Rectourethral Fistula Research Articles

Novel Utilization of a Penrose Drain as a Spacer During Temporary Artificial Urinary Sphincter Explantation and Rectourethral Fistula Repair

Novel Utilization of a Penrose Drain as a Spacer During Temporary Artificial Urinary Sphincter Explantation and Rectourethral Fistula Repair

SpaceOAR Persistence on MRI at 59 Weeks Postplacement in a Patient With Stage IV CKD

External beam radiation therapy is commonly used to treat prostate cancer, and gel spacers such as SpaceOAR Hydrogel (Boston Scientific, Marlborough, MA) are approved to limit local rectal radiation toxicity. SpaceOAR is usually reabsorbed in 12 to 24 weeks and excreted renally. It has a known low rate of rectourethral fistula that is usually associated with ectopic placement into the rectal wall. We present a case of a SpaceOAR Hydrogel insert persisting in a patient with chronic kidney disease on serial MRI scans for 59 weeks after placement with colovesical fistula development 81 weeks after placement of unclear association.

Safety and benefits of early urethral catheter removal after resectioning the recto urethral fistula during posterior sagittal anorectoplasty

Aims: A urethral catheter must be placed before PSARP (Posterior Sagittal Anorectoplasty) is performed on boys with recto-urethral fistula. However, there is no agreement on when the catheter should be removed. Surgeons usually keep the catheter for more than weeks, which is uncomfortable for patients. This study assesses the advantages and safety of removing the catheter early after PSARP. Methods: We have divided the patents into two groups. In Group 1, patients underwent PSARP with resection of RUF from January 2017 to February 2021, and the urethral catheter was kept for 14 days. In Group 2, patients were operated on between March 2021 and July 2023, and the urethral catheter was removed on the second day after the operation. The two groups ' demographic and clinical variables were compared using SPSS version 26. Outcome variables were post-operative urinary retention, difficulty in micturition, catheter blockage or dislodgement, fistula recurrence, hospital stay duration, and antibiotic therapy duration. Results: No patients in either group had urinary retention, recurrence of fistula, or lower urinary complication. However, postoperative hospital stay and antibiotic therapy significantly reduced from 11.2±2.3 days in Group 1 to 4.1±0.5 days in Group 2 (p<0.01). Conclusion: Early catheter removal after PSARP is safe, improves patient comfort, and reduces unnecessary hospital stays and antibiotic therapy.

Incidence of associated anomalies in children with anorectal malformation: A 1-year prospective observational study in a low-income setting.

Anorectal malformations (ARMs) consist of a range of anomalies that are often associated with other anomalies The purpose of the study is to assess the incidence of associated congenital anomalies that are seen in patients with ARMs. An observational prospective study was conducted on 162 cases with ARM from February 2019 to January 2020, and data were collected on patient demographics, type of ARM, and associated anomalies using a prestructured questionnaire and analysis done using SPSS (IBM), version 23, software. Relevant statistical analysis was done, and the results are presented in tables and charts. Of 162 cases studied, 70 of them were males and 92 were females with a male-to-female ratio of 0.76:1. The majority of male patients (45%) had rectourethral fistulas, whereas 63% of the females had rectovestibular fistula. While 76 (47%) patients presented with isolated ARM, 86 (53%) had ≥1 associated congenital malformations. Forty-eight (30%) patients presented with a single associated anomaly, whereas 20 (12%) patients had≥3 associated anomalies. The commonest associated anomalies were urologic 26.5% followed by genital (22.8%), cardiac 20.4%, and musculoskeletal 16.6%, and 12.3% of them had vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb association. More than half of the children have other associated abnormalities. We found urogenital anomalies to be the most common associated congenital defects. A lower incidence of cardiac and spinal cord anomalies was noted suggesting a need for active workup to be in line with the latest standards of care.

Rethinking Fistula Preservation in Anorectal Malformation Surgery: A Histopathological Perspective.

