Rectourethral Fistula NOTES

RECTOURETHRAL FISTULAS (RUF)

Etiology: congenital (i.e. imperforate anus) and acquired

Acquired:

  • Iatrogenic rectal injury during pelvic surgery
  • Anterior rectal wall biopsy
  • Inflammatory or infectious conditions
  • Trauma
  • Radiation: brachytherapy or external beam radiation

Most common causes of RUF: prostatectomy and CaP radiation

  • Incidence of rectal injury at time of radical prostatectomy = 0.5% and 9%.
    • Incidence using laparoscopic or robotic access = 1% to 2.7%.
  • Success of RUF repair in cases of radiation injury and Crohn’s disease tends to be lower than in patients with other causes of RUF. 

Management of Intraoperative Rectal Injury

  • Primary repair if the operative field is clean
  • Diverting colostomy if the field is contaminated.
  • Rectal injury from thermal energy
    • Rarely recognized intraoperatively
    • Usually presents a week later as rectal bleeding or sepsis.
    • Resuscitation, immediate diversion with drainage of abscess, and supportive care

Presentation

  • Si/Sx: pneumaturia, fecaluria, rectal bleeding, rectal voiding, leakage or watery diarrhea, severe rectal and pelvic pain.
    • May present with life-threatening bleeding, intra-abdominal abscess, sepsis, and necrotizing fasciitis, particularly if the diagnosis is delayed.
    • When a fistula recurs after initial surgical repair, patient is rarely acutely ill.
    • Recurrent UTIs: common complaint in chronic RUF patients.

Diagnosis, Evaluation, Preparation

  • CT of the abdomen and pelvis in cases of sepsis and suspected abscess
  • Diagnostic studies should be postponed in the presence of fever or sepsis and undertaken only after proximal urinary diversion, administration of intravenous antibiotics, and resolution of the acute process.
  • RUG and VCUG, cystoscopy, proctoscopy, and EUA
    • Helps determine extent of radiation damage surrounding the fistula, fistula size and location, rectal sphincter condition, and evidence of associated urethral or bladder neck stricture
    • Assess bladder capacity
  • FUDS: when the bladder is extremely contracted or fibrotic, preservation of the bladder is not likely to provide a functional outcome.

Management

  • RUFs are commonly debilitating and resistant to repeated repair procedures.
  • Need careful preoperative staging evaluation.
  • Fecal and urinary diversion should be performed in most cases before any definitive repair.
    • Diversion of fecal and urinary streams from the fistula allows inflammation to improve or resolve before repair.
    • Diversion alone is sufficient therapy to allow a small, non-radiated fistula to heal in approximately 20% to 25% of cases.
  • After fecal diversion (colostomy or ileostomy) and urinary diversion (SP tube, or rarely ileal conduit), a waiting period of 3 to 9 months is common.
    • Allows inflammation and infection to heal; in a small percentage of iatrogenic cases the fistula may resolve spontaneously.
  • Surgical Principles:
    • First attempt at closure is the best attempt.
    • Judicious use of tissue interpositions in the plane between the rectum and the urethra is recommended: omentum, gracilis muscle, sartorius muscle, and buccal mucosal grafts may be used.
    • Buccal mucosal graft can be placed over the prostatic urethral defect at the time of repair to decrease the incidence of urinary extravasation.
  • Surgical approach:
    • Some urologists favor a posterior or perineal approach.
    • Perineal approach is familiar and favors use of dartos or gracilis tissue flaps.
      • Disadvantages include a theoretical risk of impotence, limited exposure, and the possible presence of significantly scarred tissues.
    • Anterior transanorectal approach provides good exposure and also easily allows use of dartos, gracilis, or
      rectal tissue flaps for interposition.
      • Rectal sphincter muscles may be divided, but anatomic repair can maintain fecal continence.

Complications associated with the surgical repair of RUF

  • Bleeding, wound infection, and early or late recurrence of the fistula.

Postop care:

  • Oral antibiotics
  • Cystogram at 3 weeks.

 

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