7 minute read
Management of recto-urinary fistulas
Dr. Javier RomeroOtero MD PhD FEBU FECSM Chairman, Urological Department Hospital Universitario HM and ROC Clinic, Madrid (ES) jromerootero@ rocurologia.com
Recto-urinary fistulas are a rare complication that occur after radical prostatectomy, colorectal surgery, and cryosurgery. Recto-urinary fistulas are also observed in patients with Crohn’s disease or diverticular disease.
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After radical prostatectomy, the estimated incidence is lower than 2%, and rectourethral fistula is the most common type with the highest percentage in case of combined treatment for prostate cancer with surgery and pelvic irradiation. Radiotherapy or lesion of the rectal wall during radical prostatectomy are the leading causes. If a fistula occurs during the surgery, primary closure is needed. However, in some cases, the urinary-rectal fistula is diagnosed in the postoperative period.
The management acquired recto-urinary fistulas represent a challenging task. A surgical repair is required in most of the cases. Several surgical procedures were described, including resection of the fistula tract and direct closure of the fistula with a perineal approach, mucosal flaps, instillation of fibrin glue, endorectal advancement flap, a York-Mason operation, and fistula closure with an abdominal approach. The less aggressive procedures report good outcomes but not in complex fistulas. However, complex fistulas with previous surgeries or in patients with prior radiotherapy may require the interposition of tissues in the management of fistula to achieve fistula closure and reduce the incidence of recurrence. Among the tissues used for transposition in the recto-urethral fistula are gracilis muscle, rectus abdominis, omentum, dartos, gluteus maximus, and latissimus dorsi. The abdominal approach has the advantages of placing healthy well-vascularized tissue in the affected area. On the other hand, the abdominal approach has potentially significant perioperative adverse sequelae. Gracilis interposition allows a well-vascularized tissue via a perineal approach. Repair of perineal fistulas with gracilis muscle interposition was first described by Garlock et al. in 1928. In 1952, Igelman-Sundberg described the technique in patients with vesicovaginal fistulas. The interposition of gracilis muscle is one of the procedures that provide satisfactory outcomes with limited functional limitation in the donor area as gracilis muscle has an only vestigial function. Transposition of a gracilis muscle flap may be used for the surgical management of rectovaginal, rectourethral, pouch-vaginal and pouch-urethral fistula.
The gracilis muscle is situated at the thigh’s medial part from the ischiopubic branch to its tibial insertion forming the goosefoot. It is the most medial and superficial muscle of the inner thigh, fulfilling adduction functions, internal rotation, and flexion of the hip. The gracilis muscle has a very proximal pedicle consisting of the circumflex medial femoral artery, which allows adequate transposition to the perineal area. There is also a distal vascular pedicle from the deep femoral artery, which can be divided and ligated to achieve the flap’s correct rotation. Other minor pedicles can be dissected. The main advantages of a flap with the gracilis muscle include there is enough tissue provided from the donor site to correct interposition, limited functional loss, and low morbidity in the donor site. Moreover, when the procedure is carried out by an experienced surgeon, the dissection of the gracilis muscle is a simple technique.
When a complex urinary-rectal fistula is diagnosed, a faecal and urinary diversion is recommended. At the beginning of the procedure, ureteral catheterization may be performed as the fistula’s orifice may be close to the ureteral meatus. The surgical procedure with transposition of gracilis muscle consists of a perineal approach with dissection above the transversus perineum muscle and below the bulbocavernosus muscle. The dissection is carried out until the identification of the fistula. The edges of the fistula are resected to leave soft, viable tissue for the closure of the fistula. The rectal wall and the urethra is closed with absorbable stitches closed. The suture must be done using healthy tissues.
The gracilis muscle is dissected from the nondominant leg and transposed to the perineum to preserve the proximal pedicle through a subcutaneous tunnel. For the gracilis muscle, harvesting an incision at the medial thigh is made immediately from the posterior to the saphenous vein from 4 to 8 fingerbreadths distal to the anterior superior iliac spine. The gracilis muscle is then interposed between the rectal and urethral closure of the fistula and fixed with absorbable suture. The surgery is associated with a complication rate of 0% to 49%. The most common complication is perineal wound infection or delayed healing.
Although the donor site morbidity of the gracilis muscle harvesting site is low, adequate control of the donor site in the thigh is essential during the postoperative procedure. This is to minimise the incidence of wound infection or delayed healing. It is necessary to inform the patients beforehand that urinary incontinence and faecal incontinence during the postoperative period are reported in 14% and 4.2% of patients, respectively.
The surgery must be carried out by a multidisciplinary team which includes a urologist, colorectal surgeons, and urological reconstructive surgeons with specific surgical skills in the perineal surgery. Repair of the urinary-rectal fistula with transposition of the gracilis muscle is challenging as many patients have received prior radiotherapy and have had previous failed attempt to repair the fistula.
Gracilis muscle used to repair a complex fistula
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