The Surgical Management of Rectourinary Fistulas Resulting from a Prostatic Operation: A Report of 5 Cases

Vol. 111, April Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1974 by The Williams & Wilkins Co.

THE SURGICAL MANAGEMENT OF RECTOURINARY FISTULAS RESULTING FROM A PROSTATIC OPERATION: A REPORT OF 5 CASES DOUGLAS S. DAHL, PHILIP M. HOWARD

AND

RICHARD G. MIDDLETON

From the Division of Urology. Department of Surgery, University of Utah College of Medicine, Holy Cross Hospital and Veterans Administration Hospital. Salt Lake City, Utah

Although the present series cannot presume to provide definite guidelines which are applicable to all cases of rectourinary fistulas, it describes the successful management of 5 post-prostatectomy fistulas. All 5 patients are men who suffered rectourinary fistulas after a prostatic operation. The patients were managed by a similar sequence of operations, resulting in permanent healing of the fistula and complete urinary and fecal continence.

Rectourinary fistulas are a rare but devastating complication of prostatic operations. The afflicted patient suffers unrelenting distress which demands prompt and effective relief. Although spontaneous healing has been observed surgical intervention has been necessary in most reported cases. 1-3 A variety of surgical techniques has been proposed, including the rectal pull-through operation of Young and Stone,4· 5 repair through the intact, dilated anal sphincter, 6 direct exposure and repair through a perinea! prostatectomy incision, 2 , 3 , 7 closure of the fistula posteriorly through Kranske's incision 8 and transrectal repair through the divided anal sphincter described by York Mason. 9 • 10 Because of the rarity of rectourinary fistulas most of the preceding references describe a heterogeneous group of patients who vary greatly in age, etiology of the fistula and number of surgical procedures. In many cases suprapubic cystostomy diversion and colostomies were used separately or in combination with the definitive repair. In a few instances fecal and urinary diversion resulted in permanent closure of the fistula without direct repair. Thus, the concerned physician searching for guidance in the care of a specific patient is confronted with a variety of techniques and conflicting opinions regarding the role of fecal and urinary diversion. 2 • 5

PATIENTS

Accepted for publication August 31, 197:3. Read in part at annual meeting of Western Section, American Urological Association, Vancouver, British Columbia, Canada, July 2-7, 1972. 1 Wilhelm, S. F.: Rectourinary fistula. Surg., Gynec. & Obst., 79: 427, 1944. 2 Goodwin, W. E., Turner, R. D. and Winter, C. C.: Rectourinary fistula: principles of management and a technique of surgical closure. J. Urol., 80: 246, 1958. 3 Weyrauch, H. M.: A critical study of surgical principles used in repair of urethrorectal fistula: presentation of a modern technique. Stanford Med. Bull., 9: 2, 1951. 'Young, H. H. and Stone, H.B.: An operation for the urethrorectal fistula: report of three cases. Trans. Amer. Ass. Genito-Urin. Surg,, 8:270, 1913. 5 Lewis, L. G.: Repair of recto-urethral fistulas. J. Urol.. 57: 1173, 1947. • Vose, S. N.: A technique for the repair of recto-urethral fistula. J. Urol., 61: 790, 1949. 7 Culp, 0. S. and Calhoon, H. W.: A variety of rectourethral fistulas: experiences with 20 cases. J. Urol., 91: 560, 1964. 8 Kilpatrick, F. R. and Thompson, H. R.: Postoperative recto-prostatic fistula and closure by Kranske's approach. Brit. J. Urol., 34: 470, 1962. 9 Kilpatrick, F. R. and York Mason, A.: Post-operative recto-prostatic fistula. Brit. J. Urol., 41: 649, 1969. 10 Beneventi, F. A. and Cassebaum, W. H.: Rectal flap repair of prostatorectal fistula. Surg., Gynec. & Obst., 133: 489, 1971. 514

