Management of Rectourethral Fistula (RUF)

Management of
Rectourethral Fistula (RUF)
Herman Kwan R5
Urology Grand Rounds Dec 21,
2005
Summary of Iatrogenic RUF
z Non-radiation
z
Radiation RUF
RUF
z
Numerous surgical
approaches to excision
+ repair
z
Minimal literature on this
entity and it’
it’s
management
z
Presence of healthy
tissue…
tissue…results in
reasonable success
z
Local repairs will fail
z
Ultimately need anterior
exenteration,
exenteration, ileal loop
diversion, colostomy for
durable cure
1
etiology
Congenital
z Iatrogenic** (iRUF)
z Traumatic
z
z Missile,
bullet, crush injury, direct blunt
trauma
Neoplastic
z Inflammatory
z
z Crohn’s,
pseudomonas prostatitis,
malakoplakia
Iatrogenic RUF (iRUF)
z
Uncommon complication of urologic
procedures
z TURP
z Cryotherapy
z 0-5%
Cox et al 1995, Long et al 1998 JU159
z Radical
prostatectomy
z 0.20.2-2.9%
z Perineal
z 1.4%
z Simple
Scardino 1997
prostatectomy
(thomas
(thomas et al BJU 1997)
prostatectomy
2
RUF after Radiation
z
Brachytherapy 0.4 -3.3%
z
Cancer 2000, JU 1986, JCO 1996, Int J Radiat Oncol ‘99
z Brachymonotherapy
vs BT + EBRT vs
Salvage BT
z Anterior rectal biopsy in early post-tx course
z Neoadjuvant hormone ablation
z
EBRT 0-0.6%
z
JU 2000, Int J Radiat Oncol 1999
presentation
z
Usually NOT subtle!
z Fecaluria
-pneumaturia
z Urorrhea
z
12% iRUF present w/ pelvic/abdominal
sepsis…urgent exploration/fecal diversion
z
Often palpable on DRE
3
Presentation post-radiation
z
z
May initially present w/ severe rectal
pain from mucosal ulceration
Dramatically resolves when rectal wall
breaks open and fistulizes
Diagnosis
z
Radiologic options:
z CT
z Barium
enema
z VCUG
z Methylene
z
blue in bladder
Highest yield w/ cystoscopy:
z Cystourethrogram
z Retrograde
pyelogram
z Biopsy
4
Sigmoidoscopy is also vital…
Localize level of rectal entry
z Identify sphincter integrity
z Confirm absence of rectal pathology
z Define extent of radiation injury
z
Treatment
Conservative**
z
Urinary Drainage
z
z
z
SPT
IDC
Fecal Diversion
z
Colostomy
**opportunity for
spontaneous closure
Surgical Repair
-Single vs multimulti-stage
CI to 11-stage:
stage:
-radiation
-uncontrolled local/systemic infx
-Immunocompromised state
-extensive rectal injury leading to
fistula formation
-Anterior Exenteration w/
Urinary Diversion
5
Need for fecal diversion?
z
Controversial
z ??Diverting
colostomy for all vs spontaneous
closure w/ simple urinary diversion??
z
Probable indications (Hanus,
Hanus, 2002)
z Symptoms
despite abx + urinary diversion
z Persistent fecaluria despite TPN/ low residue
diet in presence of sepsis
z **Radiation induced fistulas**
Surgical Principles of Local
Repairs
Proper positioning/incision
z Excision of fistula tract
z Non-overlapping suture lines…no tension
z Separation of urethral/rectal suture line by
interposition of pedicle flap
z
z Gracilis
muscle flap
z Dartos pedicle flap
z Rectal mucosal advancement flaps
z
Effective urinary/fecal diversion
6
Surgical repairs
z
Numerous procedures described….
z reflects
uncertainty in approach
Surgical approaches
z
z
z
z
Posterior vs anterior
Transphincteric vs
non transphincteric
Midline or saggital
Open or endoscopic
7
Types of repairs
A. TransTrans-abdominal
approach
B. Kraske (posterior
sagittal)
sagittal)
C.York mason (post,
transrectal,
transrectal,
transphincteric)
transphincteric)
D. TransTrans-anal
E. Perineal (anterior)
z
Anterior transanorectal
AUAUS 2005 lesson 8
8
AUAUS 2005 lesson 8
Contemporary Urology May, 2005
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10
11
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Iatrogenic RUF
z
Nyam, Pemberton (Mayo Clinic Rochester) Dis Colon
Rectum ‘99
z Reviewed
16 RUF (‘81-’95)
z 15 CaP, 1 bladder TCC
z7
RRP
z 2 salvage RRP
z 2 BT
z 3 BT + EBR
z Rad.
