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

Abstract

Background 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. Methods 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. Results 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). Conclusions 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.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta‐analysis of the literature

“…After an initial screening of 219 articles, the full text of 135 articles was reviewed and 110 were excluded (PRISMA flowchart, Figure 1). Ultimately 25 studies [3–27] were included in the present meta‐analysis. The studies were published between 2002 and 2021; 23 studies were retrospective and two were prospective non‐randomized studies.…”

“…The gracilis muscle serves as a mechanical barrier between the urethra/vagina and the rectum which offers opportunity for healing [3]. The success and complication rates of the gracilis interposition technique are widely variable [3–27]. This systematic review aimed to assess the overall success and morbidity rates in patients undergoing gracilis muscle interposition for CPF.…”

Post-traumatic rectourethral fistula in an adolescent managed via a transperineal approach using a local gluteal tissue interposition flap: a case report

“…The basic surgical principles are excision and debridement of the fistula tract and separation of the rectum and urethra with tissue interposition [ 8 ]. These RUF repair procedures were mainly performed via transanal, transsphincteric, transabdominal, and transperineal approaches [ 9 ]. The transperineal approach was the most commonly used, accounting for 65.9% of cases.…”