Transsphincteric Approach Research Articles

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.

Urorectal fistula repair using different approaches: operative results and quality of life issues.

ABSTRACTPurpose:To evaluate efficacy of urorectal fistula (URF) repair using different approaches and the clinical factor determinant of success, and also the morbidity associated to the procedure and health-related quality of life (HRQoL) in male survivors of pelvic malignancies.Material and Methods:Retrospective evaluation of 39 patients with URF primarily intervened in three institutions using different surgical approaches. Success was defined as effective fistula closure. Variables evaluated included demographics, previous treatments, surgical approach, ancillary surgeries, complications and HRQoL by using a standardized non-validated specific questionnaire. Median follow-up from surgery to interview was 55 months (interquartile range 49, range 4-112). Factors determinant of success were investigated using logistic regression. Safety of the procedure was evaluated by Clavien-Dindo scale. Deterioration of continence and erectile function and other HRQoL issues were evaluated.Results:Prostate cancer treatment was the predominant etiology. The success rate for fistula repair was 89.5%. The surgical approach was not related to failed repair (p=0.35) or complications (p=0.29). Factors associated with failure were complications (p=0.025), radiotherapy (p=0.03), fistula location (p=0.04) and fistula size (p=0.007). Multivariate analysis revealed fistula size was the only independent determinant of failure (OR 6.904, 1.01-47.75). Complications occurred in 46.2% and severe complications in 12.8%. The mortality related to the procedure was 2.6%. Urinary incontinence was present before repair in 26.3% and erectile dysfunction in 89.5%. Fistula repair caused de novo urinary incontinence in 7.9% and deterioration of erectile status in 44.7%. Globally 79% were satisfied after repair and only 7.9% rated HRQoL as unhappy. Trans-sphincteric approach was related to less deterioration of erectile function (p=0.003), and higher perceived satisfaction in QoL (p=0.04).Conclusions:The surgical approach elected to correct URF is not determinant of success nor of complications. Fistula size appears as independent determinant for failure. Transsphincteric approach could be advantageous over other procedures regarding HRQoL issues.

Rectourethral Fistula Management Via Urological Prospective

Rectourethral fistula is a rare condition with multiple etiology. The surgical treatment is a challenge as the site is difficult to reach and also there are usually several associated comorbidities from the etiological cause which needs to be dealt with. This pathology involves different speciality i.e., general surgery, colorectal surgery, minimal access surgery, urology and reconstructive surgery etc. This being one of the reasons that several different surgical technique and approaches are devised to treat this condition. Our study is based on 19 patients in whom the etiology was trauma. The surgical approach was transperineal andwe utilizing scrotal fibrofatty vascularized flap for interposition layer. We had 89.5% (n=17) success rate and10.5% (n=2) recurrence. It is therefore concluded that perineal approach is safe and far less complication.It is also important to place vascularize interposition tissue flap for successful outcome.While more radical trans sphincteric approach with defunctional colostomy should only be reserved for more complex and recurrent cases.

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 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.

