Transperineal Repair Research Articles

Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring.

The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring. Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring. All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months. TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

Higher Symptom Score, Larger Residual Rectocele, and Lower Rectal Compliance Predict Failure of Improvement after Surgical Treatment of Rectocele

Abstract Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.

Rectourethral Fistula Induced by Localised Prostate Cancer Treatment: Surgical and Functional Outcomes of Transperineal Repair with Gracilis Muscle Flap Interposition

BackgroundTransperineal repair of rectourethral fistula (RUF) following prostate cancer treatment with gracilis muscle flap interposition (GMFI) leads to favourable outcomes, but published data are still lacking, notably concerning functional aspects. ObjectiveTo assess surgical and functional outcomes of this treatment of RUF. Design, setting, and participantsA retrospective study was conducted in two referral hospitals including 21 patients who underwent RUF transperineal repair with GMFI between 2008 and 2020. Surgical procedureThe standard vertical perineal approach is performed for fistula dissection. Bladder and rectal defects are closed separately. After dissection from its facia, the flap is harvested, preserving its pedicle; it is brought to the perineum and placed between the urethra and the rectum to fully cover the sutures. MeasurementsFistula closure (clinical data and postoperative cystography), digestive stoma closure, and complications graded according to the Clavien-Dindo classification were reviewed. Functional results were assessed using the Urinary Symptom Profile (USP) questionnaire, anal incontinence St Mark’s score, Patient Observer Scar Assessment Scale (POSAS) score, and a nonvalidated Likert scale questionnaire assessing issues with lower extremity functionality. Results and limitationsThe median (interquartile range) follow-up was 27 (8–47) mo. Fistula closure was successful for 20 patients (95% success). Digestive stoma was closed in 10/12 shunted patients (83%). Two (9%) Clavien-Dindo grade ≥3b complications were reported (one urinoma in a kidney transplant patient and one thigh haematoma evacuation). Eighteen patients (86%) completed the postoperative questionnaire; 11/18 (61%) had significant urinary incontinence. The mean (standard deviation) USP dysuria score was 1/9 (1.2), mean St Mark’s score was 5/24 (5), mean POSAS score was 19/70 (11), mean lower extremity functionality score was 2/20 (4), and mean procedure patient satisfaction score was 9/10 (2). The retrospective design and limited number of patients are the main limitations. ConclusionsThe present study found an excellent success rate and low morbidity for RUF transperineal repair with GMFI. Functional outcomes were satisfactory despite a high urinary incontinence rate. Patient summaryWe performed an analysis of the outcomes of perineal approach surgery with muscle interposition for closing abnormal communication between the bladder and the rectum after prostate cancer treatment. This surgical technique was found to be safe to perform and provides a high success rate, with patients being satisfied despite poor urinary continence outcomes.

Transperineal rectocele repair is ideal for patients presenting with fecal incontinence.

Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with rectocele. The purpose of this study was to evaluate the clinical outcome in a consecutive series of patients who underwent transperineal repair of rectocele when presenting with fecal incontinence as the predominant symptom. Twenty-three consecutive patients from April 2000 to July 2015 with symptomatic rectocele underwent transperineal repair by a single surgeon. All patients had a history of vaginal delivery, with or without evidence of associated anal sphincter injury at the time. The median age of the cohort was 53 years (range, 21-90 years). None were fully continent preoperatively. However, continence improved to just rare mucus soiling or loss of flatus in all patients 6 months after their surgery. There was no operative mortality. Postoperative complications including urinary retention and wound dehiscence occurred in 3 patients. Fecal incontinence associated with rectocele is multifactorial and may be caused by preexisting anal sphincteric damage and attenuation. Our experience suggests that transperineal repair provides excellent anatomic and physiologic results with minimal morbidity in selected patients presenting with combined rectocele and anal sphincter defect.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele.

BACKGROUNDRectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).AIMTo assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.METHODSAn organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.RESULTSAfter screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.CONCLUSIONThe transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

P0373 - Rectourethral fistula induced by localized prostate cancer treatment: Surgical and functional outcomes of transperineal repair with gracilis muscle flap interposition

P0373 - Rectourethral fistula induced by localized prostate cancer treatment: Surgical and functional outcomes of transperineal repair with gracilis muscle flap interposition

Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair.

BACKGROUNDCurrently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIMTo evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODSThis was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed.RESULTSThe direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation).CONCLUSIONStapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.

