Complex Rectourinary and Vesicoperineal Fistulas

Summary

The management and reconstruction of complex rectourinary and vesicoperineal fistulas are some of the most difficult problems to deal with in Urology. To decide on the proper management of such fistulas, a detailed knowledge of the fistula etiology, integrity of the anal and external urethral sphincters, functional status of the bladder, extent of rectal radiation damage, size and location of the urinary fistula, and the overall performance and nutritional status of the patient is needed. Few surgeons have had a large experience with such fistulas, and this is why there is no clear standard surgical repair approach. Treatment needs to be tailored to the specifics of the fistula, the etiology, and the patient. Fistulas that result from radiation therapy are more complex and more difficult to reconstruct than those developing after other forms of treatment, with the frequent concomitant problems of urinary and fecal incontinence, and/or urethral strictures. Small, non-radiated fistulas often are successfully managed by the transanal or York-Mason approach. Complex fistulas that are large, or of radiation or cryotherapy etiology, are often best managed either by primary repair, buttressed with a gracilis interposition flap, or by proctectomy and colo-anal pull through, or supravescial urinary diversion. Here-in we have detailed the varying surgical methods for fistula repair, as well as for salvage.