Management of Post-Traumatic Rectovesical/Rectourethral Fistulas: Case Series of Complicated Injuries in Wounded Warriors and Review of the Literature

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1 MILITARY MEDICINE, 182, 3/4:e1835, 2017 Management of Post-Traumatic Rectovesical/Rectourethral Fistulas: Case Series of Complicated Injuries in Wounded Warriors and Review of the Literature LT Walter B. Kucera, MC USN*; COL James R. Jezior, MC USA ; CAPT James E. Duncan, MC USN* ABSTRACT Introduction: Penetrating injuries to the pelvis and perineum can result in fistulas between the rectum and lower urinary tract. These injuries are often complicated, which creates challenges for successful repair. Operative strategies may include initial fecal and/or urinary diversion combined with an eventual trans-perineal, trans-anal, or posterior/ transrectal approach, but the selected approach should be guided by precise anatomic localization of the injury. We aim to discuss different possible repair strategies as well as the relevant data surrounding gastrointestinal-genitourinary (GI-GU) fistula management. Materials and Methods: We present this series of three post-traumatic rectovesical and rectourethral fistulas to illustrate the surgical options for treatment of these conditions. In this series, we have retrospectively reviewed our experience at Walter Reed National Military Medical Center in caring for three Wounded Warriors who had suffered these types of injuries. The study was exempt from institutional review board approval because of the size of the series. Results: Our three patients all were managed with initial urinary and fecal diversion before an eventual trans-perineal, trans-anal, or posterior/transrectal approach. All three patients ultimately underwent reversal of diverting ostomies with good functional results and successful resolution of their GI-GU fistulas. Conclusions: This series demonstrates the complexity of traumatic GI-GU fistulas. Successful management depended on early diversion of both urine and feces, localization of the fistula, and an interdisciplinary surgical approach specifically tailored to each patient. All three patients had favorable overall functional outcomes despite their devastating injuries. This review should help to illustrate some of the possible repair strategies for these difficult surgical problems. INTRODUCTION Penetrating colorectal or genitourinary (GU) injuries present a major source of morbidity as they occur in 6 to 18% of all abdominal/pelvic penetrating injuries, with 0 to 18% of these injuries resulting in fistula formation. 1 4 Colorectal trauma is particularly problematic as it is associated with a 20% sepsis rate and 3% mortality. 5 Although a small minority of peacetime colorectal injuries are characterized as destructive (greater than 25% wall involvement), up to 72% of colorectal injuries in a wartime setting meet this criterion. 5 Following injury patterns of this severity, fistulous connections between the rectum and lower urinary tract can result, posing a challenge for both accurate localization and definitive management. *Department of Surgery, General Surgery Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD Department of Surgery, Urology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD The abstract of this article was previously presented as a poster at the 2015 American Society of Colon and Rectal Surgery Annual Meeting, Boston, MA, June 1, The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency. Although we generally excise references to products, companies, manufacturers, organizations, etc., in government produced works, the abstracts produced and other similarly situated research presents a special circumstance when such product inclusions become an integral part of the scientific endeavor. doi: /MILMED-D We present the following series of three Wounded Warriors cared for at our institution who had rectovesicular or rectourethral fistulas following significant wartime injuries. Our series illustrates the complexity of these injuries as well as the diversity of surgical options for successful treatment. METHODS We retrospectively reviewed our experience at Walter Reed National Military Medical Center in caring for three Wounded Warriors who suffered penetrating combat trauma resulting in pelvic fistulas between the anorectum and lower urinary tract. CASE SERIES Patient A is a 29-year-old male