Rad. Cystectomy,
Cystectomy, continent diversion…
diversion… dilation of
stricture
Of 16 RUF from various iatrogenic
etiologies:
7 colostomy as initial mx…all req’d surgery
z 13 underwent surgical excision
z
z9
were “cured”
z 3 gracilis flaps…all “cured”
z 4 failures…permanent fecal diversion w/
“good palliation of sx’s”
z No anterior extenteration
•3 conservatively tx w/ abx…unknown
outcome
13
Conclusions from this series:
Tx w/ fecal diversion only…poor results
z Local repairs…70% success
z Interposition of gracilis flaps…100%
success
z
Case presentation
77 male intermediate risk CaP
z BT 2002
z Rectal bleeding 2004
z Colonoscopy rectal proctitis
z March 2005 rectal ulcer 15mm
z June ’05, dysuria, pneumaturia, frequency
x10
z
14
15
16
17
18
19
20
21
22
23
Pt is now admitted under Gen Surg w/
fevers to 39C, fecaluria, pneumaturia
z DRE: fistula easily admits finger
z Cysto: large fistula prostate, mild radiation
cystitis
z
How would you manage this pt?
Fecal diversion?
z Urinary drainage?
z Urinary diversion?
z Local repair and excision of fistula?
z
24
Mx of RUF post-BT
Few publications
z BJU Aug 2004, Devastating Complications
after Brachytherapy in tx of CaP
z Retrospective chart review
z 2000-’03, 11pts w/ RUF post BT
z
Mx of RUF post brachytherapy
All pts initially tx w/ diverting colostomy
z 4 had simultaneous SPT diversion
z
z
2 management arms:
1. Severe radiation damage + severe symptoms
w/ LARGE fistula (7)
2. Minor radiation damage + CONTINENT (4)
25
“Severe radiation damage”
“minimal radiation damage”
26
Summary
All received colostomy as initial
tx…unsuccesful
z Pts w/ MAJOR radiation damage +LARGE
fistula
z
z Anterior
exenteration, fistula closure, urinary
diversion…success 9/11 cases
z
Pts w/ MINOR radiation damage
z York
Mason procedure +/- Gracilis muscle
flap +/-dartos flaps
z All continent following surgery
Urinary Fistulas following external radiation
or permanent brachytherapy for CaP
JU June 2005
51pts ’72-02, h/o radiation treatment w/
subequent fistula formation
z EBRT or BT or combined
z Excluded previous RRP, diverticulitis,
crohn’s (any predisposing RF)
z
z
11 RUF
27
conclusions
Majority of pts have large fistulas into
necrotic/infected prostates, even after
fecal diversion
z Subjective/objective cure only from both
urinary (ileal loop) and fecal diversion
z bladder sparing diversion…
z
z Complicated
w/ persistent hematuria + pelvic
abscess
JU June 2005
28
Treatment principles of postradiation RUF
Fecal diversion is mandatory
z Bladder drainage unlikely to contribute to
cure except w/ small fistula + minimal
radiation damage
z Highest rate of success w/ FD +
cystoprostatectomy w/ ileal loop diversion
z Bladder sparing approach may not be best
choice
z
Back to the case…
Symptomatic despite oral abx +IDC
z Initial diverting colostomy + SPT
z Pt now resolved from symptoms
z Undergoing Hyperbaric Oxygen
z General Surgeon still unsure of final repair
z
z Permanent
colostomy vs Cystoprostatectomy
z Rectal pull down w/ coloanal anastomosis
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end
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