Fistulae are not frequent, but when they do occur they are an incapacitating problem. The most common reason is an acquired pelvic pathology, either from benign causes (trauma, infection, inflammation), malignant (from direct tumor growth), or iatrogenic (treatment of malignant pathology). This is typically secondary to surgery (radical prostatectomy, rectal surgery) or secondary to radiation therapy.
In the radical retropubic prostatectomy era, the fistulae rate was 1-11%, whereas now that the majority of prostatectomies are done robotically, the rate is ~0.17%. Radiation is responsible for nearly half of the fistulae, with brachytherapy contributing 0.3-3%, external beam radiotherapy 0.6%, and combination therapy 2.9%. Fistulae secondary to surgery often occur in the bulbar urethra, which is in close proximity to the rectum. These typical present 2-3 weeks following surgery and are often small and uncomplicated. Fistulae secondary to radiation therapy typically presents up to 3 years following treatment, are often larger, and are poorly vascularized leading to more difficult repair and worse outcomes.
According to Dr. D’Hoore, there are three phases to the diagnostic workup:
- Confirm suspicion – this is done with imaging of the urinary tract and a biopsy to rule our recurrence, particularly after radiation therapy
- Staging the tract – this includes an assessment of the size, location, associated other organs involved (ureter, etc), the quality of the surrounding tissue, and assessment of any retained materials (ie. clips, staplers)
- Function – bladder capacity and distensibility, continence (ie. stress incontinence), bladder and anal sphincter function, and sexual function
Dr. D’Hoore says that at his institution, they may give a 3-month trial of conservative management. This typically includes transurethral/suprapubic urinary drainage and fecal diversion (medical/surgical colostomy), as this reduces inflammation, pelvic sepsis and bleeding. Historically the literature quotes a resolution rate of 14-100%.
A systematic review of the surgical repair of rectourethral fistulae in 2013 found that 66% of procedures were transperineal, 16% transsphincteric, 12% transabdominal, and 6% transanal [1]. There are several common surgical procedures performed, including transanal rectal advancement flap (Parks procedure), a sphincter-splitting approach (York-Mason procedure), a transperineal (anterior) approach (typically with a gracilis flap), a buccal mucosal graft, a tunica vaginalis (Dartos) flap, or an abdominal approach with a omentoplasty.
At Dr. D’Hoore’s institution in Leuven, they have operated on 41 patients with a mean age of 65 years, 68.3% with a history of prostate cancer (24.4% with rectal cancer), and 58.5% with a history of radiation therapy. In their experience, any radiation therapy has a 6x higher odds of failure (OR 6.07, 95%CI 0.86-43.04).
Dr. D’Hoore completed his presentation with several concluding statements:
- 50% of rectourethral fistulae are linked to radiation therapy, which has a major impact on outcomes
- Transperineal approaches (York Mason) still have an indication for a non-irradiated, non-complex fistulae
- The anterior perineal approach with gracilis interposition has become the procedure of choice for irradiated patients
- The surgical approach is dictated by the clinical situation: consider possible functional outcomes
- o Adequate urinary and bowel function – restorative surgery
- o Adequate urinary function, bowel function inadequate – prostatectomy and continue the current fecal diversion
- o Adequate bowel function, urinary function inadequate – cystoprostatectomy and ileal conduit
Presented by: Andre D’Hoore, MD, Ph.D, Professor, University Hospital Gasthuisberg Leuven, Leuven, Belgium
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
References:
1. Hechenbleikner EM, Buckley JC, Wick EC. Acquired rectourethral fistulas in adults: A systematic review of surgical repair techniques and outcomes. Dis Colon Rectum 2013 Mar;56(3):374-383.
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