suffering a right groin/perineal gunshot wound (GSW) in support of Operation Enduring Freedom (OEF) that resulted in complete disruption of the bulbar urethra, saphenous vein transection, a right testicular contusion, and an extraperitoneal anorectal injury. In theater, he initially was taken to the operating room for retrograde and anterograde cystourethroscopy, which revealed the urethral injury. At this time, he had a Foley catheter and a suprapubic tube (SPT) placed. Further exploration of the wound tract was concerning for a post-traumatic fistula between the rectum and urethra, with leakage of urine into the rectum. As a result, he was taken for an exploratory laparotomy with exam under anesthesia. He was given a loop sigmoid colostomy for fecal diversion to accompany prior urinary diversion out of concern for the rectourethral fistula. After proximal urinary and fecal diversion for 4½ months, he underwent posterior urethral repair and examination under anesthesia showing spontaneous closure e1835

2 of the rectourethral fistula. Six weeks later, after confirming healing of the urethral repair, he had an uneventful reversal of his colostomy. At his postoperative appointments, he had full return of bowel and bladder function and normal continence. Computed tomography (CT) performed in the remote postoperative period showed full resolution of the prior rectourethral fistula. Patient B is a 20-year-old male suffering a transpelvic GSW in support of OEF with an entry wound to the left lateral buttock and an exit wound to the right posterior lateral hip. On initial presentation, he underwent an exploratory laparotomy, which revealed an intraperitoneal, 180-degree disruption of the left anterior rectal wall and a defect to the lateral aspect of the bladder dome near the right ureteral orifice (UO). During his initial operation, irrigation of his Foley catheter returned stool, which led to an opening of the bladder showing a long, stellate defect in the posterior bladder wall near the right UO. His rectal and bladder wounds were primarily repaired, and his rectum was packed in anticipation of a return to the operating room. On postoperative day 1, he was taken back to the operating room for a diverting sigmoid colostomy. On return to the United States, he underwent multiple irrigation and debridement procedures. In addition, he had a right nephrostomy tube placed, which was removed 3 months later in favor of a Foley catheter to manage the post-traumatic rectovesical fistula near the right UO. The fistula persisted for months despite fecal and urinary drainage, and the patient continued to have leakage of urine per rectum. A transperineal repair using gracilis muscle interposition flap was attempted but was unsuccessful at closing the fistula, which was located just above the uppermost portion of the gracilis flap. After collaborative review of his injury and prior surgeries between Urology and Colorectal Surgery, a surgical plan was created. The patient was returned to the operating room for a posterior, transrectal York-Mason repair of his fistula from anterior rectum to bladder neck. Exposure of the fistula was excellent, allowing visualization and definitive closure of the fistula. Following his repair, he had complete resolution of his urinary leakage symptoms, and his colostomy was reversed 4 months later. At his postoperative appointments, he reported return of normal bowel and bladder function with full continence and no fistula-related symptoms. Patient C is a 30-year-old male who suffered an improvised explosive device blast in support of Operation Iraqi Freedom with massive soft tissue and vascular damage. On initial presentation, he required bilateral above-knee amputations, bilateral volar fasciotomies, a right-sided chest tube, and an exploratory laparotomy. During his initial operation, he was noted to have a small bowel injury repaired by resection and primary anastomosis as well as a distal rectal injury necessitating a diverting end colostomy and placement of pelvic drains. On return to the United States, he was noted to have urine coming from these drains, as well as recurrent urinary tract infections and pneumaturia, raising concern for a rectoprostatic urethral fistula. These symptoms abated, however, leading to elective reversal of his colostomy at another institution. In the years following his colostomy reversal, however, he presented with multiple prostatic