Urorectal fistulae following the treatment of prostate cancer

Abstract

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? It is known that urorectal fistulae is a serious but rare complication of the treatment of carcinoma of the prostate. This study adds a distinction between post-surgical fistulate and post-irradiation fistulae. Essentially most post-surgical fistulae are simple and relatively easily dealt with: the expectation is that the patient will return to normality; whereas post-irradiation fistulate are by their nature complex and much more difficult to treat with a much more uncertain long-term outcome. Complexity is discussed and defined.

Objective: • To evaluate the management of urorectal fistulae (URF) in light of new technology in prostate cancer treatment, which has changed the nature of these URF and, therefore, the approach to treatment.

Patients and methods: • Between 2004 and 2009 we repaired URF after treatment for prostate cancer in 40 patients with a minimum of 1-year follow-up since their last intervention. • In 23 patients (post-surgical group) the URF resulted from open, laparoscopic or robotic radical prostatectomy. In the other 17 patients (post-irradiation group) the URF resulted from either external beam radiation (EBRT) or brachytherapy (BT), or both, salvage cryotherapy or salvage high-intensity focused ultrasound (sHIFU). • In the 23 patients in the post-surgical group a transperineal repair was performed. In the post-irradiation group a transperineal repair was performed in three of the 17 patients. A transabdominal or abdominoperineal repair was performed in the remaining 14 patients, combined with salvage radical prostatectomy in those eight patients in whom a discrete prostate still existed, and in whom this was possible.

Results: • The URF were cured in all patients. • A bladder-neck contracture (BNC) developed in two patients, one of whom is being managed by interval dilatation and the other of whom had a revision of his vesico-urethral anastomosis. Sphincter weakness incontinence required further treatment in eight patients by implantation of an artificial urinary sphincter. • A specific category of complex URF with cavitation was identified, which is particularly common after sHIFU following the combination of previous EBRT and BT, but which may result from the sequential application of any 'new technology'.

Conclusions: • URF of any degree of complexity can be managed without the need for a transanorectal sphincter-splitting approach or a covering colostomy and without the need for an interposition flap when the circumstances are appropriate and the surgeon is sufficiently experienced. URF with cavitation and in the post-irradiation group are an exception and do require an interposition flap. • The role of salvage radical prostatectomy in patients with a URF who still have a prostate, needs to be defined. • We suggest that cavitation, BNC and extensive ischaemia due to the serial application of external energy sources confer 'complexity'. Post-surgical URF are simple except for those with cavitation or a BNC. Most post-irradiation URF are complex even in the absence of cavitation or a BNC.