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News

Surgical management of complex rectourethral fistulas

A study in the latest issue of the Diseases of the Colon & Rectum evaluates the surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients.

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Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized.

Anecdotally, irradiated rectourethral fistulas portend a worse prognosis.

Dr Jennifer Hanna and colleagues reviewed outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm.

The researchers performed a retrospective review of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012.

The team identified 37 patients that presented with and were treated for rectourethral fistulas.

Only 55% of irradiated patients had their ostomy reversed
Diseases of the Colon & Rectum

Of these, 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16.

The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence.

The researchers found no significant differences in patient characteristics between groups.

The team noted that patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients.

Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps, and pelvic exenterations, whereas nonirradiated patients most commonly underwent a York-Mason repair.

The team observed no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes.

Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group.

Dr Hanna's team concludes, "Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas."

"Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate."

"We propose an algorithm for approaching rectourethral fistulas based on etiology."

Dis Colon Rectum 2014: 57(9): 1105–1112
25 August 2014

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