This study aims to assess the histopathological characteristics of the fistulous tissue in males with anorectal malformation (ARM) to determine its suitability for use in constructing a neoanus. This prospective observational study included male ARM patients with recto-urethral fistula. All other types were excluded. The tissue specimens comprised 0.5-2.0 cm of the most distal part of the rectal pouch and the fistulous tissue. Hematoxylin and eosin-stained sections were prepared. Histological features viz. internal sphincter, anal grand and crypts, ganglion cells, presence of subepithelial fibrosis, thickened nerve trunks, and metaplasia were evaluated. Of 65 patients of ARM admitted, 24 met the inclusion criteria. Gross and microscopic internal sphincter was not found in any sample. The anal mucosa was visualized in all cases; however, crypts were irregular and distorted architecture was seen in 4 (16.67%) samples. Urothelial metaplasia was identified in 10 (41.67%) cases. Adequate ganglion cells were seen only in 6 (25%) samples. Significant submucosal fibrosis was seen in all samples. Thickened nerve trunks were identified in 4 (16.67%) samples. All normal anal histological features could not be found together in the fistula tissue. With the absence of normal features, such as internal anal sphincter muscles, and the presence of abnormal histopathological features, such as subepithelial fibrosis, thickened nerve trunks, and metaplasia there are high chances of abnormal bowel function like constipation if the fistulous tissue is used for neoanus construction. It may have an impact on the quality of life of patients.

Current practice of diagnosis and treatment for rectourethral fistula in male patients with anorectal malformation: a multicenter questionnaire survey in Japan

PurposeSurgical procedures for anorectoplasty for anorectal malformations (ARMs), particularly rectourethral fistula (RUF), depend on the institution. We investigated the diagnosis and treatment of RUF in male patients with ARMs in Japan using a questionnaire survey.MethodsAn online survey inquiring about the diagnosis and treatment (diagnostic modalities, surgical approaches, fistula dissection devices, and fistula closure techniques) of each type of ARM in male patients was conducted among institutional members of the Japanese Study Group of Anorectal Anomalies. Fisher’s exact test was used to compare surgical methods between posterior sagittal anorectoplasty (PSARP) and laparoscopy-assisted anorectoplasty (LAARP).ResultsSixty-one institutions (100%) completed the survey. LAARP was the preferred approach for high-type ARM (75.4%). PSARP was preferred for intermediate-type ARM (59.0%). Monopolar devices were most commonly used (72.1%) for RUF dissection. Blunt dissection was more frequent in the PSARP group (PSARP vs. LAARP: 55.6 vs. 20.0%, p < 0.005). Cystoscopy/urethroscopy to confirm the extent of dissection was used more frequently in the LAARP group (70.0% vs. 25.0%, p < 0.005). Clips and staplers were used more frequently in the LAARP group (p < 0.05).ConclusionDistinct fistula management strategies for PSARP and LAARP were revealed. Further studies are needed to investigate the postoperative outcomes associated with these practices.

Functional Outcome in Patients With Anorectal Malformation With Recto-prostatic or Recto-bulbar Urethral Fistula and Comparison Between Different Surgical Approaches: A Multi-center Study

PurposeTo analyze and compare the outcomes in patients with anorectal malformation with rectoprostatic and rectourethral fistula between laparoscopic-assisted anorectoplasty (LAARP) versus posterior sagittal anorectoplasty (PSARP). MethodWe performed a retrospective review on all males with anorectal malformation (ARM) with recto-prostatic (ARM-RP) or recto-bulbar urethral fistula (ARM-RB) treated in five tertiary paediatric surgical centres in the past 25 years. Defecative function was assessed using the Krickenbeck classification and Kelly's score. Functional outcomes between patients with LAARP and PSARP were compared. ResultsThere were a total of 136 males with ARM-RP and ARM-RB for analysis, among which 73 (53.7%) had ARM-RP and 63 (46.3%) had ARM-RB. The median age of the patients was 9.4 years (range 0.8–24.7 years) and the median age at operation was 0.4 years (0 day–3.1 years). 57 (41.9%) and 79 patients (58.1%) underwent PSARP and LAARP respectively. 34 patients (25%) had VACTERL association. 111 (81.6%) and 103 patients (75.7%) had sacral and spinal cord anomalies respectively. 19 patients (13.9%) eventually required Malone's Antegrade Continence Enema (MACE).For the comparison between PSARP and LAARP, no difference in Kelly scores (4.58 ± 1.63 versus 4.67 ± 1.36) was identified (p = 0.79). Logistic regression for voluntary bowel movement showed that VACTER association (p = 0.02) and fistula location (p = 0.01) were significant prognostic factors, whereas the operation approach (PSARP or LAARP) was not (p = 0.65). ConclusionVACTERL association and fistula location were significant prognostic factors for voluntary bowel movement, and there appeared to be no significant difference in functional outcome between PSARP and LAARP. Level of EvidenceIV.

