Surgical Approaches To The Repair Of Urinary Rectal Fistula

Main Category: Urology / Nephrology
Article Date: 09 Aug 2008 - 1:00 PDT

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UroToday.com - In most cases, urinary rectal fistulas will involve bladder to rectum, prostatic urethra to rectum, or in some cases membranous urethra to rectum. Fistulas can be congenital or acquired; the acquired fistulas will be covered in this lecture. As such, treatment must be very individually administered. What must be considered are the topics of urinary diversion, bowel diversion, best way to close both urinary tract and bowel, and methods of tissue interposition. In many cases, the approach will facilitate or limit ones abilities to accomplish all of those.

The issue of urinary rectal fistula particularly following treatment for cancer of the prostate is not an unusual one. Following the monotherapies of radical retropubic prostatectomy, there is a 1% incidence. With brachytherapy, the incidence can be as high as 7%, with external beam a lesser percentage is seen; however, with combined brachytherapy and external beam the modern series show at least a 3% incidence. The incidence following cryotherapy or HIFU remains to be established. Following salvage therapy, the incidence rises significantly, in both radical retropubic prostatectomy as well as the other salvage therapies, those being cryotherapy, brachytherapy, and HIFU.

They are a relatively rare complication, but when they occur they are devastating for the patient. Typical onset is about a year and half or so after the administration of therapy, can be seen however immediately after radical prostatectomy. The patient will present pneumaturia, urine per rectum, dysuria, perineal pelvic pain, fever, pelvic abscess. Many patients will present with a rectal ulcer, and it is clear that the practice of biopsying those ulcers is a bad one. Likewise laser therapy for those ulcers is not recommended either.

With regards to approaches, the perineal approach will be addressed, its advantages and disadvantages and the literature will be discussed and cases will be demonstrated. The abdominal approach will likewise be demonstrated, its advantages and disadvantages discussed. The transanal approach will be demonstrated, and the Latsko technique demonstrated as well as the rectal advancement flap technique. The anterior transanal transsphincteric approach and the posterior transanal transsphincteric approaches will be demonstrated. Their advantages and disadvantages discussed. The abdominal-perineal approach will likewise be discussed and its place in the armamentarium discussed in some detail.

In summary, patients with complex fistulas should have both fecal and urinary diversion. The process must be allowed to settle down and that often times requires a wait of up to a year. There will be those patients that are medically unfit for a large operation, and they will live with diversion from that point. Those that are fit for surgery will be then categorized. In those in which there is a future potential for urinary and bowel function to be adequate, then repair of the urethral defect, repair of the bowel defect, with interposition of vascular tissue, will be the norm. On the other extreme, there will be those patients in which future urinary and bowel function is not likely to be adequate, and in many of those cases, the patient will come to cystoprostatectomy with conduit or catheterizable diversion, and fecal diversion will be permanent. The place for addressing the patient who may have potential for fecal function but none for urinary function and vice versa likewise will be covered.

Presented by: Gerald H. Jordan, MD, FACS, FAAP, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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