Functional and sexual outcome of laparoscopic ventral mesh rectopexy vs transperineal mesh repair in the treatment of rectocele: a retrospective analysis

This study aimed to compare functional outcomes and quality of life, between transperineal mesh repair (TPMR) and laparoscopic ventral mesh rectopexy (LVMR) in the treatment of rectocele. Consecutive women with symptomatic rectocele without associated internal rectal prolapse or enterocele who underwent TPMR (n = 15) or LVMR (n = 20) from January 2013 to February 2019 were included. This study was a retrospective review of a prospectively maintained database. Patient demographics and postoperative complications were evaluated. Altomare’s obstructed defecation (OD) and Cleveland Clinic Incontinence Scores (CCIS), Patient Assessment of Constipation Quality of Life (PAC-QoL), Short-Form 36 Health Survey (SF-36) and Female Sexual Function Index (FSFI) were compared before, 3 months, and 12 months after surgery. The median follow-up was 49 (range 13–65) and 28 (range 13–60) months in the TPMR (mean age 47.8 ± 11.7, years) and LVMR (mean age of 52.4 ± 9.9 years) cohort, respectively. Incontinence, OD, and PAC-QoL scores significantly improved at 3 and 12 months after surgery in both groups. FSFI did not deteriorate 3 and 12 months after LVMR. FSFI scores significantly improved 3 months after TPMR, but a significant deterioration was observed 12 months after TPMR. A gradual increase observed for SF-36 3 months after surgery in both groups, and six of the eight subscale scores improved at 12 months, but social functioning in both groups and vitality in the TPMR group returned to baseline scores. TPMR and LVMR improved defecation. Sexual function was not worsened after LVMR, and some individual domains of FSFI worsened after TPMR.

Horizontal versus vertical plication of the rectovaginal septum in transperineal repair of anterior rectocele: a pilot randomized clinical trial.

Anterior rectocele is usually an asymptomatic condition in many women, yet it can be associated with obstructed defaecation syndrome (ODS). Transperineal repair of rectocele (TPR) has been followed by variable rates of improvement in ODS. The present pilot randomized clinical trial aimed to evaluate the outcome of TPR with vertical plication (VP) of the rectovaginal septum compared to horizontal plication (HP). Adult women with anterior rectocele were recruited to the study and were randomly allocated to one of two equal groups. The first group underwent TPR with VP of the rectovaginal septum and the second group underwent TPR with HP. The main outcome measures were improvement in ODS, recurrence of rectocele, complications and dyspareunia. The trial included 40 female patients with anterior rectocele. There was no significant difference between the two groups regarding the postoperative Wexner score. Complete cure and significant improvement in ODS symptoms were comparable after the two techniques. The reduction in rectocele size after HP was significantly greater than after VP (1.7 vs. 2.6, P<0.0001). Significant improvement in dyspareunia was recorded after HP (P=0.001) but not after VP (P=0.1). There was no significant difference between the two groups with regard to operating time, complications and recurrence. VP and HP of the rectovaginal septum in TPR were associated with a comparable improvement in ODS symptoms and similar complication rates. HP was followed by a greater reduction in the rectocele size and greater improvement in dyspareunia than VP.

Specific Changes in Manometric Parameters are Associated with Non-improvement in Symptoms after Rectocele Repair.

The present study aimed to assess the changes in manometric parameters after transperineal repair (TPR) of rectocele and interpret failure of symptom improvement in light of these changes. This was an observational cohort study on patients with anterior rectocele who underwent TPR in the period of February 2016 to February 2019. Data collected included patients' demographics, rectocele size, Wexner constipation and incontinence scores, anal pressures, and rectal sensation before and 12 months after TPR. Analysis of data was done by paired t-test and chi-square test. Forty-six female patients with a mean age of 43.2 ± 10.7 years were included. After a mean follow-up of 13.9 ± 2.7 months, 30 (65.2%) patients reported clinical improvement and 16 (34.8%) had no significant improvement. At 12 months after rectocele repair, the entire cohort studied showed an insignificant increase in the mean anal pressures and a significant decrease in the thresholds of first rectal sensation, first urge, intense urge, and maximum tolerable volume (MTV). Patients who clinically improved showed similar physiologic changes to the entire cohort examined, whereas patients who had no clinical improvement showed significant increases in the mean anal pressures and insignificant decreases in rectal sensation and MTV. Patients who showed clinical improvement showed insignificant increases in anal pressures and significant decreases in thresholds of first rectal sensation, first urge, intense urge, and MTV. Contrarily, patients who did not show clinical improvement showed significant increases in anal pressures and insignificant reduction in sensory thresholds.

Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients.

Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF. This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed. Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004). Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.

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.