Reply to Editorial Comment on “Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy”

Reply to Editorial Comment on “Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy”

An Unusual Delayed Complication after Rectal Surgery – 3 Case Reports

Abstract Rectal cancer treatment is challenging and rapidly advancing, and surgical resection is often the keystone treatment and curative modality. Anastomotic complications are the most severe and feared outcomes following rectal cancer surgery considering their associated morbidity and mortality. Delayed complications occurring many years after surgery are rare and less reported. Here, we report three cases of patients with rectal carcinoma who underwent low anterior resection and presented with delayed anastomotic complications. In all three cases, anastomotic complications were found beyond one month: postoperative 1 year, 7 years, and 9 years. Disease recurrence was ruled out in all patients. The patients presented with varied symptoms, namely a delayed presentation with a pelvic abscess along with a rectourethral fistula, a rectocutaneous fistula, and bladder wall necrosis. All of them had received radiation therapy preoperatively. Chronic radiation induces widespread intestinal collagen deposition and fibrosis along with occlusive vasculitis in small arterioles. These effects may develop over several months or years, which results in bowel strictures, ulcerations, and fistulas. Therefore, delayed complications such as anastomotic dehiscence, rectourethral fistulas, and rectocutaneous fistulas appearing after many years of pelvic surgery, especially in patients who received radiation, should be investigated. Therefore, long-term monitoring to identify potential complications is crucial as they are associated with high morbidity and mortality.

Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy

OBJECTIVETo present our experience with a novel technique that combines the York–Mason transsphincteric approach with dartos muscle flap interposition to treat rectourethral fistulas. METHODSWe extracted records from our prospectively kept database of 35 procedures conducted for treating rectourethral fistulas during 2002–2023; the York–Mason approach was combined with dartos muscle flap interposition in five cases, performed for treating rectourethral fistulas due to radical prostatectomy, all of which were referral cases. RESULTSAll five patients were successfully treated and followed up for a median of 70.0 months without recurrence. Before the fistula repair, all had a diverting stoma. In all cases, the first voiding cystourethrogram revealed a healed fistula. The posterior and the scrotal incisions healed uneventfully. All patients reported normal voiding and no urinary incontinence. To date, the stoma has closed in three patients, all of whom had intact fecal continence and no postoperative anal stenosis. CONCLUSIONThe transsphincteric modified York–Mason approach combined with dartos muscle flap interposition resulted in complete healing of rectourethral fistulas.

Long-term (> 10years) bowel function of anorectal malformations: a retrospective single-center study.

To describe the long-term bowel function of anorectal malformation (ARM) patients and explore the potential influence factors. ARM patients with follow-up data > 10years were included. Cases of cloaca, Currarino syndrome, and VACTERL syndrome were excluded. Rintala score and PedsQL 4.0 were used to assess bowel function score (BFS) and quality of life (QoL). Based on the results, patients were divided into satisfactory group with BFS ≥ 17 and unsatisfactory group with it < 17. Comparisons between the groups were made. Among the 81 patients were 44 males and 37 females. Follow-up time was 138 (126,151) months. 16 (19.75%) patients had associated anomalies. 23 (28.40%) patients had reoperations, and fistula recurrence was the most common reason. BFS of the patients was 20 (18,20). QoL score was 100 (100,100), which correlated positively with BFS (r = 0.648, P < 0.001). The satisfactory and the unsatisfactory groups had 69 and 12 cases, and their BFS were 20 (20,20) and 11 (8,15) respectively, which had statistical difference (P < 0.001). Total QoL score and psycho-social health score of the unsatisfactory group were lower (P < 0.001). Only reoperations were statistically different between the groups (P < 0.001). Long-term (> 10years) bowel function of ARM patients is good in this study. Defecation problems have negative impacts on QoL and mainly affects their psycho-social health. Primary anorectoplasty is extremely important. Reoperations, which are most commonly seen in recto-urethral fistula recurrence, adversely affect the outcome.

Comparison of postoperative urinary complications in laparoscopic-assisted anorectoplasty versus posterior sagittal anorectoplasty for anorectal malformation with rectourethral fistula.

Long-term urinary outcomes after anorectal malformation (ARM) repair are affected by surgical approach and sacral anomalies. This study aimed to compare laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) in terms of urinary complications. Between 2001 and 2022, 45 patients were treated with LAARP or PSARP. The rectourethral fistula and inflow angle between the fistula and rectum was confirmed by preoperative colonography. The incidence of urinary complications and treatment were compared between the two groups. Four patients (14%) had remnant fistula and five patients (17%) had neurogenic bladder dysfunction in LAARP group, while three patients (18%) had urethral injury in PSARP group. All patients with remnant fistula were asymptomatic and followed without treatment. The incidence of remnant fistula improved between earlier decade and later decade. In all cases with urethral injury, suture repair was performed and no postoperative leakage was noted. All five patients with neurogenic bladder dysfunction had spine abnormalities that required clean intermittent catheterization (CIC) and two were free from CIC finally. It is important to check inflow angle preoperatively to prevent remnant fistula. For PSARP, meticulous dissection is required when separating fistula from urethra because they create common wall. The most contributing factor to neurogenic bladder is sacral anomalies. Preoperative evaluation and postoperative urinary drainage are important.

