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BACKGROUND:Bladder outlet dysfunction (BOD) is a common complication of pelvic radiation. Patients who receive pre-operative radiation are predisposed to developing BOD due to bladder neck contracture (BNC) or stress urinary incontinence (SUI). Here, we review our experience with gracilis flap fistula repairs for rectourinary fistulae (RUF) in patients who underwent pelvic radiation.
METHODS:We reviewed 20 patients who underwent a gracilis flap repair of a RUF between the years 2003 and 2013. Patients were assessed for post-operative fistula closure and BOD due to SUI or BNC. Possible risk factors associated with repair failures were examined, such as age, hypertension, diabetes, coronary artery disease, smoking, obesity, ASA score intraoperative urinary/fecal diversion, and prior radiation.
RESULTS:The mean age in our series was 62 years (50-73) at time of surgery with median follow-up of 23.6 months (3.6-64.9). Among patients who underwent pelvic radiation prior to fistula repair, 11/13 (85%) developed BOD compared to 2/7 (29%) who were not radiated (p=0.02). Flap failure was noted in 4/13 radiated patients vs. 3/7 non-radiated patients (p=0.65). Of the 7 flap failures, revisions included repeat gracilis flap (2), coloanal pull-through (2), omental flap (1), sliding flap (1), and rectal advancement flap (1). The median time to revision was 6.7 months (3.5-24.9).
CONCLUSIONS:Flap failure and bladder outlet dysfunction are more common in patients who underwent pre-operative radiation prior to gracilis flap rectourinary fistula repair. Even in successful fistula repairs, patients may still experience substantial urinary incontinence. Therefore, patients should be carefully counseled about all possible risks of gracilis flap genitourinary fistula repair as well as the option of performing permanent urinary diversion as the primary therapy.