Repair of Iatrogenic Recto-Urethral Fistulas : Experience of 6 Cases

I repaired iatrogenic recto-urethral fistulas (RUF) in 6 patients. All the fistulas had developed after surgery, 5 for prostate cancer (prostatectomy) and the remaining one for pelvic solitary fibrous tumor. All of them were"simple"fistulas. I performed repair using the transperineal approach with gracilis muscle flap interposition in 4 cases, and using the transsphincteric approach (modified York-Mason method) in 2, with the cooperation of general surgeons and/or plastic surgeons. All fistulas were successfully repaired. The operation time ranged from 414 to 464 minutes for transperineal repair and 246 and 253 minutes for transsphincteric repair. The blood loss ranged from 100 to 533 ml for transperineal repair and 30 and 60 ml for transsphincteric repair. Transsphincteric approach was less invasive and may be the first choice for simple RUF repair.

Management of pelvic fracture urethral injuries in the developing world.

Pelvic fracture causes urethral injury in about 10% of patients. The etiology of injury is different in developing and developed world. While high-velocity automobile accidents are common in developed countries, where patients are in the car and there is usually a side impact, in the developing world, significant number of injuries are caused by two-wheeler accidents, pedestrians, farming accidents, fall from height, fall from tractor, fall from tree, and other causes like earthquake. We share our experience which is the largest in the reported literature. In our tertiary referral center, we get referrals from all across the globe. Since 1995 till 2018 we have performed 1307 surgeries for Pelvic fracture urethral injury. Our referrals are for complex urethroplasty. Our data from 1995-2018 was analyzed. Data after June 2018 was not included so as to have a minimum follow up of 6 months. 1296 patients were males and 11 were females. In the group of 1296 males, mean age was 32.4years (range 1-79years). The minimum follow-up was 6months, and the median follow-up was 56.7months (range 6.2-233.7). The overall success rate was 88.79% for primary cases while re-do urethroplasty patients had a success rate of 83.70%. The majority of our patients (more than 61.40%) needed inferior pubectomy: Of the total 1307 cases of urethroplasty for pelvic fracture urethral injury data was available for 1042 patients. Data were available for 1042 patients. The data from 2012 onwards were prospectively analyzed while the previous data were retrospectively analyzed. PFUI are common in the developing world. They tend to be more complex and have longer gaps as compared to developed world. This could be related to the anthropometric differences between races as well as nature of injury. They are best managed with delayed transperineal repair with excellent outcomes. Ancillary maneuvers are more frequently required. Re-do urethroplasty can achieve good results.

Stapled Transperineal Fistula Repair of Rectovaginal Fistula: A Preliminary Experience.

This study is designed to assess the safety, efficacy, and postoperative outcomes of stapled transperineal repair in management of rectovaginal fistula (RVF). A prospective database of patients with RVF undergoing stapled transperineal repair between May 2015 and December 2017 was established and studied retrospectively. Seven consecutive RVF patients underwent stapled transperineal repair. The mean operative time was 119 ± 42 minutes. The estimated blood loss during operation was 24 ± 14 mL. Concomitant levatorplasty was performed with 4 patients and sphincteroplasty with 2 patients. Over a median follow-up of 6 months (range 3-33 months), no case was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (mean preoperative vs postoperative Wexner scores 3 [range 3-4] vs 1 [range 1-2], respectively; P = .01). Stapled transperineal repair of RVF appears safe and effective. The initial results are encouraging, suggesting the need for a more formal prospective assessment of this technique as part of a randomized trial for the management of low- and mid-vaginal fistulas.

Transperineal rectocele repair with biomesh: updating of a tertiary refer center prospective study.

Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. A variety of surgical procedures have been used in the rectocele repair to enhance anatomical and functional results and to improve long-term outcomes. In this prospective study, we treated 25 selected women suffering from simple symptomatic rectocele with transperineal repair using porcine dermal acellular collagen matrix Biomesh (Permacol®). Watson score and SF-36 questionnaire were used to evaluate postoperative outcomes and quality of life. Follow-up ranged from 12 to 24months, the mean total Watson score was significantly lower than the preoperative score (P< 0.001), and every patient has improved functional outcomes. There were no major intraoperative or postoperative complications. Two cases of urinary infection and 4 patients delayed wound healing were reported. Those patients who were sexually active prior to surgery have not experienced problems with sexual function or dyspareunia. Despite lack of comparative study in literature, rectocele repair with Permacol® by the transperineal approach seems an effective and safe procedure that avoids some of the complications associated with synthetic mesh use.

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 ...