Individualized Treatment for a Rectourethral Fistula: Rare Complications

See Article on Page 35-41 Most rectourethral fistulas (RUFs) are associated with prostate cancer treatment. Historically, such fistulas occur as a result of complications after a radical or transurethral prostatectomy. However, they are also caused by cancer, infection, inflammation or trauma. Over the past 20 years, treatment of prostate cancer, as well as rectal cancer, has changed; today, multimodality treatment, including radiation therapy, has been established as one of the standard treatments. The history of radiation therapy for prostate or rectal cancer is often associated with rectourethral fistulas. Up to 3% of patients undergoing these kinds of therapies will develop RUFs [1]. Spontaneous healing of such RUFs is rare, and a variety of surgical options have been described, but RUFs can still be extremely challenging to treat. In addition, multiple surgical repairs are often required to heal these types of fistulas. A transperineal repair, which can provide optimal exposure, is a good initial approach to treating both simple and complex RUFs. It would obtain a successful closure rate of up to 90%, regardless of the addition of radiation therapy. Alternatively, a transsphincteric approach can be considered, with closures rates of 85% to 88%, but generally in nonirradiated patients [2]. For some cases involving radiation-induced, large, and fibrotic RUFs, muscle flaps are required. The Gracilis muscle is most commonly used for transperineal approaches to buttress the repair. Transabdominal and abdominoperineal repairs are often performed in irradiated patients and are generally reserved for extensive resections that may result in permanent fecal diversion and/or urinary diversion because of nonfunctional fecal and urinary systems [3]. Because of the relative rarity of the fistula, as well as technical challenges inherent in successful repair, most series include very few patients, and authors have often applied heterogeneous therapeutic options with mixed postoperative results. The varying descriptions of RUF repairs, the small patient numbers, and the inconsistent reporting of outcomes preclude objective comparisons. Choi et al. [4] described their personal experience with the treatment for six patients with RUFs. Although patients were heterogeneous in etiology and treatment, as in other studies, the study is worthwhile because the authors showed results of treatment according to surgical options for this rare complication. The authors introduced surgical methods by using figures, which was useful. A comprehensive review of treatment methods, their results, and their indications based on previous reports, in addition to personal experience, would be worthwhile. The numerous surgical repairs, including those used in this study, highlight the variability in surgeon preference and technical expertise, as well as the need for individualized plans based on patient-specific anatomic and functional characteristics. In addition, collaboration between colorectal and urologic surgeons has to be considered for successful management. Successful RUF closure can be achieved through individualized therapy based on the etiology, the severity and the recurrence status of the RUF.

York Mason Procedure to Repair Iatrogenic Rectourinary Fistula: Our Experience

Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

Which is the best surgical approach for anorectal gastrointestinal stromal tumors in the post-imatinib era?

Anorectal gastrointestinal stromal tumors (GISTs) represent about 5 % of all GISTs. Local recurrence, although with a long latency period, occurs in more than a half of cases and is a major concern. Prognostic factors for recurrence are the tumor size and the mitotic index. However, for anorectal lesions, the particular location represents a main obstacle to achieving a radical (R0) resection. Surgery is the treatment of choice for patients with localized or potentially resectable GIST lesions. The goal is to achieve complete gross resection of the tumor with an intact pseudocapsule. Current guidelines recommend wide resection with clear margins (such as abdominoperineal or anterior resection) [1, 2]. Local removal of the tumor has also been proposed, performed by a transanal, transsacral, or transvaginal approach, even if abdominal surgery is more likely to result in negative margins than local surgery [3]. In the article by Centonze et al. [4], a new local technique has been proposed for anorectal GIST excision. A transsphincteric approach was used, with a right ischiorectal fossa incision. Although in the two cases presented the tumor size was C8 cm and the mitotic index was high, the procedure seems feasible, with low morbidity and good early oncological outcomes. Both the patients underwent adjuvant therapy with imatinib, as recommended for high risk GISTs. There are two important considerations to be made. The first concerns the preoperative workup. All anorectal GIST patients should be managed by a multidisciplinary team with expertise in sarcoma. The workup should include: history, physical examination, abdominal/pelvic computed tomography (CT) scan with contrast and/or magnetic resonance imaging (MRI), and chest imaging. A positron emission tomography (PET) scan is not a substitute for CT, however, it may be used to clarify ambiguous findings seen on CT or MRI. Finally, endoscopic ultrasound-guided fine needle aspiration biopsy is necessary to confirm the diagnosis of primary GIST prior to the initiation of any preoperative therapy [5]. The second concerns the use of imatinib associated with surgery. This selective inhibitor of the KIT protein tyrosine kinase has drastically improved the prognosis of patients with GIST. The results of a recently completed trial suggest that in patients with a high risk of recurrence adjuvant imatinib administered for 36 months significantly improves relapse-free and overall survival compared to 12 months of imatinib therapy [6]. Since sphincter-sparing surgery is a primary goal in treating rectal tumors, the use of preoperative imatinib has also been investigated. The published trials show that preoperative imatinib is safe, and associated with a higher R0 rate, lower risk of tumor rupture, acceptable perioperative morbidity, and good disease-free survival [7–10]. However, the survival benefit is not well determinable since most of the patients included in these studies also received imatinib postoperatively for at least 2 years [7–9]. Thus, at the present time, the decision to use preoperative therapy for patients with resectable primary, locally advanced, or recurrent GIST should be made on an individual basis. In our opinion, patients with high risk anorectal GIST (tumor size > 5 cm and/or documented mitotic rate > 5 mitoses/50 high power field) should be treated with preoperative imatinib, followed by sphincter-saving surgery. Adjuvant imatinib for high-risk patients should be S. Pucciarelli (&) I. Maretto Clinica Chirurgica I, Department of Surgery, Oncology, and Gastroenterology, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy e-mail: puc@unipd.it

