Urethrorectal fistula


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Urethrorectal fistula by M.A.Wadood Aref

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Urethrorectal fistula

  1. 1. ByM.A.Wadood Aref
  2. 2.  By defnition, a fistula is an extra- anatomic, epithelialized tract between two hollow organs or between a hollow organ and the body surface. In case of urethrorectal fistulas, the tract occur between the urethra and the rectum.
  3. 3.  urethrorectal fistulas may be congenital (associated with imperforate anus & extremely rare) or acquired (iatrogenic or non- iatrogenic ).
  4. 4.  Acquired urethrorectal fistulas are typically associated with iatrogenic injury during pelvic surgical procedures and uncommonly associated with pelvic radiotherapy. Prtedisposing factors for post- prostatectomy urethrorectal fistulas are: radiation, previous rectal surgery, or TURP.
  5. 5. Iatrogenic causes of URFs include:1. Radical Prostatectectomy (RP) Incidence of Rectal injury during RP is less than 1 - 2%, However, it is considered the most common cause due to increased number of radical prostatectomies done yearly.
  6. 6. 2. Local treatments for prostatic cancer: including Radiotherapy, Brachytherapy (0.4%), Cryotherapy (0.5 to 2%) or HIFU.3. Open prostatectomy or TURP or overly aggressive TUR of bladder neck contracture.4. Anorectal surgery: abdomino-perineal resect.5. Urethral instrumentation is also a rare cause of urethrorecal fistula
  7. 7. Non-iatrogenic causes of URFs include: Trauma: penetrating trauma. Malignancy: prostatic or rectal malignancy. Infection such as tuberculosis, Ruptured prostatic abscess. Inflammatory diseases: such as Crohns disease (0.3%). ©
  8. 8. Patient with URF can be presented by: Fecaluria. Hematuria. Recurrent UTI refractory to treatment . Peritonitis and sepsis. Fever, Nausea and vomiting.
  9. 9.  Digital rectal examination (DRE): during rectal examination fistula track can be felt along the anterior rectal wall. Cystoscopy and sigmoidoscopy can be used for visualization of the fistula track & biopsy for detection of malignancy. Upper tract imaging can be used to exclude a related ureteral injury.
  10. 10.  Diagnosis of rectourethral fistula can be confirmed with RUG or VCUG.
  11. 11.  Pre-op assessment of continence and sphincteric function is important in rectourethral fistula after radical prostatectomy because most rectourethral fistulas lie at or near the vesicourethral anastomosis and membranous urethra. So, stress urinary incontinence can occur after repair. ©
  12. 12.  Conservative treatment can cure some cases of post- prostatectomy URFs (open or laparoscopic). Conservative treatment include catheter drainage, NPO, IV Total parentral nutrition, anal dilatation and Antibiotics
  13. 13.  Fecal diversion may be needed in urethrorectal fistulas after brachytherapy or cryosurgry. repair of such fistulas is quiet difficult because it is usually large with induration, fibrosis and ischemia.
  14. 14.  Surgery is the main line of treatment in most of cases of urethrorectal fistulas. It can be performed as single stage or staged repair. Some authors have advocated fecal diversion and staged repair of all URFs.
  15. 15. Staged repair is done with fecal diversionperformed before repair of the rectourethralfistula.Staged repair is indicated in: large fistulas, post-radiation therapy, uncontrolled local or systemic infection, Immunocompromised, inadequate bowel preparation at initial oper.
  16. 16. Single stage repair Indicated in surgically induced Small fistula with no infection, abscess. Advantage of a successful one-stage approach is limiting the potential morbidity and cost of multiple procedures with the staged repair. ©
  17. 17.  Tranarectal approach Without division of anal sphincter (Transanal) With division of anal sphincter (York-Mason) Transperineal approach Transabdominal approach ©
  18. 18.  Transrectal approaches for URF rapair (York- Mason approach or transanal approach) are performed in the prone jackknife position.
  19. 19.  The transanal approach to rectourethral fistula repair does not involve division of the anal sphincter. In contrast to York-Mason approach. Techniques include rectal advancement flap or Latzko method. The main limitation of this approach is the limited exposure and it is best suited for small distal fistulae. ©
  20. 20.  Exposure of the fistula is provided by dilation of the anus and fixed retraction. Through the anal canal, an ellipse of rectal mucosa is removed.
  21. 21.  A full-thickness U- shaped flap of rectal wall is elevated above the fistula.
  22. 22.  The full-thickness flap of rectal wall is brought down over the fistula and sutured in two layers to the rectal wall.
