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