Review examines the management of radiotherapy induced rectourethal fistula

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Apr 11 2006

Rectourethral fistulas (RUF) are a challenging problem observed by urological and colorectal surgeons.

The etiology of RUF includes previous surgery, trauma, inflammatory processes, congenital defects and radiation to the pelvis. An increase in the number of men presenting with RUF has occurred secondary to the increase in the number of men undergoing brachytherapy or a combination of brachytherapy and external beam radiotherapy for the treatment of prostate cancer. Several approaches to the management of these fistulas have been described but series are small and no consensus regarding management has been achieved.

A recent review by Ken Angermeier and colleagues from the Cleveland Clinic discusses their experience with the management of 22 patients with radiation induced rectourethral fistulas. The review is published in the April 2006 issue of the Journal of Urology.

Of the 22 patients, 21 had received radiotherapy as the primary mode of therapy for prostate cancer and one had received adjuvant external beam radiotherapy after biochemical failure following radical retropubic prostatectomy. Six patients had undergone brachytherapy alone, 5 had undergone external beam radiotherapy and 10 had a combination of the two modalities. The average age of the men was 66.1 years, and the average time from last radiation treatment to fistula presentation was 6 months to as long as 20 years.

The initial management consisted of fecal diversion in 20 patients and suprapubic catheter placement in 17 patients and urethral catheters in 2. One patient voided entirely per rectum. A total of 17 patients underwent definitive surgical repair an average of 9 months after diversion. Two patients underwent definitive urinary diversion with ileal conduits secondary to extensive radiation damage noted on cystoscopy and proctoscopy. One patient underwent a transanal repair using the York-Mason approach but recurrence developed after 1 month.

Abdominoperineal resection and end colostomy were performed with cystectomy and urinary diversion in 4 patients all of which were successful. These patients had severe radiation damage and/or multiple cutaneous fistulas. Five patients underwent abdominoperineal repair with preservation of either the urinary or rectal sphincter but not both.

Six patients underwent abdominoperineal repair with preservation of both fecal and urinary function. Five patients underwent reconstruction with Turnbull-Cutait colonic pull through and staged colo-anal anastomosis in conjunction with a buccal mucosa graft repair of the prostatic urethra. In these patients, the rectal excision and urethral closure was performed initially with the patient in the prone position and the patient was placed supine for the remainder of the procedure. The colonic pull through was performed with the mesentery oriented anteriorly to provide support for the buccal mucosa graft. Another patient underwent perineal repair with buccal mucosa graft urethral repair, primary closure of the rectum, and a gracilis muscle interposition flap was then placed between the rectum and urethra. All six of these patients were free of fistula recurrence, were voiding without catheters and underwent stoma closure.

The authors supply a nice algorithm detailing treatment based on clinical presentation with confirmation using cystoscopy, proctoscopy and digital rectal examination with the patient under anesthesia. The combination of a buccal mucosa graft closure of the urethra with Turnbull-Cutait colo-anal pull through was the most common procedure in this series and showed good results in this very difficult patient population.

By Michael J. Metro, MD