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RECONSTRUCTIVE
UROLOGY
doi: 10.1590/S1677-553820100002000024
Management
of radiotherapy induced rectourethral fistula
Lane BR, Stein DE, Remzi FH, Strong SA, Fazio VW, Angermeier KW
Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland,
Ohio, USA
J Urol. 2006; 175: 1382-7; discussion 1387-8
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Purpose:
An increasing number of men are being treated with BT or a combination
of external beam radiation therapy and BT for localized prostate cancer.
Although uncommon, the most severe complication following these procedures
is RUF. We reviewed our recent experience with RUF following radiotherapy
for prostate cancer to clarify treatment in these patients.
Materials and Methods: We recently treated 22 men with RUF following
primary radiotherapy for adenocarcinoma of the prostate in 21 and
adjuvant external beam radiation therapy following radical prostatectomy
in 1. Time from the last radiation treatment to fistula presentation
was 6 months to 20 years.
Results: Four patients underwent proctectomy with permanent fecal
and urinary diversion. RUF repair in 5 patients was performed with
preservation of fecal or urinary function. Six patients were candidates
for reconstruction with preservation of urinary and rectal function,
including 5 who underwent proctectomy, staged colo-anal pull-through
and BMG repair of the urethral defect. The additional patient underwent
primary closure of the rectum, BMG repair of the urethra and gracilis
muscle interposition. Successful fistula closure was achieved in the
9 patients who underwent urethral reconstruction. All 8 candidates
for rectal reconstruction showed radiological and clinical bowel integrity
postoperatively with 2 awaiting final diverting stoma closure.
Conclusions: With the increasing use of prostate BT the number of
patients with severe rectal injury will likely continue to increase.
Radiotherapy induced RUF carries significant morbidity and most patients
are treated initially with fecal and urinary diversion. In properly
selected patients good outcomes can be expected following repair using
BMG for the urethral defect along with colo-anal pull-through or primary
rectal repair and gracilis muscle interposition.
- Editorial
Comment
These two single institution case series review management and outcome
of rectourethral fistula repair in two vastly different patient groups:
surgery vs. radiation. It is well accepted that rectourethral fistula
repair is made more difficult by prior radiotherapy. Another difference
between the two groups is that the post-radical prostatectomy patients
were primarily managed by the authors whereas in post-radiation patients
were referred for management after a failed period of conservative
management.
In the radical prostatectomy series by Thomas et al., nearly half
of the fistulas closed spontaneously, a few even without a colostomy.
Importantly, the authors note that the absence of fecaluria was a
good indicator of a fistula that would close spontaneously: 4 of 8
closed spontaneously in the absence of fecaluria (3 without a colostomy)
but only 1 of 5 with fecaluria. Spontaneous closure occurred after
1-3 months of urethral catheterization. All fistula repairs were accomplished
transperineally.
The radiation series is quite different. No fistulas closed spontaneously.
Fistulas were much larger, ranging in size up to 7 cm. Patients presented
with severe problems secondary to the fistula such as sepsis and Fournier’s
gangrene. Only 6/22 could be repaired with preserved orthotopic fecal
and urinary function; the remainder had one or both streams diverted
with an ostomy. Perioperative morbidity was likewise much higher in
those undergoing fistula repair after radiation.
Rectourethral or rectovesical fistula is a rare but morbid complication
of surgery or radiation for prostate cancer. These series highlight
the fact that with appropriate expertise good outcomes can be achieved
in those who have not been previously radiated however.
Dr.
Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.edu
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