Abstract
Background
Rectourethral fistula is a challenging complication of radical retropubic prostatectomy. Several treatments have been proposed, with varying outcomes. The available data are difficult to interpret, because patient and disease characteristics differ significantly among reports. Details of long-term follow-up and functional status are rarely provided. We describe a technique of rectourethral fistula repair via an intersphincteric route.
Methods
Preoperative workup included proctoscopy and urethrocystography. All patients already had a stoma at the time of fistula repair. Mechanical cleansing of the bowel distal to the colostomy was routinely performed, and perioperative antibiotic prophylaxis was administered. Patients were placed in the lithotomy position. Under spinal anesthesia, a curvilinear anteanal incision was made, to expose the external sphincter. The anterior portion of the external sphincter was gently displaced along half of its circumference. The anterior rectal wall was sharply dissected free from the urethra, approximately up to 2 cm above the fistula level through the intersphincteric plane. The fistula was identified. The surrounding tissues were mobilized to obtain a tension-free repair of the urethral defect, using a single row of 4–0 polyglactin transverse, interrupted sutures. Transanally, a U-shaped full-thickness rectal flap was advanced and sutured with 3–0 monofilament interrupted sutures to cover the rectal opening, and care was taken to ensure that the two suture lines were in different planes. The catheter was left in place for 4 weeks. Patients were evaluated at 3-month follow-up for stoma closure.
Results
We successfully treated five patients. Only one minor complication was observed (surgical site infection). Stomas were taken down uneventfully. After a median follow-up duration of 2 years (range 2–3 years), no patients had fistula recurrence or impaired continence.
Conclusions
Intersphincteric repair should be considered as an effective option in patients with iatrogenic rectourethral fistulas. This technique offers several advantages over alternative procedures that require more extensive approaches or invasive manipulation of the anal sphincters.
References
Thomas C, Jones J, Jäger W, Hampel C, Thüroff JW, Gillitzer R (2010) Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy. J Urol 183:608–612
Hanna JM, Turley R, Castleberry A et al (2014) Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients. Dis Colon Rectum 57:1105–1112
Katz R, Borkowski T, Hoznek A, Salomon L, de la Taille A, Abbou CC (2003) Operative management of rectal injuries during laparoscopic radical prostatectomy. Urology 62:310–313
Masuda T, Kinoshita H, Nishida S, Kawa G, Kawakita M, Matsuda T (2010) Rectal injury during laparoscopic radical prostatectomy: detection and management. Int J Urol 17:492–495
Chun L, Abbas MA (2011) Rectourethral fistula following laparoscopic radical prostatectomy. Tech Coloproctol 15:297–300
Al-Ali M, Kashmoula D, Saoud IJ (1997) Experience with 30 posttraumatic rectourethral fistulas: presentation of posterior transphincteric anterior rectal wall advancement. J Urol 158:421–424
Shah SA, Cima RR, Benoit E, Breen EL, Bleday R (2004) Rectal complications after prostate brachytherapy. Dis Colon Rectum 47:1487–1492
Verriello V, Altomare M, Masiello G, Curatolo C, Balacco G, Altomare DF (2010) Treatment of post-prostatectomy rectourethral fistula with fibrin sealant (Quixil™) injection: a novel application. Tech Coloproctol 4:341–343
Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M (2006) Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 49:1316–1321
Rouanne M, Vaessen C, Bitker MO, Chartier-Kastler E, Rouprêt M (2011) Outcome of a modified York Mason technique in men with iatrogenic urethrorectal fistula after radical prostatectomy. Dis Colon Rectum 54:1008–1013
Altomare DF, Greco VJ, Tricomi N et al (2011) Seton or glue for trans-sphincteric anal fistulae: a prospective randomized crossover clinical trial. Colorectal Dis 13:82–86
Selvaggi F, Pellino G (2015) Pouch-related fistula and intraoperative tricks to prevent it. Tech Coloproctol 19:63–77
Selvaggi F, di Carlo ES, Maffettone V, Silvestri A, Notaroberto A (1992) Intersphincteric surgical access to the rectum for the treatment of villous adenomas. Dis Colon Rectum 35:92–94
Rivera R, Barboglio PG, Hellinger M, Gousse AE (2007) Staging rectourinary fistulas to guide surgical treatment. J Urol 177:586–588
Plaikner M, Loizides A, Peer S et al (2014) Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis. Tech Coloproctol 18:165–171
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This study was approved by Institutional Review Board (IRB).
Informed consent
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Amato, A., Pellino, G., Secondo, P. et al. Intersphincteric approach for rectourethral fistulas following radical prostatectomy. Tech Coloproctol 19, 699–703 (2015). https://doi.org/10.1007/s10151-015-1346-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-015-1346-x