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RECTOURINARY FISTULA REPAIR USING THE LATZKO TECHNIQUE
oOn-5347/99/1615-1518/0 THEJOLXNAL OF U R O ~ Y Copyright 0 1999 by AMERICAN
Vol. 161, 1518-1520,May 1999 Printed in U.S.A.
UROUKICALk ? o C u T l O ~ ,I N C
RECTOURINARY FISTULA REPAIR USING THE LATZKO TECHNIQUE JOACHIM NOLDUS, SALVADOR FERNANDEZ
AND
HARTWIG HULAND
From the Department of Urology, Uniuersity Hospital Hamburg, Hamburg, Germany
ABSTRACT
Purpose: We report our experience with the Latzko technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. Materials and Methods: We performed 7 fistula repairs in 6 patients. The 1-stage procedure was based on a technique for vesicovaginal fistula closure with denudation of the rectal mucosa and muhilayer closure of the fistulous tract. Results: Closure was successful in all patients, although 1 had to undergo the procedure twice. There were no postoperative complications. Conclusions: The Latzko procedure is effective for rectourinary fistula repair and associated with minimal morbidity. KEYWoms: fistula, bladder, prostate, rectum, urinary tract
Rectal injury is a rare complication of radical prostatectomy1-" which may be predisposed to advanced local disease, previously administered radiation therapy of the prostate or pelvis,s previous bacterial prostatitis and transurethral resection of the prostate within a few months before radical prostatectomy. Most rectal injuries occur in the attempt to avoid positive surgical margins when the terminal end of Denonvilliers' fascia under the urethra is excised.6 When a rectal injury is discovered during radical prostatectomy, the lesion is usually closed in 2 layers and irrigated copiously.~-* Some authors also recommend interposition of a flap of greater omentum to cover the repair completely.'.4 If a rectourinary fistula occurs despite primary closure of the injury or a rectal injury is noted postoperatively with feces in the urine, initial treatment is conservative and includes parenteral nutrition, antibiotics and a transurethral catheter.3.4 In some cases conservative treatment fails to close a rectourinary fistula spontaneously and surgery is necessary. Multiple methods of rectourinary fistula repair have been reported using ~ e r i n e a l , ? - posterior ~ pararectal,1° abdominal and transvesical,8-9 and posterior sagittal transanal transrectal We describe our experience with a simple approach using the Latzko technique,'" which was first reported for vesicovaginal or enterovaginal fistula closure after hysterectomy. 13
ating table (pelvis up, head down). A circular area of rectal mucosa is incised for 1.0 to 1.5 cm. from the fistula opening (fig. 1).The rectal mucosa is denuded in 4 quadrants (fig. 2). No rectal mucosa is allowed to remain between the edges of the incision and the fistulous opening. The ureteral catheter is removed and the fistula is closed with 2 layers of side by side absorbable 3-ZerO polyglactin sutures (fig. 3, A and B ) . The margins of the rectal wound are closed similarly (fig. 3, C).A Foley catheter is placed in the bladder. Postoperative management focuses on protection of the rectal closure. A 5-day bed rest, 7-day fully absorbable diet and antibiotics are recommended. Closure is confirmed on cystography on day 14, and even if the urinary tract demonstrates no leakage, the Foley catheter remains indwelling for another 7 days.
distal anterior rectal wall
MATERIALS A N D METHODS
Rectourinary fistulas occurred in 5 patients during radical retropubic prostatectomy for clinically localized prostatic cancer and in 1 during cystoprostatectomy for muscle invasive bladder cancer. All rectal injuries were diagnosed intraoperatively and closed primarily in a 2-layer fashion. Diagnoses were made based on pneumaturia or feces in the urine and cystography. Surgery was performed after failed conservative treatment with an indwelling Foley catheter for up to 3 months. All patients receive mechanical and antimicrobial bowel preparation preoperatively. The patient is placed in the lithotomy position and cystoscopy is performed to localize the fistula. A 5F ureteral catheter is placed through the fistula endoscopically and the area of the fistula a t the site of the rectum is exposed with an anal retractor. Good exposure of the anterior rectal wall can be achieved by tilting the operAccepted for publication December 11, 1998. Presented at annual meeting of American Urological Association, New Orleans, Louisiana, April 12-17, 1997.
proximal
I
FIG. 1. Circular incision of rectal mucosa 1.0 to 1.5 cm. around fistulous opening.
