UROLOGICAL SURVEY
Reconstructive urology
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
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
Publication Dates
-
Publication in this collection
31 May 2010 -
Date of issue
Apr 2010