Local excision with adjuvant imatinib therapy for anorectal gastrointestinal stromal tumors

Rectal gastrointestinal stromal tumors (GISTs) are uncommon, and the role of local excision versus a more extensive resection after the advent of effective targeted chemotherapy with imatinib is not known. Our aim is to present two cases of large anorectal GIST treated with local excision through a new anterolateral trans-sphincteric approach followed by adjuvant therapy with imatinib. Two patients (both males, 68 and 63 years old) presented at our institution with anorectal GIST in the period October-November 2010. Their medical records, pathology results, and imaging studies were retrospectively reviewed. Both patients presented with an anterior perianal mass. Imaging studies were characteristic of GIST originating in the lower rectum, circumscribed by a pseudocapsule, and protruding into the ischiorectal fossa. Both patients underwent local excision via an anterolateral trans-sphincteric approach. Both tumors were removed intact, with microscopically negative margins. The maximum tumor diameter was 8 and 9 cm, and the diagnosis of GIST was confirmed by positive CD117 and CD34 staining in both cases. Both tumors had a high (>5/50HPF) mitotic index. The patients had an uneventful postoperative course and were discharged on days 5 and 6. Both patients were started on imatinib 400 mg bid postoperatively. Postoperative magnetic resonance imaging and positron emission tomography computed tomography were carried out at 12 months and did not reveal any signs of recurrence. The patients are currently disease-free at 24 and 23 months of follow-up. In selected cases, complete excision of rectal GIST with negative margins is feasible via a trans-sphincteric approach. With the use of adjuvant therapy, which is currently advocated in all high-risk cases, it is possible that local excision with its reduced morbidity may become a viable alternative, especially in patients who would otherwise require abdominoperineal excision such as the two presented here. Prospective studies with longer follow-up are needed to confirm adequate oncologic results.

The trans-sphincteric posterior sagittal repair of recto-urinary and recto-vaginal fistulae using Surgisis™ mesh and fibrin sealant

Recto-urinary, recto-vaginal and ileo-anal pouch-associated fistulae are rare yet a significant clinical problem due to their profound impact on patients' quality of life and are a challenge to repair. In this report, we describe repair of these complex fistulae using a modified trans-sphincteric posterior sagittal approach with Surgisis™ mesh and fibrin sealant and review our repair outcomes.

Surgical Treatment of Iatrogenic Rectourinary Fistula—York-Mason Technique—a Case Report

Introduction. Recto-urinary fistulas resulting from trauma or surgery are a serious and debilitating complication. They represent a challenge not only because of the difficulty on choosing the best technique to solve them but also because of the risk of recurrence. Spontaneous cure is rare. Materials and Methods. We describe the case of a 61-years-old man that on the 9th postoperative day of a laparoscopic radical prostatectomy (LRP) started with fecaluria and liquid faeces. Recto-urinary fistula was confirmed at the 10th postoperative day by CT scan and contrast enema. Discussion. We chose the York-Mason technique, because it is simple to perform, effective and has minimal morbidity. This is a posterior, transrectal, and transsphincteric approach, carried out on healthy tissues without previous scarring phenomena. Results. The postoperative period progressed without complications, and the patient discharged on the 4th day. The closure of the fistula was confirmed radiologically by retrograde cystography after 4 weeks allowing the removal of drainage catheter. The reconstruction of intestinal transit was carried out 2 months later. Conclusion. The York-Mason technique, a transrectal and transsphincteric approach with minimal morbidity, proved to be effective on the resolution of the recto-urinary fistula, a rare complication of the radical prostatectomy.

