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Management of Management of RectourethralRectourethral Fistula (RUF)Fistula (RUF)

Herman Kwan R5Herman Kwan R5Urology Grand Rounds Dec 21, Urology Grand Rounds Dec 21,

20052005

Summary of Iatrogenic RUFSummary of Iatrogenic RUFNonNon--radiation radiation RUFRUF

Numerous surgical Numerous surgical approaches to excision approaches to excision + repair+ repair

Presence of healthy Presence of healthy tissuetissue……results in results in reasonable successreasonable success

Radiation RUFRadiation RUF

Minimal literature on this Minimal literature on this entity and itentity and it’’s s managementmanagement

Local repairs will failLocal repairs will fail

Ultimately need anterior Ultimately need anterior exenterationexenteration, , ilealileal loop loop diversion, colostomy for diversion, colostomy for durable curedurable cure

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etiologyetiology

CongenitalCongenitalIatrogenic** (Iatrogenic** (iRUFiRUF))Traumatic Traumatic

Missile, bullet, crush injury, direct blunt Missile, bullet, crush injury, direct blunt traumatrauma

NeoplasticNeoplasticInflammatoryInflammatory

CrohnCrohn’’ss, pseudomonas , pseudomonas prostatitisprostatitis, , malakoplakiamalakoplakia

Iatrogenic RUF (Iatrogenic RUF (iRUFiRUF))

Uncommon complication of urologic Uncommon complication of urologic proceduresprocedures

TURPTURPCryotherapyCryotherapy

00--5% Cox et al 1995, Long et al 1998 JU1595% Cox et al 1995, Long et al 1998 JU159Radical prostatectomyRadical prostatectomy

0.20.2--2.9% 2.9% ScardinoScardino 19971997PerinealPerineal prostatectomy prostatectomy

1.4% (1.4% (thomasthomas et al BJU 1997)et al BJU 1997)Simple prostatectomySimple prostatectomy

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RUF after RadiationRUF after Radiation

BrachytherapyBrachytherapy 0.4 0.4 --3.3%3.3%Cancer 2000, JU 1986, JCO 1996, Cancer 2000, JU 1986, JCO 1996, IntInt J J RadiatRadiat OncolOncol ‘‘9999

BrachymonotherapyBrachymonotherapy vsvs BT + EBRT BT + EBRT vsvsSalvage BTSalvage BTAnterior rectal biopsy in early postAnterior rectal biopsy in early post--txtx coursecourseNeoadjuvantNeoadjuvant hormone ablationhormone ablation

EBRT 0EBRT 0--0.6%0.6%JU 2000, JU 2000, IntInt J J RadiatRadiat OncolOncol 19991999

presentationpresentation

Usually NOT subtle!Usually NOT subtle!FecaluriaFecaluria --pneumaturiapneumaturiaUrorrheaUrorrhea

12% 12% iRUFiRUF present w/ pelvic/abdominal present w/ pelvic/abdominal sepsissepsis……urgent exploration/fecal diversionurgent exploration/fecal diversion

Often palpable on DREOften palpable on DRE

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Presentation postPresentation post--radiationradiationMay initially present w/ May initially present w/ severe rectal severe rectal pain from mucosal ulcerationpain from mucosal ulcerationDramatically resolves when rectal wall Dramatically resolves when rectal wall breaks open and breaks open and fistulizesfistulizes

DiagnosisDiagnosis

RadiologicRadiologic options:options:CTCTBarium enemaBarium enemaVCUGVCUGMethyleneMethylene blue in bladderblue in bladder

Highest yield w/ Highest yield w/ cystoscopycystoscopy::CystourethrogramCystourethrogramRetrograde Retrograde pyelogrampyelogramBiopsyBiopsy

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SigmoidoscopySigmoidoscopy is also vitalis also vital……

Localize level of rectal entryLocalize level of rectal entryIdentify sphincter integrityIdentify sphincter integrityConfirm absence of rectal pathology Confirm absence of rectal pathology Define extent of radiation injuryDefine extent of radiation injury

TreatmentTreatmentConservative**Conservative**

Urinary DrainageUrinary DrainageSPTSPTIDCIDC

Fecal DiversionFecal DiversionColostomyColostomy

**opportunity for **opportunity for spontaneous closurespontaneous closure

Surgical RepairSurgical Repair--Single Single vsvs multimulti--stagestage

CI to 1CI to 1--stagestage::--radiationradiation

--uncontrolled local/systemic uncontrolled local/systemic infxinfx--ImmunocompromisedImmunocompromised statestate

--extensive rectal injury leading to extensive rectal injury leading to fistula formationfistula formation

--Anterior Anterior ExenterationExenteration w/ w/ Urinary DiversionUrinary Diversion

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Need for fecal diversion?Need for fecal diversion?