abscess requiring frequent courses of antibiotics. Eventually, imaging with CT demonstrated a small but persistent fistula between the rectum and prostate, which was confirmed with endoscopic evaluation of the rectum. After review of his injury between involved surgeons, he underwent successful endorectal advancement flap closure of the rectal side of the fistula. His recurrent prostatic abscesses resolved, as did the radiographic evidence of a fistula between the rectum and prostatic urethra. DISCUSSION The diagnosis of post-traumatic injuries to the rectum and lower urinary tract especially injuries resulting in a fistula between the two systems can present a particular challenge. Rectal injuries are particularly difficult to detect on exam, with only 25% having hematochezia or blood on rectal exam. 6 Bladder injuries, on the other hand, are heralded by hematuria with 93 to 100% sensitivity. 3,7 Urethral injuries typically present with hematuria or difficulty voiding, combined with high riding prostate on digital rectal exam. 3 Fistulas in the setting of gastrointestinal (GI) and genitourinary (GU) trauma present with passage of urine per rectum, pneumaturia, and/or persistent urinary tract infections. 8 Among GU injuries seen in the recent war in Iraq, 8% of lower GU penetrating injuries involved the bulbo-prostatic urethra. 1 During this conflict, 53 to 67% of injuries to the anterior urethra came from improvised explosive device blasts, whereas 78 to 83% of posterior urethral injuries resulted from GSW. 1 Despite the potential difficulty with detection with physical exam, these injuries do have associated injury patterns. 92% of GU GSW wounds associated with injuries to other organ systems, with 58 to 60% having intestinal injuries and 23 to 34% having rectal injuries. 2,9 Bladder injuries have a 49% association with small and large bowel injuries and a 41.3% association with rectal injuries. 2 In hemodynamically stable patients, triple-contrast CT with oral, intravenous, and rectal contrast has been shown to be up to 100% sensitive, 96% specific, and 100% negative predictive value for peritoneal violation in addition to colonic, vascular, and urinary tract injuries. 10 The low sensitivity of a digital rectal exam necessitates additional investigation when rectal injury is suspected. Rigid proctoscopy in the operating room hasuptoan80%successinidentifyinginjuries,whichcompares to only a 33% sensitivity of rigid proctoscopy performed in the emergency department. 7,10 Patients with pelvic fractures or penetrating injuries to the pelvis, buttock, or lower abdomen in setting of hematuria should undergo urgent cystoscopy or cystogram in addition to a CT of the abdomen and pelvis. 3 Potential urethral injuries are best evaluated with a retrograde urethrogram. 3 Repair of these injuries, particularly GI-GU fistulas, rest on the foundation of proximal diversion of the involved system(s), e1836

3 debridement of nonviable or infected tissue, and closure of the defect with or without interposition of healthy tissue. There is no statistical difference in morbidity between loop and end colostomies for GI diversion. 7 Diversion of the GU system can be accomplished by either Foley catheter or SPT diversion, with SPT drainage used for complete disruption of the urethra or an inability to pass a Foley. 3 Repair of either system typically occurs at least 1 month after diversion, particularly if the patient is too unstable to tolerate reanastomosis within 36 hours of injury, with diversion left in place for 6 to 8 weeks after repair. 8,10,11 Repair should consist of closure with nonoverlapping suture lines, ideally with interposed vascularized tissue. 2,4 Closure following urinary and/or fecal diversion alone can occur with 46% of patients, particularly if they have small fistulas that are associated with trauma instead of radiation therapy. 8 Diversion is of particular importance for curtailing or controlling sepsis with major injury or if the patient is in shock. Even if surgical repair is planned on initial evaluation, it is generally recommended that diversion be performed with nondestructive injuries more than 12 hours old, destructive injuries older than 6 hours, or patients needing more than 6 units of packed red blood cells for resuscitation. 5 Although GI-GU fistulas can close spontaneously following diversion, those not healing within 3 to 6 months of diversion will need additional surgical intervention. 