1518
RECTOURINARY FISTULA REPAIR
1519
RESULTS
era1 considerations for surgical treatment are the timing of the procedure, repair technique and whether to excise the fistula. Our experience revealed that a conservative approach is the first choice because about 50% of fistulas can be cured.3 In some cases a Foley catheter remained in place for 3 months and surgical repair was not needed before then. Moreover, tissue that is operated on when inflamed or infected is much less likely to heal, and so it is wise to wait until all inflammation has resolved before attempting repair. Many techniques of surgical closure of rectourinary fistulas have been reported5.7-11 and some are major abdominal procedures.s.9 The technique selected depends in part on the site of the lesion. Fistulas associated with radical retropubic prostatectomy or cystoprostatectomy are usually in the distal rectum close to the sphincteric muscle of the anus, and are ideal for the Latzko procedure as there is no difficulty exposDISCUSSION ing the fistula. Fistulas in the middle to lower rectum require Treatment of rectourinary fistulas is challenging. Most a different a p p r ~ a c h . ~ The Latzko procedure is simple and morbidity is minimal fistulas are due to previous prostatic surgery but some have a traumatic, neoplastic or inflammatory 0rigin.5.~.8.11Gen- because the lesion is closed after denudation of the mucosa without excision of the fistulous tract or any other incision. Success rates of up to 100% for vesicovaginal fistulas have been reported.14.15 To our knowledge we are the first to use distal this simple procedure for rectourinary fistulas, and our results are as encouraging as those of Latzko who repaired 32 anterior rectal wall fistulas14 and Tancer who repaired 98 vesicovaginal fistuias.15 Some procedures for rectourinary fistula closure include total excision of the fistulous tract before closure,5.*. alforceps though some authors do not recommend excision of vesicovaginal fistulas.14.16.*7If the tract is excised, a small fistula becomes a large fistula, which can lead to tension on the closure and subsequent failure. Other disadvantages include bleeding of the freshly excised wound margins followed by coagulation, which can compromise healing and potentially damage the ureteral 0rifices.1~Moreover, Raz considered the well formed fistula scar a protection against postoperative bladder ~ p a s m s . 1 ~ The necessity for postoperative bladder drainage via a rectal mucosa transurethral catheter after the Latzko procedure for vesicovaginal fistula repair has been approached differently. Tancer removed the catheter on postoperative day 1 or 2 because there were no sutures in the bladder wall.15 Others usually left the transurethral catheter indwelling for 10 t o 14 days.18 We used a more conservative approach and left the catheter in place for 21 days mainly because of our lack of experience and the rectum, instead of the vagina, was involved. In conclusion, the Latzko procedure is a n effective and simple technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. FIG.2. Denudation of rectal mucosa in 4 quadrants
Between 1992 and 1997, 689 radical retropubic prostatectomies and 59 cystoprostatectomies were performed at our hospital for clinically localized prostatic cancer and bladder cancer, respectively. Overall, 25 rectal injuries (3.3%) occurred during these 748 procedures, and all but 2 of these injuries were diagnosed intraoperatively and closed. One patient whose rectal injury was first noted postoperatively required a colostomy. A rectourinary fistula developed in 13 patients, of whom 7 had spontaneous closure after conservative management. The remaining 6 patients underwent the Latzko procedure. Closure of the fistula was successful in all cases, although 2 procedures were required in the cystoprostatectomy case. There were no postoperative complications or adverse effects on urinary and stool continence.
FIG.3. Steps 1 @) and 2 ( B ) of fistula closure with absorbable sutures. In step 3 incision margins of rectal mucosa are closed with absorbable sutures (C).
1520
RECTOURINARY FISTULA REPAIR REFERENCES
1. Leandri, P., Rossignol, G., Gautier, J.-R. and Ramon, J.: Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases. J . Urol.. 141: 883, 1992. 2. Borland, R. N. and Walsh. P. C.: The management of rectal injury during radical retropubic prostatectomy. J. Urol., 147: 905, 1992. 3. Gross, A. J.. Hdbner. D., Meyer-Moldenhauer, W.-H. and Huland, €3.: Die Behand lung von Rektumverletzungen mit vesikorektaler Fistelbildung bei radikaler Prostatektomie. Urologe A, 34: 43. 1995. 4. Harpster. L. E., Rommel. F. M., Sieber, P. R., Breslin, J. A., Agusta, V. E., Huffnagle,H. W. and Pohl, C. E.: The incidence and management of rectal injury associated with radical prostatectomy in a community based urology practice. J. Urol., 1 5 4 1435. 1995. 5. Fengler. S. A. and Abcarian, H.: The York Mason approach to repair of iatrogenic rectourinary fistulae. Amer. J. Surg., 173: 213. 1997. 6. Stamey, T. A.: Techniques for avoiding positive surgical margins during radical prostatectomy. Atlas Urol. Clin. N. Amer., 2 37, 1994. 7. Goodwin, W. E., Turner, R. D. and Winter, C. C.: Rectourinary fistulas: principles of management and a technique of surgical closure. J . Urol., 80: 246, 1958. 8. Culp, 0. S. and Calhoon, H. W.: A variety of rectourethral fistulas: experiences with 20 cases. J. Urol., 91: 560, 1964.
