of radiation induced RUF is not uniform. A variety of alternatives are offered to manage RUF, including but not limited to the transanal, transrectal approach (York-Mason), pure perineal and combined abdomino-perineal approaches. It is of utmost importance that the genitourinary reconstructive surgeon be familiar with the etiology, anatomy and options to treat RUF. Treatment strategies must be tailored with consideration toward the etiology of the fistula and to the patient status.

Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy

Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy

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

Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience. From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy. Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3). The therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.

Diagnosis and surgical management of rectourethral fistulas

Diagnosis and surgical management of rectourethral fistulas