Panel Discussion: Reconstruction Of Recto-Urethral/Bladder Fistula

Main Category: Urology / Nephrology
Also Included In: Prostate / Prostate Cancer
Article Date: 14 Jun 2008 - 10:00 PDT

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ORLANDO, FL (UroToday.com) - Dr. Jack McAninch led the panel on recto-urethral fistula (RUF). About 1% of patients undergoing any type of treatment for localized prostate cancer form a RUF. Dr. Hull, a colorectal surgeon at the Cleveland Clinic discussed their role in the management of these patients. They can perform fecal diversion to reduce inflammation in the fistula area. Repair depends on the location, cause, history of radiotherapy among others. Endoscopy and anal physiology can provide useful information. A proctectomy is recommended if the rectal ulcer is extensive. A trans-abdominal repair includes a staged repair of rectal advancement and reconstruction. For smaller lesions, a trans-anal rectal flap gives 83% success. All failures occurred in Crohn's disease patients. Perineal repair with muscle interposition also has good results. She was not in favor of a trans-sphincteric repair as she was opposed to cutting across "normal" tissue.

Dr. Middleton discussed the York-Mason trans-sphincteric approach. Symptoms of urinary drainage, pneumoturia and fecaluria prompt evaluation with cystoscopy. He favored the York-Mason repair. In 44 patients reported, 27 had a RUF due to radical prostatectomy and the rest from other types of prostatectomies, TURP or radiotherapy. Positioning is prone with the buttock checks taped apart. The fistula is circumferentially excised after the external and internal sphincters have been incised. After the RUF is excised, the bladder is closed, tissue interposed and rectum closed. They now perform this as one stage without a colostomy if the fistula is 2cm or less and the patient has not had prior radiotherapy. They report 3 failures in their series. Anticipated failures include large size, prior radiotherapy or prior cryotherapy. Hospitalization is 4-5 days with a foley in place for 2-3 weeks. Good case selection is critical to obtaining these outcomes, he concluded.

Professor Fisch discussed the role of salvage prostatectomy and urinary diversion for complex RUFs. Brachytherapy, external radiotherapy or cryotherapy, size greater than 2cm, urethral stricture and anal sphincter dysfunction define the complex RUF, she stated. The indication for salvage RP includes stenosis of the posterior or Intraprostatic urethra. Anastomotic stricture and incontinence are up to 41% and 60%, respectively. Cystoprostatectomy and urinary diversion is considered when the bladder capacity is small due to radiotherapy. The best urinary diversion is controversial. The most conservative approach is use of the transverse colon for incontinent and continent urinary reconstruction.

Dr. Angermeier discussed the role of tissue grafts and flaps for the complex RUF. A history of radiotherapy correlates with symptoms of severe pain in 50%, bleeding in 23%, and infection in 18%. For these patients, fecal and urinary diversion is critical. The bladder can be salvaged if the capacity is >200cc, the infection is resolved by CT imaging and exam under anesthesia supports it. Anal manometry and cystometrograms are often useful. Grafting with buccal mucosa and dartos tissue are reported, but his experience is with omentum or gracilis flaps. He performs a proctectomy to optimize urethral repair. The omentum is mobilized and placed in the rectal area. Once the patients if flipped to the prone position, the omentum is brought into the rectal space for utilization. An option is use of gracilis interposition by a transperitoneal approach where bladder preservation is planned. In 15 patients undergoing gracilis interposition 14 had successful outcomes.

Moderated by: Jack W. McAninch, MD, with Tracy Hull, MD, Richard Middleton, MD, Margit Fisch, MD and Kenneth W. Angermeier, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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