Correlation between congenital pelvic floor muscle development assessed by magnetic resonance imaging and postoperative defecation.

Children with congenital anorectal malformation (CAM) experience challenges with defecation. This study aims to assess defecation in preschool-age children with CAM and to evaluate the correlation between pelvic floor muscle developed assessed by magnetic resonance imaging (MRI) and postoperative defecation. We collected clinical data and MRI results from 89 male children with CAM. The bowel function scores for children with Perineal (cutaneous) fistula, Rectourethral fistula(Prostatic or Bulbar), and Rectovesical fistula were computed. MRI scans were subjected to image analysis of the striated muscle complex (SMC). The association between pelvic floor muscle score and bowel function score was examined using the Cochran-Armitage Trend Test. We observed that 77.4% of the SMC scores by MRI for Perineal fistula were good. The Rectourethral fistula SMC score was 40.6% for moderate and 59.4% for poor. The SMC score for Rectovesical fistula was 100% for moderate. Furthermore, 77.4% of patients with Perineal fistula had bowel function scores (BFS) ≥ 17 points. Among those with Rectourethral fistula and Rectovesical fistula, 12.5% and 0 had BFS ≥ 17 points, respectively. An analysis of muscle development and bowel function in patients with Rectovesical fistula, Rectourethral fistula, and Perineal fistula revealed a correlation between SMC development and BFS. Subgroup analysis showed that the Perineal fistula had statistical significance; however, the Rectourethral fistula and Rectovesical fistula were not statistically significant. A correlation exists between pelvic floor muscle development and postoperative defecation in children with Perineal fistula.

Palliative surgery for metastatic prostate cancer

Androgen deprivation in combination with novel hormonal agents, docetaxel, or in combination with abiraterone/prednisone plus docetaxel or darolutamid plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favorable response rates, basically all patients will develop castration resistant prostate cancer (CRPC) within 2.5to 4years. In addition to systemic chemotherapy, second-line hormonal treatment of systemic application of radionuclides such as radium223 or 177Lu-PSMA represent salvage management options. However, nowadays about 50-65% of patients will develop symptoms due to local progression of prostate cancer which is the result of improved oncological outcomes with significantly prolonged survival times due to the new medical treatment options. Management of such symptomatic local progression will become more important in upcoming years so that all uro-oncologists need to be aware of the various surgical management options. Complications of the lower urogenital tract such as recurrent gross hematuria ± bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction and acute urinary retention, rectourethral or rectovesical fistulas might be managed by palliative surgery such as palliative transurethral resection of the prostate (TURP), radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract might be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of the Detour® system (Coloplast GmbH, Hamburg, Germany).

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes

IntroductionRecto-urethral fistulas (RUF) remain a difficult management problem. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. MethodsWe identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months pre-operatively), and 20 men suprapubic catheter placement (median, 5.5 months pre-operatively). ResultsRUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intra-operatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%).At a median follow up of 55.7 months (IQR, 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. ConclusionsPosterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis.

Rectal ulceration and rectourethral fistula as rare complications of radiotherapy for prostate cancer—a case report and literature review

Rectal ulceration and rectourethral fistula as rare complications of radiotherapy for prostate cancer—a case report and literature review

Results of transanal irrigation in intestinal dysfunction associated with anorectal malformations.

