Treatment of a Rectourethral Fistula After Radical Prostatectomy by York Mason Posterior Trans-Sphincter Exposure

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1 Original Articles Treatment of a Rectourethral Fistula After Radical Prostatectomy by York Mason Posterior Trans-Sphincter Exposure Miguel Pera, a Sandra Alonso, a David Parés, a José Antonio Lorente, b Óscar Bielsa, b Marta Pascual, a Ricard Courtier, a M. Jose Gil, a and Luis Grande a a Unidad de Cirugía Colorectal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario del Mar, Barcelona, Spain b Servicio de Urología, Hospital Universitario del Mar, Barcelona, Spain Abstract Introduction. Recto-urethral fistula is an uncommon complication after radical prostatectomy, occurring in less than 2% of patients. Our aim is to review our experience for repairing these fistulas with the posterior trans-sphincter approach of York Mason. Patients and method. Retrospective review. All patients who underwent repair of postoperative recto-urethral fistula in our unit were included.the procedure described by York Mason was performed in all cases. Results. During the last 6 years, 5 patients with rectourethral fistulas after radical prostatectomy were repaired by using this method. Symptoms, including faecaluria and/or passing of urine via the anus, appeared between the postoperative day 4 and 7 weeks after surgery, and confirmation was obtained by cystography. Initial faecal diversion with sigmoid loop colostomy was performed in 3 cases, whereas in the other 2 patients a loop ileostomy was performed at the time of surgical repair. The posterior trans-sphincter approach and fistula repair was performed between 5 and 10 months after diagnosis. Morbidity included wound infection in 2 cases and skin dehiscence in another 2 patients. Successful fistula closure was achieved in all cases with complete faecal continence. No recurrence has been observed after a mean follow-up of 22 (4-40) months. Conclusions. The posterior trans-sphincter approach of York Mason is effective for the repair of recto-urethral fistulas after radical prostatectomy with minor morbidity and no impairment of continence. Presented at the XII National Meeting of the Spanish Coloproctology Association; Valencia, May 14-16, Correspondence: Dr. M. Pera. Unidad de Cirugía Colorrectal. Servicio de Cirugía General y del Aparato Digestivo. Hospital del Mar. Pg. Marítim, Barcelona. España. mpera@imas.imim.es Manuscript received May 21, 2008; accepted for publication July 14, Key words: Prostatectomy. Rectal injury. Recto-urethral fistula. Posterior trans-sphincter approach. TRATAMIENTO DE LA FÍSTULA RECTOURETRAL TRAS PROSTATECTOMÍA RADICAL MEDIANTE LA EXPOSICIÓN TRANSESFINTERIANA POSTERIOR DE YORK MASON Introducción. La fístula rectouretral tras prostatectomía radical es una complicación poco frecuente que ocurre en menos de un 2% de los casos. El objetivo es analizar nuestra experiencia en el tratamiento de la fístula rectouretral mediante la exposición transesfinteriana posterior de York Mason. Pacientes y método. Estudio retrospectivo. Se ha incluido a todos los pacientes intervenidos en nuestro hospital de fístula rectouretral tras prostatectomía radical. En todos los casos se realizó la técnica de York Mason. Resultados. Durante los últimos 6 años, 5 pacientes han precisado tratamiento quirúrgico de fístula rectouretral tras prostatectomía radical. Los síntomas (fecaluria y/o emisión de orina por ano) aparecieron entre el cuarto día y las 7 semanas tras la intervención, y la fístula fue confirmada mediante cistografía. En 3 pacientes se practicó una colostomía sigmoidea derivativa en el momento del diagnóstico, mientras que en los otros 2 el diagnóstico fue tardío y se realizó la derivación fecal mediante ileostomía en el momento de la reparación de la fístula. La reparación transesfinteriana posterior se realizó entre 5 y 10 meses después del diagnóstico. Dos pacientes presentaron infección de la herida que no afectó a la reconstrucción esfinteriana y otros 2 presentaron dehiscencia cutánea sin infección. Ninguno de los pacientes ha tenido recidiva tras un seguimiento medio de 22 (4-40) meses, y la continencia, una vez cerrados los estomas, es completa en todos los casos. Conclusiones. La reparación mediante la vía de abordaje transesfinteriana posterior de York Mason Cir Esp. 2008;84(6):

