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Long-Term Successful Closure of Radiation and Surgically Induced Rectourethral Fistulas with Buccal Mucosa Graft and Muscle Interposition Flap
Daniel A Kaufman1, Leonard N Zinman1, Jill C Buckley2, Peter Marcello3, Alex J Vanni1, Brendan M Browne4
1Lahey Hospital and Medical Center, Department of Urology, Burlington, MA;2University of California, San Diego Medical Center, Department of Urology, San Diego, CA;3Lahey Hospital and Medical Center, Department of Colon and Rectal Surgery, Burlington, MA;4Lahey Hospital and Medical Center, Burlington, MA
Introduction: Rectourethral fistulas (RUF) resulting from pelvic radiation and surgery are a reconstructive challenge. Despite recent reports that most radiation induced RUF require urinary diversion, we believe that most fistulas can be successfully reconstructed regardless of etiology and size. We report our long-term outcomes over a 17-year period with a standardized approach for complex RUF closure.
Materials & Methods: We performed a retrospective review of patients undergoing RUF repair between January 1, 1998 and February 28, 2015 at a single institution. Patient demographics as well as preoperative, operative and postoperative data were reviewed. All RUF were repaired using an anterior transperineal approach with an interposition muscle flap and selective use of a buccal mucosa onlay patch.
Results: A total of 102 patients with RUF underwent repair with an anterior perineal approach and gracilis muscle interposition flap (96 gracilis muscle interposition flaps, 6 other muscle interposition flaps). We compared 49 non-radiation induced and 53 radiation/ablated induced RUF. At a mean follow-up of 18 months, 98% (48/49) of non-radiated RUF were closed with 1 procedure, while 85% (45/53) of radiated RUF were closed in a single stage.
Conclusions: Successful RUF closure is possible in 98% of surgical patients and 85% of radiated/ablated patients with 1 procedure. Most complex radiation induced RUF, regardless of size, can be successfully repaired with an anterior transperineal approach with buccal mucosa patch onlay and interposition muscle flap, avoiding permanent urinary and fecal diversion in the majority of patients.
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