The Use of Posterior Trans‐Sphincteric Approach in Surgery of the Rectum: A Chinese 16‐Year Experience

The posterior trans-sphincteric approach to treat different lesions of the rectum has been known since the last century. Although there are many advantages to this procedure, it has never been widely accepted because many surgeons fear its potential postoperative complications. The purpose of this study is to reevaluate the role of this conventional approach to surgery of the rectum from the authors' 16 years experience. Data were collected retrospectively from clinical records of 102 patients with mid- to low-lying rectal neoplastic disease treated by a single surgeon using a posterior trans-sphincteric approach to the rectum at Peking Union Medical College Hospital, China, between August 1990 and August 2006. The Williams incontinence scale of every patient was assessed preoperatively and postoperatively and the results were analyzed. Forty men and 62 women with a median age of 55.5 years (range = 21-87 years) underwent this approach. Their preoperative anal continence was assessed as grade 1 in 98 and grade 2 in 4. Indications for surgery were rectal villous adenoma in 36, early rectal carcinoma in 43, advanced rectal carcinoma in 10, and rectal submucosal neoplastic disease in 13. The median operating time, blood loss, and postoperative hospital stay were 75 min (range = 40-180 min), 60 ml (range = 0-300 ml), and 8 days (range = 7-60 days), respectively. All 102 rectal neoplastic diseases achieved complete excision (partial rectectomy in 96, segmental rectectomy in 6), and the resection margins were all clear. Three patients (2.9%) developed postoperative wound infection, and 4 patients (3.9%) developed fecal fistula. Thirty-three patients (32.4%) developed postoperative initial incontinence to flatus (n = 26) or liquid stool (n = 7) within 1 week. Three months after the operation, 94 patients (92.2%) achieved grade 1 continence and only 8 patients (7.8%) had occasional episodes of flatus incontinence. No patient developed postoperative anal stricture. There was no operation-related mortality. Three patients (2.9%) developed local tumor recurrence during median follow-up of 76.8 months (range = 10-192 months). The posterior trans-sphincteric approach is suitable for mid- to low-lying rectal lesions amenable to treatment using local therapy.

Selective surgery for carcinoma of the rectum.

The importance of selecting the best operation for each patient in the management of carcinoma of the rectum is emphasized. Selection must be based upon many factors, including the level of the lesion, and the mode and extent of spread. Using these important guidelines, the place of local excision, tube resection, and abdominal resection with anastomosis by the trans-sphincteric approach are discussed and the techniques described.

Posterior sagittal approach in complicated Swenson′s pull-through

Context:Swenson's pull-through is one of the standard operations for the treatment of children with Hirschsprung's disease. Complications arising from the operation are difficult to treat because of fibrosis in the pelvis. The posterior sagittal approach may be a safer alternative.Aims:The aim of this paper is to highlight our experience with the use of the posterior sagittal trans-sphincteric approach to treat unusual complications of Swenson's pull-through.Settings and Design:A retrospective study of four patients who had posterior sagittal repair of their complications of Swenson pull-through at the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria.Materials and Methods:Four cases of Hirschsprung's disease that developed post-Swenson pull-through complications are presented. There were three males and one female. Their age ranged between 10 months and 15 years. The patients had rectovaginal fistula, rectourethral fistula, high trans-sphincteric fistula-in-ano and complete anastomotic disruption.Result:All the patients were successfully treated using the posterior sagittal approach. The approach was used twice in one patient without significant sequelae. The three patients were old enough to be assessed and had a Kelly score of 4-6 at follow-up.Conclusion:The posterior sagittal technique offers a safe approach to treat the complications of Swenson pull-through.