2 proporciona excelentes resultados en el tratamiento de la fístula rectouretral. Palabras clave: Prostatectomía. Lesión rectal. Fístula rectouretral. Reparación transesfinteriana posterior. Introduction Acquired rectourethral fistula is a rare complication that may occur after prostate cancer treatment, whether it is by radiation therapy or surgery. It has also been described in patients with inflammatory bowel disease and following pelvic trauma. Though its incidence following radical prostatectomy is less than 2%, 1 the complexity of its treatment, due to difficult access to the fistula tract and the high risk for recurrence, creates a challenge for the surgeon. The first attempts at repair should be definitive given that the difficulty of the technique increases in cases of recurrence. 2 As occurs in other complex surgical problems, multiple approaches and techniques have been described for its treatment, included among which are the posterior trans-sphincter apprach, 3-8 the perineal approach, 9-11 advancement flap via the transanal approach and, most recently, laparoscopic repair. 14 In the majority of cases, a small series of patients is treated with very disparate results, making determining the best option difficult. The objective of this work is to analyse our experience in the treatment of rectourethral fistula using the York Mason posterior transrectal trans-sphincteric technique. Patients and Method This is a retrospective study in which 5 patients who have undergone surgery in the past 6 years in our colorectal surgery unit for rectourethral fistula following radical prostatectomy after failing conservative treatment are studied. The York-Mason technique was used on all 5 patients. Table summarized the patient characteristics.the prostatectomy was performed laparoscopically in all cases and conversion to open surgery was necessary in 1 case. In 2 cases, the rectal lesion was identified during the prostatectomy and repair was made, while the lesion was unseen in the other 3 cases. The symptoms (faecaluria and/or urine discharge from the anus) appeared between the fourth day and 5 weeks following surgical intervention and the fistula was confirmed using cystography (Figure 1). Conservative treatment was initiated in all cases using a bladder catheter, and 3 patients also underwent a sigmoid colostomy which was placed at the moment of diagnosis. In the other 2 patients, the diagnosis was delayed and faecal diversion was performed using and ileostomy at the time of fistula repair. The clinical characteristics of the patients, the interval between diagnosis and treatment, the data related to the surgery, morbidity and the final result Figure 1. Cystography in which complete filling of the rectum and sigmoid colon through the rectourethral fistula is seen. of the follow-up period have been collected.the patients were questioned specifically about their symptoms of recurrence, urinary incontinence, and faecal incontinence. Description of the Technique The surgical technique follows the principles of the original description performed in 1970 by the English surgeon Aubrey York Mason of the St. Helier University Hospital in London. 3 The patients receive mechanical preparation of the colon (if they had not already undergone a diversion stoma) and antibiotic prophylaxis. We performed cystoscopy in all cases in order to identify the location of the fistula and its relationship with the meatus of the ureters and the bladder catheter was then reinserted. In patients whom the orifice of the fistula is close to one of the meatus, the introduction of a ureter catheter is necessary in order to avoid injury during the repair. The patient is then placed in the jack-knife position with the gluteus muscles separated with tape. A paracoccigeal incision is made which is extended to the anal margin. Even though we have made an incision on the left side in the majority of cases, it is sometimes preferable to make the incision on the right side when the orifice is not situated in the midline but instead displaced to that side.the incision passes through the subcutaneous tissue until reaching the gluteus maximus at its proximal end and the levator ani and the external sphincter at its distal end (Figure 2). After separately identifying the levator ani, external sphincter and the internal sphincter, they are sectioned by using sutures at their extremes, which will later facilitate reconstruction.then the posterior wall of the inferior rectum is exposed, which is sectioned longitudinally in order to leave the fistula and the passage of urine through it exposed (Figure 3). We use a Lone-Star separator in order to keep the posterior rectal wall separated. We then proceed to resect the fistula tract (Figure 4) and dissect the borders of the urethra and the anterior rectal wall separately. We use 2-0 Vicryl to Characteristics of Patients Who Underwent Surgery in this Series Using the York-Mason Technique and Results of the Treatment Age Symptoms Surgery- Faecal Diagnosis- Morbidity Recurrence Follow-up, Diagnosis, Diversion Repair, mo d mo 70 Urine through the anus 35 Ileostomy 10 Extrusion of cyanoacrylate No Urine through the anus 25 Ileostomy 9 Wound dehiscence No Faecaluria 4 Colostomy 10 Wound infection No Faecaluria 15 Colostomy 5 Wound dehiscence No 8 75 Faecaluria 7 Colostomy 10 Wound infection No Cir Esp. 2008;84(6):323-7