9. Wilhelm, S. F.: Rectourinary fistula. Surg. Gynec. & Obst., 79: 427, 1944. 10. Kilpatrick, F. R. and Thompson, H. R.: Post-operative recto-
prostatic fistula and closure by Kraske's approach. Brit. J. Urol., 3 4 470, 1962. 11. Stephenson, R. A. and Middelton, R. G.: Repair of rectourinary fistulas using a posterior sagittal transanal transrectal (modified York-Mason) approach: an update. J. Urol., 1 5 5 1989, 1996. 12. Noldus, J., Graefen, M. and Huland, H.: An "old technique" for a new approach for repair of rectourinary fistulas. J. Urol., 157: 395, abstract 1547, 1997. 13. Latzko, W.: Behandlung hochsitzender Blasen-und Mastdarmscheidenfisteln nach Uterusexstirpation mit hohem Scheidenverschluli Zentralbl. Gynakol. 25: 906, 1914. 14. Latzko, W.: Postoperative vesicovaginal fistulas. Genesis and therapy. Amer. J. Surg., 5 8 211, 1942. 15. Tancer, M. L.: Observation on prevention and management of vesicovaginal fistula after total hysterectomy. Surg. Gynec. & Obst., 175: 501, 1992. 16. Margolis, T. and Mercer, L. J.: Vesicovaginal fistula. Obst. Gynec. Surv., 4 9 840, 1994. 17. Raz, S.: Vesicovaginal fistulas. In: Atlas of Transvaginal Surgery. Edited by S. Raz. Philadelphia: W. B. Saunders CO., chapt. 7, pp, 141-165, 1992. 18. Elkins, T. E., Drescher, C., Martey, J. O., Fort, D.: Vesicovaginal fistula revisited. Obst. Gynec., 72: 307, 1988.
Vol. 161, 1518-1520,May 1999 Printed in U.S.A.
UROUKICALk ? o C u T l O ~ ,I N C
RECTOURINARY FISTULA REPAIR USING THE LATZKO TECHNIQUE JOACHIM NOLDUS, SALVADOR FERNANDEZ
AND
HARTWIG HULAND
From the Department of Urology, Uniuersity Hospital Hamburg, Hamburg, Germany
ABSTRACT
Purpose: We report our experience with the Latzko technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. Materials and Methods: We performed 7 fistula repairs in 6 patients. The 1-stage procedure was based on a technique for vesicovaginal fistula closure with denudation of the rectal mucosa and muhilayer closure of the fistulous tract. Results: Closure was successful in all patients, although 1 had to undergo the procedure twice. There were no postoperative complications. Conclusions: The Latzko procedure is effective for rectourinary fistula repair and associated with minimal morbidity. KEYWoms: fistula, bladder, prostate, rectum, urinary tract
Rectal injury is a rare complication of radical prostatectomy1-" which may be predisposed to advanced local disease, previously administered radiation therapy of the prostate or pelvis,s previous bacterial prostatitis and transurethral resection of the prostate within a few months before radical prostatectomy. Most rectal injuries occur in the attempt to avoid positive surgical margins when the terminal end of Denonvilliers' fascia under the urethra is excised.6 When a rectal injury is discovered during radical prostatectomy, the lesion is usually closed in 2 layers and irrigated copiously.~-* Some authors also recommend interposition of a flap of greater omentum to cover the repair completely.'.4 If a rectourinary fistula occurs despite primary closure of the injury or a rectal injury is noted postoperatively with feces in the urine, initial treatment is conservative and includes parenteral nutrition, antibiotics and a transurethral catheter.3.4 In some cases conservative treatment fails to close a rectourinary fistula spontaneously and surgery is necessary. Multiple methods of rectourinary fistula repair have been reported using ~ e r i n e a l , ? - posterior ~ pararectal,1° abdominal and transvesical,8-9 and posterior sagittal transanal transrectal We describe our experience with a simple approach using the Latzko technique,'" which was first reported for vesicovaginal or enterovaginal fistula closure after hysterectomy. 13
ating table (pelvis up, head down). A circular area of rectal mucosa is incised for 1.0 to 1.5 cm. from the fistula opening (fig. 1).The rectal mucosa is denuded in 4 quadrants (fig. 2). No rectal mucosa is allowed to remain between the edges of the incision and the fistulous opening. The ureteral catheter is removed and the fistula is closed with 2 layers of side by side absorbable 3-ZerO polyglactin sutures (fig. 3, A and B ) . The margins of the rectal wound are closed similarly (fig. 3, C).A Foley catheter is placed in the bladder. Postoperative management focuses on protection of the rectal closure. A 5-day bed rest, 7-day fully absorbable diet and antibiotics are recommended. Closure is confirmed on cystography on day 14, and even if the urinary tract demonstrates no leakage, the Foley catheter remains indwelling for another 7 days.