  23. 23.  The technique is similar to the Latzko method for transvaginal VVF repair . Exposure of the fistula is provided by dilation of the anus and fixed retraction. The fistula track and surrounding rectal mucosa are denuded in all four quadrants. The fistula is then closed in three layers. The major disadvantages to this approach are the relatively poor exposure. ©
  24. 24.  York-Mason procedure is a transrectal, transsphincteric approach that has been shown to be effective with low morbidity. Staged York-Mason approach is the classically described repair. Single-stage York-Mason approach can be used in patients with small, non-irradiated fistulas with vigorous bowel preparation and broad-spectrum antibiotics. ©
  25. 25.  performed in a prone jackknife position with the buttocks taped laterally. Incision is performed from the sacrococcygeal juncture to the anus.
  26. 26.  incision is deepened through the posterior anus and dorsal rectal wall and deepened down to the level of the coccyx through the external anal sphincter
  27. 27.  The fistula track is excised, and the anterior rectal wall is mobilized circumferentially around the fistula margins. The urethra is closed. Anterior rectal wall is closed. Rectal mucosa is re- approximated This provides 3-layer closure. reapproximating the post. rectal wall & anal sphincter.
  28. 28.  Results of York-Mason procedure are excellent. Based upon literature reports, the York-Mason approach has become the favored repair for URFs not amenable to a transanal approach. Renschler and Middleton in 2003 reported a successful repair in 22 of 24 patients. No serious complications were reported, and no patient developed anal incontinence or stenosis. Similar excellent results have been noted by other authors ( Prasad et al, 1983 ; Bukowski et al, 1995 ; Fengler and Abcarian, 1997) .
  29. 29.  A perineal approach to rectourethral fistula has been described in selected cases with good results. Advocated by:  Bukowski et al, 1995.  Nyam and Pemberton, 1999.  Youssef et al, 1999.  Zmora et al, 2003.
  30. 30.  Advantages of perineal approach include: being a familiar approach for many urologists and local accessability to a variety of potential interpositional flaps. Perineal approach with interpositional flap provided Excellent results.
  31. 31.  Interposition grafts include: Gracilis muscle: Ryan et al, 1979 ; Rius et al, 2000 ; Zmora et al, 2003. Pedicled dartos muscle: Venable, 1989 ; Youssef et al, 1999 ; Yamazaki et al, 2001. Penile skin: Morgan, 1975. levator muscle: Goodwin et al, 1958. Bladder: Kokotas and Kontogeorgos, 1983.
  32. 32.  patient in the extended lithotomy position. a 20 F 30-ml filled balloon catheter is inserted. Use retractors to bring fistula into the wound, and insert a finger into the rectum as a guide. Divide the fistula and excise all surrounding scar tissue.
  33. 33.  assistant draw up on the catheter. blunt and sharp dissection between the rectum and prostate well above the fistula to reach normal tissue. Closure of the rectal fistula. ©
  34. 34.  Graft can be interposed between urethra & rectum esp. in teneous repair. urethral defect is closed in two layers with 4-0 absorbable suture.
  35. 35.  Transabdominal approach has been described for URF rapair with limited success. Advocated by: Bukowski et al, 1995 ; Nyam and Pemberton, 1999 ; Shin et al, 2000. The principal advantage to this technique is the availability of greater omentum for an interpositional flap.
  36. 36. Potential disadvantages include: morbidity and prolonged postoperative convalescence associated with a laparotomy incision the poor exposure of the operative field limited maneuverability in the deep pelvis risk of urinary and fecal incontinence.
  37. 37.  Continue antibiotic administration and a low- residue diet postoperatively. Shorten the drain in 3 days and remove it the next day. Remove the catheter or cystostomy no sooner than the 8th day.
  38. 38.  Rectourethral fistulas are uncommon complication, it occur mostly after surgery, radiotherapy or minimally invasive treatments for prostatic cancer. Rare causes include surgery for BPH, rectourethral fistulas are usually suspected clinically and diagnosis can be confirmed with voiding cystourethrography or retrograde urethrogram. ©
  39. 39.  Treatment of rectourethral fistula most commonly involves surgical repair; however, select patients may respond to conservative therapy. York-Mason approach have good results and minimal morbidity in cases not amenable to transanal approach. Transperineal approach with interpositional graft is familiar with good results. ©