Controversial Controversial ??Diverting colostomy for all ??Diverting colostomy for all vsvs spontaneous spontaneous closure w/ simple urinary diversion??closure w/ simple urinary diversion??

Probable indications Probable indications ((HanusHanus, 2002), 2002)

Symptoms despite Symptoms despite abxabx + urinary diversion+ urinary diversionPersistent Persistent fecaluriafecaluria despite TPN/ low residue despite TPN/ low residue diet in presence of sepsisdiet in presence of sepsis**Radiation induced fistulas****Radiation induced fistulas**

Surgical Principles of Local Surgical Principles of Local RepairsRepairs

Proper positioning/incisionProper positioning/incisionExcision of fistula tractExcision of fistula tractNonNon--overlapping suture linesoverlapping suture lines……no tensionno tensionSeparation of urethral/rectal suture line by Separation of urethral/rectal suture line by interposition of pedicle flapinterposition of pedicle flap

GracilisGracilis muscle flapmuscle flapDartosDartos pedicle flappedicle flapRectal mucosal advancement flapsRectal mucosal advancement flaps

Effective urinary/fecal diversionEffective urinary/fecal diversion

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Surgical repairsSurgical repairs

Numerous procedures describedNumerous procedures described……. . reflects uncertainty in approachreflects uncertainty in approach

Surgical approachesSurgical approaches

Posterior Posterior vsvs anterioranteriorTransphinctericTransphincteric vsvsnon non transphincterictransphinctericMidline or Midline or saggitalsaggitalOpen or Open or endoscopicendoscopic

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Types of repairsTypes of repairsA. TransA. Trans--abdominal abdominal

approachapproachB. B. KraskeKraske (posterior (posterior

sagittalsagittal))C.YorkC.York mason (post, mason (post,

transrectaltransrectal, , transphincterictransphincteric))

D. TransD. Trans--analanalE. E. PerinealPerineal (anterior)(anterior)

Anterior Anterior transanorectaltransanorectal

AUAUS 2005 lesson 8AUAUS 2005 lesson 8

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AUAUS 2005 lesson 8AUAUS 2005 lesson 8

Contemporary Urology May, 2005Contemporary Urology May, 2005

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Iatrogenic RUFIatrogenic RUF

NyamNyam, Pemberton , Pemberton (Mayo Clinic Rochester)(Mayo Clinic Rochester) DisDis Colon Colon Rectum Rectum ‘‘9999

Reviewed 16 RUF (Reviewed 16 RUF (‘‘8181--’’95)95)15 15 CaPCaP, 1 bladder TCC, 1 bladder TCC

7 RRP7 RRP2 salvage RRP2 salvage RRP2 BT2 BT3 BT + EBR3 BT + EBRRadRad. . CystectomyCystectomy, continent diversion, continent diversion…… dilation of dilation of stricturestricture

Of 16 RUF from various iatrogenic Of 16 RUF from various iatrogenic etiologies:etiologies:

7 colostomy as initial 7 colostomy as initial mxmx……all all reqreq’’dd surgerysurgery13 underwent surgical excision13 underwent surgical excision

9 were 9 were ““curedcured””3 3 gracilisgracilis flapsflaps……all all ““curedcured””4 failures4 failures……permanent fecal diversion w/ permanent fecal diversion w/ ““good palliation of good palliation of sxsx’’ss””No anterior No anterior extenterationextenteration

••3 conservatively 3 conservatively txtx w/ w/ abxabx……unknown unknown outcomeoutcome

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Conclusions from this series:Conclusions from this series:

TxTx w/ fecal diversion onlyw/ fecal diversion only……poor resultspoor resultsLocal repairsLocal repairs……70% success70% successInterposition of Interposition of gracilisgracilis flapsflaps……100% 100% successsuccess

Case presentationCase presentation

77 male intermediate risk 77 male intermediate risk CaPCaPBT 2002BT 2002Rectal bleeding 2004Rectal bleeding 2004Colonoscopy rectal Colonoscopy rectal proctitisproctitisMarch 2005 rectal ulcer 15mmMarch 2005 rectal ulcer 15mmJune June ’’05, 05, dysuriadysuria, , pneumaturiapneumaturia, frequency , frequency x10x10

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Pt is now admitted under Gen Pt is now admitted under Gen SurgSurg w/ w/ fevers to 39C, fevers to 39C, fecaluriafecaluria, , pneumaturiapneumaturiaDRE: fistula easily admits fingerDRE: fistula easily admits fingerCystoCysto: large fistula prostate, mild radiation : large fistula prostate, mild radiation cystitiscystitis

How would you manage this pt?How would you manage this pt?