There are multiple tools available to optimize defecation in patients with anorectal malformation (ARM), such as habits, laxatives, and retrograde or anterograde irrigations, which are usually adapted in a progressive and combined fashion. The objective of this study was to assess the incorporation of transanal irrigation (TAI) to constipation and fecal incontinence treatment in patients with ARM. A retrospective study of ARM patients with indication of TAI according to the colorectal pathology unit's intestinal management protocol from 2015 to 2022 was carried out. Following use for over 3 months, patients or their guardians completed a phone survey of our own approved by the ethics committee. 39 ARM patients participated in the study. Pathologies included 11 rectourethral fistulas, 6 rectovesical fistulas, 16 cloacae, 2 rectovaginal fistulas, 2 perineal fistulas, and 2 vestibular fistulas. 44% of them had a sacral index <0.4. 62% had constipation, and 38% had incontinence. Thanks to TAI, confidence and safety improved in a very high and a high degree in 89% of the patients, whereas time devoted to intestinal management decreased a lot in 68% of them. 79% reported a 9- and 10-point quality-of-life improvement. 92% rated overall satisfaction with TAI with a score of 8, 9, and 10 - 10 meaning "completely satisfied." 100% recommend TAI. TAI is a good alternative for the intestinal management of fecal incontinence and constipation.

Redo Surgeries in Anorectal Malformations: A Single-center Experience.

Complications following posterior sagittal anorectoplasty (PSARP) for ARM are well known. In this article, we present our experience of managing five patients who required major redo surgeries for complications resulting from previous attempts to correct ARM. We reviewed all patients who underwent major redo surgeries in our hospital for complications from previous repairs for ARM, from June 2013 to June 2019. Data was obtained from hospital records and analysed. Five patients whose ages ranged from 5 months to 14 years were included in the study. Four were boys and 1 was a girl. All patients had undergone PSARP in other hospitals. The presentations were retained distal bowel causing urinary retention and constipation (n=1), pulled through proximal urethra and bladder neck presenting as passage of urine from neo-anus (n=1), retained common channel (of cloaca) causing a 'H' type configuration (n=1), mispositioned neo-anus (n=1) following a primary PSARP and lastly undivided recto-urethral fistula causing fecaluria (n=1). All of them underwent redo repairs by posterior sagittal approach with documented improvement in their symptoms. Two of them required total bowel management to remain clean. All the complications reported here have been described in literature nevertheless, this report will add to the body of experience. Posterior sagittal approach (PSA) has proved to be very successful technique in correcting these complications.

Recto-urethral fistula repair using gracilis muscle interposition: Complications, functional results and management of residual stress urinary incontinence

Recto-urethral fistula repair using gracilis muscle interposition: Complications, functional results and management of residual stress urinary incontinence

Postoperative complications in males with anorectal malformations depending on the surgical approach

BACKGROUND: Anorectal abnormalities occur in 1:1,500 to 1:5,000 live births. There is still no agreement on the best surgical procedure for treating some types of anorectal abnormalities in males. Anorectoplasty could be performed using the posterior sagittal approach and using laparoscopic techniques.&#x0D; AIM: To assess the risk of postoperative complications and determine their specificity in males with anorectal malformations, depending on the surgery approach.&#x0D; MATERIALS AND METHODS: A single-center retrospective cohort study was performed. Male patients with anorectal malformations who had surgical correction of anorectal malformation by posterior sagittal (group I) or laparoscopic-assisted anorectoplasty (group II) at the age of up to 1 yr at the N.F. Filatov Childrens City Clinical Hospital from 2008 to 2022. Postoperative and intraoperative problems and the number of surgical interventions that had to be redone to correct issues were noted.&#x0D; RESULTS: Of the 33 patients in group I, 18 (55%) had anorectal malformations with bulbar fistula, 12 (36%) had anorectal malformations without fistula, and three (9%) had a prostatic fistula. Group II included 99 patients, with 53 (54%) having anorectal malformations with prostatic fistula, 30 (30%) having anorectal malformations with bulbar fistula, nine (9%) having anorectal malformations with bladder neck fistula, and seven (7%) having anorectal malformations without a fistula. The incidence of intraoperative and postoperative complications was statistically significantly higher in children after posterior sagittal anorectoplasty than laparoscopic-assisted anorectoplasty: I, 19 (58%) versus II, 33 (33%); p = 0.014. The number of redo surgical interventions to correct complications did not differ significantly between the studied groups: I, 8 (24%) versus II, 26 (26%); p = 0.819. The incidence of urethral damage was identified with posterior sagittal anorectoplasty compared with laparoscopic-assisted anorectoplasty: I, 4 (12%) versus II, 0 (0%); p 0.001. We found no differences in postoperative complications between laparoscopic-assisted and posterior sagittal anorectoplasty.&#x0D; CONCLUSIONS: The results define laparoscopic-assisted anorectoplasty as a viable and promising method that does not have specific postoperative complications if it is technically correctly performed. It is necessary to develop clear criteria for rectum mobilization and the volume of rectourethral fistula dissection during laparoscopic-assisted surgery to reduce the risks of postoperative problems and repeat surgery.