distal anterior rectal wall
MATERIALS A N D METHODS
Rectourinary fistulas occurred in 5 patients during radical retropubic prostatectomy for clinically localized prostatic cancer and in 1 during cystoprostatectomy for muscle invasive bladder cancer. All rectal injuries were diagnosed intraoperatively and closed primarily in a 2-layer fashion. Diagnoses were made based on pneumaturia or feces in the urine and cystography. Surgery was performed after failed conservative treatment with an indwelling Foley catheter for up to 3 months. All patients receive mechanical and antimicrobial bowel preparation preoperatively. The patient is placed in the lithotomy position and cystoscopy is performed to localize the fistula. A 5F ureteral catheter is placed through the fistula endoscopically and the area of the fistula a t the site of the rectum is exposed with an anal retractor. Good exposure of the anterior rectal wall can be achieved by tilting the operAccepted for publication December 11, 1998. Presented at annual meeting of American Urological Association, New Orleans, Louisiana, April 12-17, 1997.
proximal
I
FIG. 1. Circular incision of rectal mucosa 1.0 to 1.5 cm. around fistulous opening.
1518
RECTOURINARY FISTULA REPAIR
1519
RESULTS
era1 considerations for surgical treatment are the timing of the procedure, repair technique and whether to excise the fistula. Our experience revealed that a conservative approach is the first choice because about 50% of fistulas can be cured.3 In some cases a Foley catheter remained in place for 3 months and surgical repair was not needed before then. Moreover, tissue that is operated on when inflamed or infected is much less likely to heal, and so it is wise to wait until all inflammation has resolved before attempting repair. Many techniques of surgical closure of rectourinary fistulas have been reported5.7-11 and some are major abdominal procedures.s.9 The technique selected depends in part on the site of the lesion. Fistulas associated with radical retropubic prostatectomy or cystoprostatectomy are usually in the distal rectum close to the sphincteric muscle of the anus, and are ideal for the Latzko procedure as there is no difficulty exposDISCUSSION ing the fistula. Fistulas in the middle to lower rectum require Treatment of rectourinary fistulas is challenging. Most a different a p p r ~ a c h . ~ The Latzko procedure is simple and morbidity is minimal fistulas are due to previous prostatic surgery but some have a traumatic, neoplastic or inflammatory 0rigin.5.~.8.11Gen- because the lesion is closed after denudation of the mucosa without excision of the fistulous tract or any other incision. Success rates of up to 100% for vesicovaginal fistulas have been reported.14.15 To our knowledge we are the first to use distal this simple procedure for rectourinary fistulas, and our results are as encouraging as those of Latzko who repaired 32 anterior rectal wall fistulas14 and Tancer who repaired 98 vesicovaginal fistuias.15 Some procedures for rectourinary fistula closure include total excision of the fistulous tract before closure,5.*. alforceps though some authors do not recommend excision of vesicovaginal fistulas.14.16.*7If the tract is excised, a small fistula becomes a large fistula, which can lead to tension on the closure and subsequent failure. Other disadvantages include bleeding of the freshly excised wound margins followed by coagulation, which can compromise healing and potentially damage the ureteral 0rifices.1~Moreover, Raz considered the well formed fistula scar a protection against postoperative bladder ~ p a s m s . 1 ~ The necessity for postoperative bladder drainage via a rectal mucosa transurethral catheter after the Latzko procedure for vesicovaginal fistula repair has been approached differently. Tancer removed the catheter on postoperative day 1 or 2 because there were no sutures in the bladder wall.15 Others usually left the transurethral catheter indwelling for 10 t o 14 days.18 We used a more conservative approach and left the catheter in place for 21 days mainly because of our lack of experience and the rectum, instead of the vagina, was involved. In conclusion, the Latzko procedure is a n effective and simple technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. FIG.2. Denudation of rectal mucosa in 4 quadrants
Between 1992 and 1997, 689 radical retropubic prostatectomies and 59 cystoprostatectomies were performed at our hospital for clinically localized prostatic cancer and bladder cancer, respectively. Overall, 25 rectal injuries (3.3%) occurred during these 748 procedures, and all but 2 of these injuries were diagnosed intraoperatively and closed. One patient whose rectal injury was first noted postoperatively required a colostomy. A rectourinary fistula developed in 13 patients, of whom 7 had spontaneous closure after conservative management. The remaining 6 patients underwent the Latzko procedure. Closure of the fistula was successful in all cases, although 2 procedures were required in the cystoprostatectomy case. There were no postoperative complications or adverse effects on urinary and stool continence.