Local Resection for Early Rectal Tumours: Comparative Study of Transanal Endoscopic Microsurgery (TEM) versus Posterior Trans-sphincteric Approach (Mason's Operation)

To compare local resection of early rectal tumours by transanal endoscopic microsurgery (TEM) and the conventional posterior trans-sphincteric approach (Mason's operation). The study group comprised 31 consecutive patients with early rectal tumours (18 villous adenomas, 13 adenocarcinomas) who underwent TEM in Kwong Wah Hospital, Hong Kong. The control group consisted of 51 patients with early rectal tumours (27 villous adenomas, 24 adenocarcinomas) who underwent Mason's operation in Peking Union Medical College Hospital, Beijing. Outcome measures included morbidity and mortality, operation time, recurrence rate and postoperative pathological staging. Age, sex and pathological staging were similar in the two groups. The tumour size, operation time and blood loss were similar. The median distance from the anal verge was significantly higher in the TEM group (TEM/Mason = 8.0/6.4 cm, p = 0.042). The postoperative resumption of food intake (TEM/Mason = 1/5 days, p = 0.002) and the median hospital stay (TEM/Mason = 4/10 days, p = 0.005) were significantly shorter in the TEM group. Analgesic intake was significantly less in the TEM group (TEM/Mason = 0/100 mg, p = 0.0003). There was no operation-related mortality and the resection margins were clear in both groups. Two patients (3.9%) in the Mason's group developed postoperative wound infection, and two patients (3.9%) developed faecal fistulae. There was one secondary haemorrhage in the TEM group that required injection sclerotherapy. On median follow-up of 23 months, there was no tumour recurrence in the TEM group, whereas two patients (3.9%) in the Mason's group experienced recurrence during a median follow-up of 30 months. TEM is as effective as the conventional posterior trans-sphincteric approach (Mason's operation) for local curative resection of early rectal tumours. TEM is less invasive, with shorter hospital stay and fewer complications than conventional Mason's operation.

Long‐term results of surgically treated traumatic rectourethral fistulas

Rectourethral fistulas are uncommon, usually iatrogenic injuries that are demanding to treat. We present the challenging problems involving the treatment of rectourethral fistulas caused by war wounds. In the period 1991-1996, during the war in Croatia and Bosnia, six patients with rectourethral fistulas caused by war injuries were operated in our institution by the same surgeon. All patients were young males with a mean age of 24.6 years. In all patients, double diversion (diversion colostomy and cystostomy) was performed at the time of the injury in military hospitals. In three patients, multiple unsuccessful operations were performed in other institutions to close rectourethral fistula. We found urethrocystography and proctoscopy as the most reliable diagnostic studies and performed them in all patients. In first three patients, we performed transanal repair with anterior rectal wall advancement flap. Because it failed in all three patients, we performed York-Mason trans-sphincteric approach and anterior rectal wall advancement flap after which rectourethral fistula closed in all patients. Because of the satisfactory results, we performed the same procedure in other three patients. In all patients rectourethral fistula healed 2 months after the operation. Closure of diverting colostomy was performed after urethrocystography and proctoscopy proved that the rectourethral fistula has healed. There were no operative deaths and no major complications. Urethral stenosis developed in one patient and was successfully managed by dilatation. We believe that York-Mason trans-sphincteric approach offers straightforward access through healthy tissues and good fistula visualization. Anterior rectal wall advancement flap can easily be performed and offer good chances for definitive closure of the rectourethral fistula.

