Rectourethral fistula: systemic review of and experiences with various surgical treatment methods

Abstract

Purpose: A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF.

Methods: The outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed.

Results: The causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion.

Conclusion: Depending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.

Keywords: Complication; Rectal fistula; Surgical flap; Urinary fistula.

Fig. 1

Diagnostic procedures of rectourethral fistula. (A) Fistulography showing the rectourethral fistula tract. (B) Colonoscopic view of the fistulous opening in the rectum.

Fig. 2

Gracilis muscle flap interposition. A 75-year-old male underwent seed implantation for brachytherapy. About nine months later, a rectourethral fistula (RUF) developed, and a diversion colostomy was performed. However, the RUF persisted for a year after the diversion, so the patient was referred to our hospital to receive a radical retropubic prostatectomy and restoration of a colostomy with a simultaneous gracilis muscle flap interposition. The gracilis muscle harvested from its bed (A) was rotated into the fistula site (B) through a capacious subcutaneous tunnel made between the perineum and the thigh (C).

Fig. 3

Omental flap interposition. A 49-year-old male patient was severely injured in a traffic accident, and a double diversion was performed immediately. Because he had to undergo exploration for other potential intra-abdominal injuries, a transabdominal approach with omental flap interposition and concomitant sigmoidostomy were performed. (A) An omentectomy along the right gastroepiploic arcade was done while the left gastroepiploic pedicle was saved. (B) The omental flap was used to cover the fistula site. (C) The fistula tract was removed, and primary repair was performed.

Fig. 4

Flow diagram of treatment outcomes of treatments for a rectourethral fistula.