Gracilis Muscle Interposition for Rectourethral Fistula After Laparoscopic Prostatectomy: A Prospective Evaluation and Long-term Follow-up.

Postoperative rectourethral fistula after radical prostatectomy is an infrequent but very serious problem. We aimed to describe our experience with transperineal repair and unilateral gracilis muscle interposition in patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. This was a cohort study. All of the procedures were performed at the same hospital by the same multidisciplinary team made up of a senior colorectal surgeon and a senior urologist. Patients with postoperative rectourethral fistula after laparoscopic prostatectomy were included. Transperineal fistula repair and gracilis muscle interposition were included. Fistula healing rate was measured. Nine patients with postoperative rectourethral fistula were treated between November 2009 and February 2016. Four of them had received other previous treatments without success, and 5 had previously been treated with this technique. Seven patients had a fecal diverting stoma. After a median follow-up of 54 months (range, 2-72), all of the fistulas had successfully healed, and, to date, the patients remain asymptomatic without urinary diversion. Fecal diversion was closed in all but 1 patient. No intraoperative or infectious complications were detected. With the results of our series, we present specific technical details of our technique and hope to provide additional evidence of the low morbidity profile and excellent healing rate of this treatment. Moreover, we note that, although small, this series corresponds with a homogeneous group of patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. This is a small but very homogeneous group of patients. Simple repair with perineal gracilis muscle interposition is a safe and effective technique for the treatment of postoperative rectourethral fistulas after nonradiated prostate cancer surgery.

Comparative Study Between Trans-perineal Repair With or Without Limited Internal Sphincterotomy in the Treatment of Type I Anterior Rectocele: a Randomized Controlled Trial

Background and AimTwo types of rectocele exist; type I is characterized by relatively high resting anal pressures, whereas type II has lower resting anal pressures with associated pelvic organ prolapse. We compared trans-perineal repair (TPR) of rectocele with or without limited internal sphincterotomy (LIS) in the treatment of type I anterior rectocele. Patients and InterventionsConsecutive patients with anterior rectocele were evaluated for inclusion. Sixty-two female patients with type I anterior rectocele were randomized and equally allocated to receive TPR alone (group I) or TPR with LIS (group II). The primary outcome was the clinical improvement of constipation. Secondary outcomes were recurrence of rectocele, operative time, and postoperative complications including fecal incontinence (FI). ResultsClinical improvement of constipation and patients’ satisfaction were significantly higher in group II at 1 year of follow-up (93.3 versus 70 %). Constipation scores significantly decreased in both groups postoperatively with more reduction being observed in group II (11.1±2.1 in group I versus 8 ± 1.97 in group II). Significant reduction in the resting anal pressure was noticed in group II. Recurrence was recorded in three (10 %) patients of group I and one patient of group II. No significant differences between the two groups regarding the operative time and hospital stay were noted. ConclusionAdding LIS to TPR of type I rectocele achieved better clinical improvement than TPR alone. The only drawback of LIS was the development of a minor degree of FI, which was temporary in duration.

Short- and Long-term Complications and Outcomes of Radiation and Surgically Induced Rectourethral Fistula Repair With Buccal Mucosa Graft and Muscle Interposition Flap

To analyze and report 30-day, 90-day, and long-term complications and surgical outcomes over a 17-year period for anterior transperineal repair of rectourethral fistulas (RUFs) resulting from pelvic radiation and surgery. We performed a retrospective review of patients undergoing RUF repair between January 1, 1998 and February 28, 2015, at a single institution. All RUF were repaired using an anterior transperineal approach with an interposition muscle flap and selective use of a buccal mucosa graft onlay. Ninety-eight patients underwent repair with an anterior transperineal approach and muscle interposition flap (49 non-radiation induced and 49 radiation or ablation induced). Thirty- and 90-day complication rates were 29% and 2%, respectively, for non-radiated RUF, and 29% and 24%, respectively, for radiated RUF. Urethral diverticula, urinary incontinence, urethral stricture, and bowel problems were delayed complications requiring surgery. At a median follow-up of 14.5 months (range 3-144), 98% (48 of 49) of non-radiated RUF were closed with 1 procedure, whereas 86% (42 of 49) of radiated RUF were closed with 1 procedure. Gastrointestinal tract continuity was restored in 94% (45 of 48) of non-radiated RUF and in 65% (30 of 46) of radiated RUF. Successful RUF closure is possible in 98% of non-radiated and in 86% of radiated or ablated patients with 1 procedure. Most radiation-induced RUF, regardless of size, can be successfully repaired with minimal short-term complications. Delayed complications may arise and require surgery, and thus continued surveillance is recommended.