Rectourethral Fistulae: The Perineal Approach

Editorial Comment: Rectourethral fistulas are usually iatrogenic, occurring after treatment of prostatic disease. Fecal diversion is essential in complex cases and controversial in others. While an initial trial of fecal and urinary diversion alone may promote spontaneous closure, many patients will require open surgery. The authors describe excellent outcomes using a perineal approach via a prone jackknife position, conducted by a colorectal and urological surgeon. This transsphincteric approach allows repair of the rectal and urethral aspects of the fistula, including any complex membranoprostatic urethral damage. It is interesting that in several patients subsequent artificial sphincter implantation was successful despite extensive bulbar urethral mobilization during fistula repair.

Synchronous abdominotrans-sphincteric resection of low rectal cancer: new technique for direct colo-anal anastomosis.

Sixty-five patients with low rectal cancer 4-9 cm from the anal margin were treated by rectal resection and direct colo-anal anastomosis. The procedure simultaneously combined abdominal dissection with the patient in the lateral position with a trans-sphincteric approach. In 57 cases a temporary defunctioning colostomy was performed. There were no postoperative deaths. Six patients (9 per cent) developed pelvic sepsis or anastomotic leakage. Faecal continence was normal in 46 of 51 patients (91 per cent) who were operated on at least 1 year previously. The remaining 5 complained of occasional minor soiling. No patients require a permanent colostomy for incontinence. Of 29 patients treated for potential cure greater than 3 years previously, 24 (82 per cent) were alive without recurrence. Local recurrence occurred in four patients (6 per cent). Direct colo-anal anastomosis using a combined abdominotrans-sphincteric approach has produced good functional results without impairing the patient's life expectancy.

Transsphincteric repair of rectourethral fistulas following laparoscopic radical prostatectomy

Rectourethral fistula is a serious complication following laparoscopic radical prostatectomy. We report our experience with a transsphincteric approach in the repair of this uncommon complication. The rectourethral fistula was repaired in a three-stage procedure comprising fecal diversion, transsphincteric repair of the fistula and, finally, closure of the stoma. Two patients with rectourethral fistulas underwent this procedure and the postoperative course was uneventful. In conclusion, a transsphincteric approach in the repair of rectourethral fistula by a three-stage procedure is safe and may be the treatment of choice.

The posterior sagittal trans-sphincteric approach

The posterior sagittal, transphincteric approach to treat different pelvic problems has been known since last century. Although some surgeons have embraced it and have enthusiastically advocated it s use, it has never become an overly popular technique. The purpose of this study is to evaluate the advantages and disadvantages of the approach, both from an historical perspective and from the authors experience. The international literature on the subject was reviewed since 1877 up to the present date. A retrospective evaluation of the authors experience was conducted, and the results reviewed. Specific attention was paid to the final result obtained in the treatment of the original condition, surgical complications and the effect of the surgical approach on bowel and urinary control. The experiential review included 114 cases. They were divided into two groups. A included 85 patients who underwent a posterior sagittal transphincteric approach that included 49 cases of Hirschsprung s disease (primary 21, secondary 28), 15 presacral masses; 10 rectaltumors; 7 acquired recto-genito-urinary fistulae; and 4 cases of idiopathic rectal prolapse. Group B included 29 patients who underwent a posterior sagittal trans-anorectal approach, in which the anterior wall of the rectum and the sphincter was divided as well.. This group included 12 cases of urogenital sinuses; 8 acquired urethral stricture or atresia after trauma; and 9 posterior urethral masses. Post-operative bowel control was normal all cases except in those patients whose basic condition had resulted in fecal incontinence, or who had sustained an irreversible injury prior tothe operation. Urinary control was normal except in cases with pre-operative incontinence. Complications included recurrence of recto-genitourinary fistulae in 3 cases, recto-cutaneous fistula in 3 Hirschsprung s patients and 2 partial wound dehisences. The posterior sagittal trans-sphincteric approach represents a useful technical alternative. It seems to be particularly useful to treat complications after surgery for Hirschsprung s disease, pre-sacral masses, acquired recto-genito-urinary fistula and idiopathic rectal prolapse. The transanorectal approach provides excellent exposure to the posterior urethra and vagina. Boweland urinary control are not compromised.