Fecal diversion?Fecal diversion?Urinary drainage?Urinary drainage?Urinary diversion?Urinary diversion?Local repair and excision of fistula?Local repair and excision of fistula?

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MxMx of RUF postof RUF post--BTBT

Few publicationsFew publicationsBJU Aug 2004, BJU Aug 2004, Devastating Complications Devastating Complications after after BrachytherapyBrachytherapy in in txtx of of CaPCaPRetrospective chart reviewRetrospective chart review20002000--’’03, 11pts w/ RUF post BT03, 11pts w/ RUF post BT

MxMx of RUF post of RUF post brachytherapybrachytherapy

All pts initially All pts initially txtx w/ diverting colostomyw/ diverting colostomy4 had simultaneous SPT diversion4 had simultaneous SPT diversion

2 management arms:2 management arms:1. Severe radiation damage + severe symptoms 1. Severe radiation damage + severe symptoms

w/ LARGE fistula (7)w/ LARGE fistula (7)2. Minor radiation damage + CONTINENT (4)2. Minor radiation damage + CONTINENT (4)

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““Severe radiation damageSevere radiation damage””

““minimal radiation damageminimal radiation damage””

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SummarySummaryAll received colostomy as initial All received colostomy as initial txtx……unsuccesfulunsuccesfulPts w/ MAJOR radiation damage +LARGE Pts w/ MAJOR radiation damage +LARGE fistulafistula

Anterior Anterior exenterationexenteration, fistula closure, urinary , fistula closure, urinary diversiondiversion……success 9/11 casessuccess 9/11 cases

Pts w/ MINOR radiation damagePts w/ MINOR radiation damageYork Mason procedure +/York Mason procedure +/-- GracilisGracilis muscle muscle flap +/flap +/--dartosdartos flapsflapsAll All continentcontinent following surgeryfollowing surgery

Urinary Fistulas following external radiation Urinary Fistulas following external radiation or permanent or permanent brachytherapybrachytherapy for for CaPCaP

JU June 2005JU June 2005

51pts 51pts ’’7272--02, 02, h/oh/o radiation treatment w/ radiation treatment w/ subequentsubequent fistula formationfistula formationEBRT or BT or combinedEBRT or BT or combinedExcluded previous RRP, Excluded previous RRP, diverticulitisdiverticulitis, , crohncrohn’’ss (any predisposing RF)(any predisposing RF)

11 RUF11 RUF

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conclusionsconclusions

Majority of pts have large fistulas into Majority of pts have large fistulas into necrotic/infected prostates, even after necrotic/infected prostates, even after fecal diversionfecal diversionSubjective/objective cure only from both Subjective/objective cure only from both urinary (urinary (ilealileal loop) and fecal diversionloop) and fecal diversionbladder sparing diversionbladder sparing diversion……

Complicated w/ persistent Complicated w/ persistent hematuriahematuria + pelvic + pelvic abscessabscess

JU June 2005JU June 2005

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Treatment principles of postTreatment principles of post--radiation RUFradiation RUF

Fecal diversion is mandatoryFecal diversion is mandatoryBladder drainage unlikely to contribute to Bladder drainage unlikely to contribute to cure except w/ small fistula + minimal cure except w/ small fistula + minimal radiation damageradiation damageHighest rate of success w/ FD + Highest rate of success w/ FD + cystoprostatectomycystoprostatectomy w/ w/ ilealileal loop diversionloop diversionBladder sparing approach may not be best Bladder sparing approach may not be best choicechoice

Back to the caseBack to the case……

Symptomatic despite oral Symptomatic despite oral abxabx +IDC+IDCInitial diverting colostomy + SPTInitial diverting colostomy + SPTPt now resolved from symptomsPt now resolved from symptomsUndergoing Hyperbaric OxygenUndergoing Hyperbaric OxygenGeneral Surgeon still unsure of final repairGeneral Surgeon still unsure of final repair

Permanent colostomy Permanent colostomy vsvs CystoprostatectomyCystoprostatectomyRectal pull down w/ Rectal pull down w/ coloanalcoloanal anastomosisanastomosis

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