12 Of patients requiring bulbo-prostatic urethral repair, there is up to 24% mortality, usually secondary to associated major vascular injury. Of those that survived, as few as 43% can have fully successful repair with 35 to 50% having complications such as urethral strictures and erectile dysfunction. 1,13 With GI repairs, while up to 91% will have successful repair, as many as 35% can have associated complications. 5,10,14 Likely owing to the association with high velocity weaponry, blast injuries, and increased injury severity, military series report 13 to 30% anastomotic leak rates compared to 0 to15% rates in civilian series. 10 Not surprisingly, higher rates of complications are seen in the setting of intra-abdominal abscesses or shock with more than 6 units of packed red blood cells needed for resuscitation. 5,10 Despite previous practices, recent series have shown little benefit in presacral drainage, with 4% of patients having complications without a drain and 8% of patient with a drain having complications. 10 Although there are over 40 different techniques described in the literature for the management of GI-GU fistulas, we focus on three specific approaches that were used at Walter Reed National Military Medical Center to treat injuries sustained during Operation Iraqi Freedom and OEF. All three techniques are typically performed in conjunction with fecal (59 73%) and/or urinary (64%) diversion. 14,15 For the posterior urethral repair, the patient was placed in exaggerated dorsal lithotomy. An inverted Y incision over the perineum was used to expose the urethra after dividing the bulbospongiosus and Buck s fascia and separating the urethra from the corpora cavernosa. The urethra is then dissected away from the rectum, taking care to avoid injury to the anal sphincters. The fistulous connection is identified and excised, after which the two ends of the urethra are spatulated, then anastomosed over a 14-French Foley catheter using a combination of 3-0 Polydioxanone suture (PDS) (Ethicon, Somerville, New Jersey) and 4-0 Monocryl suture (Poliglecaprone suture, Ethicon, Guaynabo, Puerto Rico). No distinct rectal injuries were identified during our case, having likely healed with diversion and time, but any communication to the rectum should be closed in a layered fashion, if present. The urethral closure is then done in layers with absorbable monofilament suture, reapproximating the bulbospongiosus and Colles fascia before closing the skin over a closed suction drain. 16 York-Mason repair begins with the patient in the prone jack-knife position. After rigid sigmoidoscopy to evaluate the rectum, a para-coccygeal incision is made and carried through the subcutaneous fascia and gluteus to the anal margin. The levator ani, external sphincter, and internal sphincter were divided in sequence after being individually tagged with matched 0 Vicryl sutures (Polyglactin suture, Ethicon, Somerville, New Jersey). (Fig. 1) The posterior wall of the rectum can then be divided to expose the lumen with the fistulous tract. The anterior rectal wall is dissected away from the urethra, excising the fistula tract. The urethra is then closed over a Foley catheter using absorbable suture, such as Vicryl or PDS. The anterior rectal wall can then be closed using interrupted 2-0 PDS suture, taking care not to overlap the urethral and rectal suture lines. The posterior rectal wall is then closed in the same fashion, with or without oversewing of the FIGURE 1. York-Mason approach. e1837

4 suture line with nonabsorable suture. The sphincters and levator ani are closed individually using interrupted 2-0 PDS before closing the skin. 17,18 To perform an endorectal advancement flap, the patient is placed in the prone jack-knife position. Either a LoneStar retractor (CooperSurgical, Trumbull, Connecticut) or retention sutures are used to expose the fistula tract in the rectum. Using electrocautery, a 3 to 5 cm long partial-thickness or fullthickness anterior rectal wall flap is created. (Fig. 2) To ensure adequate blood supply to the flap, the proximal base of the flap should be as broad as possible; ours was 4 cm wide, but they can be as small as 2 to 3 cm. The distal end of the flap should contain the fistula tract, which is excised before advancement. If using a partial thickness flap, the remaining fistula tract on the anterior rectal wall should be closed with absorbable suture. The flap can then be advanced over the denuded area before being secured centrally and circumferentially using interrupted absorbable suture. After ensuring hemostasis, the retractor or stay sutures are removed to complete the case. 8 Long-term data on these procedures are limited to small series. Posterior urethral repairs, either delayed and immediate, have an 80 to 87% success rate, particularly when in conjunction with SPT drainage. 