Five men were treated during a 4-year period which began in March 1968 and ended in March 1972. The youngest patient was 55 years old while the oldest was 77. Two fistulas resulted from rectal injury during radical perinea! prostatectomy and in each case the tear was repaired immediately but broke down later. Two fistulas developed after transurethral resection of the prostate in patients with unsuspected foci of adenocarcinoma. The fifth fistula resulted when secondary suprapubic enucleation of residual benign prostatic tissue was necessary to control post-transurethral resection hemorrhage. Patients in cases 2, 3 and 5 had rectoprostatic fistulas, patient 1 had a rectourethral fistula and patient 4 a Y-shaped rectovesical fistula that communicated with the perinea! skin. In all 5 cases a diverting colostomy was constructed shortly after the fistula was recognized. A simultaneous suprapubic cystostomy was performed upon 2 patients and the remaining 3 were managed by urethral catheter drainage. The fistulas in 2 patients healed following diversion procedures; each had a colostomy and 1 of the 2 had a suprapubic cystostomy. Delayed direct repair was necessary in the remaining 3 cases and each fistula was permanently closed by the posterior, trans-sphincteric technique of York Mason. 9 CASE REPORTS

Case I. A 58-year-old man with stage II adenocarcinoma of the prostate sustained a rectal tear during radical perinea! prostatectomy. Despite immediate repair of the rectal wound urine began passing per rectum 19 days postoperatively. A sigmoid colostomy was constructed and a urethral catheter was used at intervals. The fistula persisted for approximately 4 months but then was noted to have healed spontaneously. The patient was rehospitalized for colostomy closure 7 months after radical prostatectomy. The urinary control was normal and the fistula remained closed but the

SURGICAL MANAGEMENT OF RECTOURINARY FISTULAS

patient died of metastatic carcinoma 3 years after Case 2, 68-year-old man required transurethral resection of the prostate for urinary retention, Eight later a second transurethral procedure was necessary because of Suprapubic excision of residual adenoma was performed 11 later for a third Postoperative fever, chills and fecaluria led to the discovery of a fistula, A diverting colostomy produced marked improvement in the patient's health, permitting hospital 11 days lateL Because he experienced a continuous leakage of urine per rectum, trans-sphincteric repair of the fistula was 5 months after the colostomy was constructed, The course was was discharged from The fistula repair was successful so the was closed 2 months later. The patient has complete urinary and fecal continence, Case 3, A 77-year-old man required trans urethral resection of the prostate, The gland was benign but study of the resected tissue revealed focal adenocarcinoma, rectal bleeding led fistula, A and suprapubic cystostomy were estabafter the transurethral resection, The was discharged to a nursing home, Comspontaneous healing of the fistula was documented in the 5 months after the injury so the was closed, The patient has no evidence of carcinoma and the urinary and fecal control are normaL Case 4, A man underwent radical perinea] prostatectomy for stage II adenocarcinoma of the prostate, the operation a rectal injury was closed, Subsequently, breakdown of repair was evidenced by fecal drainage from the perineum and bladder, defined a rectovesical fistula communicating with a fistula-in-ano, A colostomy was leakage from the perineum and anus persisted so a transrectal fistula was performed, Primary healing occurred despite a superficial wound infection and the patient was discharged from the hospital, Nine weeks later he was rehospitalized for colostomy closure, The persistent fistula-in-ano required excision 3 months later. Urinary and fecal continence are complete and the has no evidence of residual tumor. Case 5, A 71-year-old man underwent trans urethral resection of the prostate for urinary retention, An immediate was performed for control of the operation the patient had melena and was treated for a bleeding duodenal ulcer. The melena was arrested medication, The health was improving until 17 postoperatively when feces issued from the cystostomy sinus, He was febrile when he was transferred to the University of Gtah Medical Center, A barium enema demonstrated a prostato-

51b

rectal fistula, A transverse was formed and cystostomy drainage was re-est ab lished, producing an immediate resolution of the fever and fecal drainage, The fistula persisted until closure the York l\1ason tech nique 40 days later, Ten after the trans sphincteric repair the cystostomy moved and the patient was hospital, Five weeks later the closed, The patient has normal fecal and controL TECHNIQUE OF THE OPERATION