3 Discussion Figure 2. Left parasacral-coccigeal incision. close the urethra horizontally with individual sutures over the bladder catheter and 3-0 Vicryl to close the anterior rectal wall longitudinally. The posterior rectal wall is closed with a continuous 3-0 Vicryl suture. Finally, the muscle structures that were sectioned during access: internal sphincter, external sphincter, and levator ani, are reconstructed with separated sutures of 2-0 PDS. In all cases, we leave an aspiration drain in the first subcutaneous layer and the skin is sutured with silk. Results The repair was made using posterior trans-sphincteric exposure in all cases, as described in Patients and Method, between 5 and 10 months after diagnosis. The average operative time was 210 ( ) minutes. Blood transfusion was not needed in any of the cases. A cyanoacrylate adhesive was placed between the urethral and rectal sutures in the first patient in this series.two months after repair, the patient had acute urinary retention and extrusion of this material in the urethral lumen was confirmed by cystoscopy and it was removed. We did not use any material between the suture layers in the patients that followed. Two patients suffered an infection of the wound that did not affect the fistula repair or the sphincter reconstruction, and another 2 had cutaneous dehiscence without infection. The diversion stomas were closed between 3 and 6 months after repair of the fistula, after performing cystography and an enema using water-soluble contrast media that did not show signs of dehiscence in the suture lines or communication between the urethra and the rectum. Only 1 patient suffered soiling in the immediate postoperative period, which was resolved with 3 sessions of biofeedback. Currently, continence is complete in all of the cases. Two patients had urinary incontinence in relation to the prostatectomy. None of the patients have had a recurrence after a median follow-up of 22 (13) months. Treatment of prostate cancer is the most common cause of acquired rectourethral fistula whether it is secondary to radiation treatment or injury to the anterior wall of the rectum during prostatectomy. This surgical lesion, inadvertent in many cases, has been described in 0.5%-10% of cases in the different large studies of radical prostatectomy, with the resulting increase in septic complications. Recently, an increase in rectal injuries related to the learning curve for laparoscopic radical prostatectomy has been described. In a series of 110 radical laparoscopic prostatectomies performed over a 2-year period, 18 9 (8%) were complicated by an injury to the rectum. Of the 9 injuries, 7 occurred in the first 50 patients, while only 2 occurred in the subsequent 50 cases. Together, rectourethral fistula occurs in less than 2% of patients who undergo this procedure. The first choice of treatment is conservative, using a bladder catheter and a diversion stoma for a minimum period of 3 months. 6 Though this treatment can be effective in some cases, 12 it is often associated with repeated episodes of sepsis, meaning surgical treatment is necessary in the majority of patients. The results of this series confirm that the York-Mason posterior transrectal trans-sphincteric approach achieves the best cure of the rectourethral fistula with a success rate that approaches 100%.The good results obtained with this technique, to a large extent due to access through the unscarred tissue and the excellent exposure that it provides, makes it one of the most widely used techniques. 4-8,19,20 In the largest series of patients treated with the York-Mason technique, satisfactory results were achieved in 22 out of 24 patients. 7 Despite sectioning the sphincter, faecal incontinence has been reported in less than 1% of cases and when it does occur, conservative treatment using biofeedback is possible. In our experience, we do not believe that the systematic use of preoperative manometry studies is necessary. This study may be considered in patients with a history of previous anorectal Puborectal M. Internal Sphincter M. External Sphincter M. Figure 3. Posterior transrectal trans-sphincteric exposure of the fistula tract located in the anterior wall of the rectum. Cir Esp. 2008;84(6):

4 Figure 4. Exeresis of the fistula tract including all of the scar tissue around it. surgery. On the other hand, the posterior trans-sphincteric repair is contraindicated in patients with faecal incontinence and those patients with severe radiation proctitis. It has been shown that one of the disadvantages of the York-Mason technique is the inability to intersperse vascularised tissue between the urethral and rectal suture lines. 8,11 Nevertheless, in our experience the success of the procedure does not depend on interspersing tissue or any other type of material. In fact, the only case in which cyanoacrylate was interspersed between the suture lines resulted in extrusion of the material through the urethra, though it did not affect the repair.we believe that interspersion of tissue in not necessary in small fistulas, while it may be recommended in larger fistulas that are surrounded by necrotic tissue. 