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RECONSTRUCTIVE
UROLOGY
doi: 10.1590/S1677-553820100002000025
Incidence,
clinical symptoms and management of rectourethral fistulas after radical
prostatectomy
Thomas C, Jones J, Jäger W, Hampel C, Thüroff JW, Gillitzer
R
Department of Urology, Johannes Gutenberg University, Mainz, Germany
J Urol. 2010; 183: 608-12
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Purpose:
Rectourethral fistula is a rare but severe complication after radical
prostatectomy and there is no standardized treatment. We retrospectively
evaluated the incidence, symptoms and management of rectourethral
fistulas based on our experience. Materials and Methods: From 1999
to 2008 we performed 2,447 radical prostatectomies. Patients in whom
postoperative rectourethral fistulas developed were identified. Based
on the therapeutic approach patients were categorized into group 1-conservative
treatment, group 2-colostomy with or without surgical closure and
group 3-immediate surgical closure without colostomy.
Results: Rectourethral fistulas developed in 13 of 2,447 patients
(0.53%) after radical prostatectomy. The risk of rectourethral fistulas
was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than
for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients
(54%) a rectal lesion was primarily closed at radical prostatectomy.
Median followup was 59 months. In all patients in group 1 (3) the
fistula closed spontaneously with conservative treatment. None of
these patients had fecaluria. In group 2 of the 9 patients 3 (33%)
experienced spontaneous fistula closure after temporary colostomy
and transurethral catheterization. In this group 6 patients (67%)
required additional surgical fistula closure, which was successful
in all. Surgical fistula closure (1) without colostomy in presence
of fecaluria failed (group 3).
Conclusions: The therapeutic concept for rectourethral fistulas should
be guided by clinical symptoms. Rectal injury during radical prostatectomy
is a major risk factor. In cases with fecaluria colostomy is required
for control of infection and may allow spontaneous fistula closure
in approximately a third of cases. In the remainder of cases surgical
fistula closure was successful in all after protective colostomy.
- 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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