York l\1ason's been used with minor modification, In mir opinion at least 1 month should elapse between the construction of the and the definitive operation, The distal colon and rectum oughly cleansed with enemas on the the anesthesia and anesthesia have been in the from the verge ( part A of figure), The coccyx is dissected free from the dense connective and excised, Short, strokes of the allow layer-by-layer incision of the fascia, rectal wall and anus, Each 1s with several sutures, Three-zero chromic Z are at right Later during wound is tied to its opposite accurate reconstruction of the anus, After the anus is divided and the dorsal rectal lumen is the fistula is completely visible, The fistulmrn orifice is circumscribed, the full thickness of the rectal wall is elevated with traction sutures undermined radially for 2 to :3 cm, , The uum,,,,,u is excised and the urethral defect are approximated with 2-zero chromic sutures, The mobile of the rectum can be closed in 2 1 row of 2-zero chromic sutures is placed through the musculari~, and submucosa while the second row of w.tures everts the mucosa into the rectal lumen (part figure), A continuous Connell suture is used obtain an inverting closure of the dorsal mucoim, Each limb of the tag suture 1,: tied to its matching nnnn
516

DAHL, HOWARD AND MIDDLETON

Mason reports closing the colostomy as soon as the patient is voiding normally, we have allowed at least 1 month to pass between the repair of the fistula and the closure of the colostomy. DISCUSSION

Our results lead us to advocate the systematic, planned, :3-stage treatment of rectourinary fistulas. An immediate colostomy and cystostomy comprise the first stage. Direct repair of the fistula by York Mason's technique is accomplished when the patient's status is optimal, usually at least 4 weeks later. Finally, the colostomy is taken down when the fistula repair is sound. Although preliminary fecal diversion may seem overly cautious, the procedure has produced immediate, significant improvement in several patients. Systemic toxicity, wound infections and urinary tract symptoms have resolved dramatically following the creation of a colostomy. A colostomy alone in case 1 and a colostomy plus a cystostomy in case 2 allowed the spontaneous healing of 2 established rectourinary fistulas. The apparent benefits of colostomy diversion in our experience disputes the opinion of Goodwin and associates. Although a colostomy had been performed upon half of the

cases successfully treated by their technique of perinea! repair, they state that a colostomy is not necessary and has no effect upon the healing of a fistula. 2 Although our small series does not permit evaluation of the value of supra pubic cystostomy diversion of the urine, we favor the cystostomy tube in preference to long-term urethral catheter drainage with the attendant risk of strictures, etc. Actually, patients who did not have a cystostomy did not seem severely inconvenienced by the passage of urine per rectum once fecal diversion had stopped fecaluria. Since 1 fistula closed without urinary diversion, obviously it is not always necessary. We have no experience with other methods and cannot compare the York Mason operation with the perinea! techniques advocated by Weyrauch, 3 Goodwin and associates 2 and Culp and Calhoon. 7 We have no reason to use another method since the trans-sphincteric transsacral operation has proved simple and completely reliable. It affords rapid exposure through fresh, unscarred tissues. Bleeding is slight and bleeding points are obvious. The exposure provides excellent visualization of the fistula and room to maneuver surgical instruments, ensuring certain separation of the rectal and urinary components of the fistula. The stress of the

SURGICAL MANAGEMENT OF RECTOURINARY FISTULAS

operation is slight and ma!.

care 1s mm1-

SUMMARY

Five men were treated for rectourinary fistulas representing complications of operations ·upon the prostate. A colostomy was ortnr,~ on alls and 2 fistulas healed without direct repair. In the remaining :3 cases York Mason's trans-sphincteric transrectal operation resulted in prompt, primary 0 "

7

healing of the fistula. Subsequent sure left all S patients with normal urmary 2-nd fecal control. The role of not clear from our data. A systematic 3-step sequence of advocated for the treatment of rectourinary fistulas which complicate York Mason operation excellent exposure and reliable closure of rectourinary fistulas.