9,14 The York-Mason repair has a 98 to 100% closure rate in nonirradiated fields. 14,15,18 A York-Mason approach provides rapid entry to the area of concern through a bloodless plane that avoids the neurovascular bundles and pelvic floor structures needed for sexual function and urinary continence. 12 It cannot, however, be used in patients with known anorectal dysfunction, and can result in 9 to 26% rate of transanal fistulization. 15 Endorectal advancement flaps are useful as primary procedures because of preservation of dissection fields thanks to the utilization of a natural orifice and they are associated with comparatively short hospital stays. 14,19 These procedures are associated with 75 to 100% success rates with up to 100% fecal continence. 14,15,19 CONCLUSION This series demonstrates the complexity of traumatic GI-GU fistulas and the diversity within this particular injury pattern. Successful management depends on early diversion of both urine and feces, precise localization of the fistula, and an understanding of the varied options for repair. An interdisciplinary FIGURE 2. Endorectal advancement flap. (A) Dissection of mucosal flap, (B) closure of underlying defect, (C) excision of fistula opening from flap, and (D) advancement of mucosal flap. e1838

5 surgical approach between Urology and Colorectal Surgery, specifically tailored to each patient, optimizes the chances for successful repair and positive outcomes. REFERENCES 1. Al-Azzawi IS, Koraitim MM: Lower genitourinary trauma in modern warfare: the experience from civil violence in Iraq. Injury 2014; 45: Najibi S, Tannast M, Latini JM: Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes. Urology 2010; 76(4): Shewakramani S, Reed KC: Genitourinary trauma. Emerg Med Clin N Am 2011; 29: Crispen PL, Kansas BT, Pieri PG, et al: Immediate postoperative complications of combined penetrating rectal and bladder injuries. J Trauma 2007; 62: Choi WJ: Management of colorectal trauma. J Korean Soc Coloprotol 2011; 27(4): Pereira BM, Reis LO, Calderan TR, de Campos CC, Fraga GP: Penetrating bladder trauma: a high risk factor for associated rectal injury. Adv Urol 2014: Franko ER, Ivatury RR, Schwab DM: Combined penetrating rectal and genitourinary injuries: a challenge in management. J Trauma 1993; 34(3): Al-Ali M, Kashmoula D, Saoud IJ: Experience with 30 posttraumatic rectourethral fistulas: presentation of posterior transsphincteric anterior rectal wall advancement. J Urol 1997; 158: Cinman NM, McAninch JW, Porten SP, et al: Gunshot wounds to the lower urinary tract: a single-institution experience. J Trauma Acute Care Surg 2013; 74(3): Johnson EK, Steele SR: Evidence-based management of colorectal trauma. J Gastrointest Surg 2013; 17: Papadopoulos VN, Michalopoulos A, Apostolidis S, et al: Surgical management of colorectal injuries: colostomy or primary repair. Tech Coloproctol 2011; 15(Suppl 1): S Bukowski TP, Chakrabarty A, Powell IJ, Frontera R, Perlmutter AD, Montie JE: Acquired rectourethral fistula: methods of repair. J Urol 1995; 153: Tausch TJ, Cavalcanti AG, Soderdahl DW, Favorito L, Rabelo P, Morey AF: Gunshot wound injuries of the prostate and posterior urethra: reconstructive armamentarium. J Urol 2007; 178: Nfonsam VN, Mateka JJL, Prather AD, Marcet JE: Short-term outcomes of the surgical management of acquired rectourethral fistulas: does technique matter? Res Rep Urol 2013; 5: Hanna JM, Turley R, Castleberry A, et al: Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients. Dis Colon Rectum 2014; 57(9): Gupta G, Kumar S, Kekre NS, Gopalakrishnan G: Surgical management of rectourethral fistula. J Urol 2008; 71(2): Massaolu D, Chetrus-Mariage D, Baqué P: York-Mason repair of rectourethral fistula. J Visc Surg 2015; 152: Hadley DA, Southwick A, Middleton RG: York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience. Br J Urol Int 2011; 109: Razi A, Yahyazadeh SR, Gilani MAS, Kazemeyni SM: Transanal repair of rectourethral and rectovaginal fistulas. Urol J 2008; 5(2): e1839