FIG.3. Steps 1 @) and 2 ( B ) of fistula closure with absorbable sutures. In step 3 incision margins of rectal mucosa are closed with absorbable sutures (C).
1520
RECTOURINARY FISTULA REPAIR REFERENCES
1. Leandri, P., Rossignol, G., Gautier, J.-R. and Ramon, J.: Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases. J . Urol.. 141: 883, 1992. 2. Borland, R. N. and Walsh. P. C.: The management of rectal injury during radical retropubic prostatectomy. J. Urol., 147: 905, 1992. 3. Gross, A. J.. Hdbner. D., Meyer-Moldenhauer, W.-H. and Huland, €3.: Die Behand lung von Rektumverletzungen mit vesikorektaler Fistelbildung bei radikaler Prostatektomie. Urologe A, 34: 43. 1995. 4. Harpster. L. E., Rommel. F. M., Sieber, P. R., Breslin, J. A., Agusta, V. E., Huffnagle,H. W. and Pohl, C. E.: The incidence and management of rectal injury associated with radical prostatectomy in a community based urology practice. J. Urol., 1 5 4 1435. 1995. 5. Fengler. S. A. and Abcarian, H.: The York Mason approach to repair of iatrogenic rectourinary fistulae. Amer. J. Surg., 173: 213. 1997. 6. Stamey, T. A.: Techniques for avoiding positive surgical margins during radical prostatectomy. Atlas Urol. Clin. N. Amer., 2 37, 1994. 7. Goodwin, W. E., Turner, R. D. and Winter, C. C.: Rectourinary fistulas: principles of management and a technique of surgical closure. J . Urol., 80: 246, 1958. 8. Culp, 0. S. and Calhoon, H. W.: A variety of rectourethral fistulas: experiences with 20 cases. J. Urol., 91: 560, 1964.
9. Wilhelm, S. F.: Rectourinary fistula. Surg. Gynec. & Obst., 79: 427, 1944. 10. Kilpatrick, F. R. and Thompson, H. R.: Post-operative recto-
prostatic fistula and closure by Kraske's approach. Brit. J. Urol., 3 4 470, 1962. 11. Stephenson, R. A. and Middelton, R. G.: Repair of rectourinary fistulas using a posterior sagittal transanal transrectal (modified York-Mason) approach: an update. J. Urol., 1 5 5 1989, 1996. 12. Noldus, J., Graefen, M. and Huland, H.: An "old technique" for a new approach for repair of rectourinary fistulas. J. Urol., 157: 395, abstract 1547, 1997. 13. Latzko, W.: Behandlung hochsitzender Blasen-und Mastdarmscheidenfisteln nach Uterusexstirpation mit hohem Scheidenverschluli Zentralbl. Gynakol. 25: 906, 1914. 14. Latzko, W.: Postoperative vesicovaginal fistulas. Genesis and therapy. Amer. J. Surg., 5 8 211, 1942. 15. Tancer, M. L.: Observation on prevention and management of vesicovaginal fistula after total hysterectomy. Surg. Gynec. & Obst., 175: 501, 1992. 16. Margolis, T. and Mercer, L. J.: Vesicovaginal fistula. Obst. Gynec. Surv., 4 9 840, 1994. 17. Raz, S.: Vesicovaginal fistulas. In: Atlas of Transvaginal Surgery. Edited by S. Raz. Philadelphia: W. B. Saunders CO., chapt. 7, pp, 141-165, 1992. 18. Elkins, T. E., Drescher, C., Martey, J. O., Fort, D.: Vesicovaginal fistula revisited. Obst. Gynec., 72: 307, 1988.