7 Among the drawbacks are postoperative pain and surgical wound complications, which may prolong hospital stay. In our series, 4 of the 5 patients had some type of wound complication and required treatment, first as inpatients and then on an ambulatory basis for several weeks. One modification of this procedure is the anterior transanal, trans-sphincteric approach (ASTRA) originally described for the treatment of urethral stenosis. This consists of a perineal incision that is extended from the scrotum to the anal margin and is carried down until reaching the fistula, which is resected. Afterwards, the sphincter system is reconstructed. Nevertheless, the experience with this procedure is still scarce. 21 As we have mentioned above, despite the excellent results of the posterior access approach, many other techniques have been described for the treatment of rectourethral fistula. Even though the surgeon is more used to a laparotomy approach, this route of access provides inadequate exposure in the pelvic floor and carries with it an increase in morbidity. Laparoscopic repair, which has recently been described, provides better visualization and all of the advantages of minimally invasive surgery. Nevertheless, it is a technically difficult procedure that requires a lot of experience in laparoscopic pelvic surgery and only a few cases have been described until now. 14 Repair via the perineum provides good exposure of the urethra and the neck of the bladder and it allows for interposition of pediculated muscle flaps such as the gracilis muscle 9,22 or the subcutaneous perineal dartos flap used in the repair of hypospadias, one with which urologists are especially familiar. 10,11 One of the main drawbacks of perineal access is the presence of scar tissue. Impotence due to injury of neurovascular structures, urethral stenosis and urinary incontinence are some of the complications, in addition to those related to the muscle pedicle used. The use of an advancement flap from the mucosa of the rectal wall using the transanal approach has also been described, in the same manner as has been used for many years in the treatment of complex perianal fistulas. 12,13 In a series of 12 patients with iatrogenic rectourethral fistula or secondary to Crohn s disease, Garofalo et al 12 achieved satisfactory initial results in 8 (67%) of cases, even though the other 2 patients were treated successfully following a second repair. However, it should be pointed out that all of the failures occurred in patients with Crohn s disease. This approach has not either offered good results in traumatic fistulas. 23 The minimal postoperative pain, the absence of a diversion stoma and the possibility of repeating the procedure are some of the advantages of this technique. 13 Nevertheless, there is still little experience. Transanal endoscopic microsurgery (TEM) has also been described in the treatment of these fistulas, though only anecdotally until now. 24 The technique known as direct open repair, or the Latzko technique, was first described for repair of rectovaginal and vesicovaginal fistulas. 25 This technique, used in fistulas located in the inferior rectum, is characteristic because the fistula tract is not dissected, which may favour recurrence. In a series of 6 patients, Noldus et al 26 managed to successfully repair all of the cases, though no follow-up was specified. 326 Cir Esp. 2008;84(6):323-7

5 A classification system for rectourethral fistulas has recently been proposed, with the goal of facilitating selection of the most appropriate technique for each patient 27 : stage I corresponds to fistulas located at least 4 cm from the anal margin and non-irradiated, while stage II fistulas are also not irradiated but higher (more than 4 cm from the anal margin). Stages III and IV correspond to fistulas located in tissues that were previously irradiated that are <2 or >2cm, respectively. Finally, the stage V fistulas are larger, generally secondary to decubitus ulcers of the ischium. According to this classification, some authors recommend transanal repair in stage I fistulas, while the technique of choice in stage II and III fistulas would be the York-Mason technique. The perianal access route with interspersion of pediculated flaps, according to the same authors, would be indicated in stage IV and V fistulas. All of the fistulas in our series correspond to stage II. The majority of studies agree on the need for a bladder catheter and faecal diversion in the initial stage of treatment of the rectourethral fistula. In 2 of the patients in our series, the diversion stoma was not performed until the moment of repair, given that the only symptom was urine discharge through the anus. The stoma can be closed after the repair after performing not only a cystography that shows the complete resolution of the fistula, but also a contrast enema to confirm the absence of dehiscence of the posterior wall of the rectum. Repair of the rectourethral fistula has also been described without the need of a faecal diversion in patients in which the transanal approach was used. 28 Nevertheless, we believe that it is necessary when the posterior trans-sphincteric approach is used. Conclusions Repair via the York-Mason posterior trans-sphincteric approach provides excellent results in the treatment of rectourethral fistula. References 1. 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