Rectourinary fistulas

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Rectourinary fistulas (RUF) are uncommon. They include rectourethral, rectovesical, and enterourinary fistulas.
Signs and symptoms depend on the type of fistula and may include urinary tract infections, pneumaturia, fecaluria, and urine leakage per rectum. Evaluation and work-up for RUF includes a physical examination and history including previous radiation or gastrointestinal disease, cystoscopy, colonoscopy, barium enema, retrograde urethrogram, and CT scan with contrast.

Rectourethral fistula

The most common cause of the rectourethral fistula is a consequence of prostate treatments (e.g. TURP, EBRT, HIFU, cryotherapy, rectal surgery, brachytherapy (BT) and radiotherapy to the rectum). It is important to note that although it is thought that rectourethral fistulas occur after a radical prostatectomy, semantically, it should be considered a rectovesical fistula because it developed close to the anastomosis with the bladder being the origin.

Rectourethral fistulas have been reported in approximately 0.3-3% of patients after BT (1) and in 0-0.6% after EBRT (2). With the increasing use of HIFU, rectourethral fistula has been reported as a complication after this treatment modality; Netsche (3) reported an overall incidence of 2.2%, with a higher probability to develop a fistula after a salvage or repeated session of HIFU. Additionally, the use of cryotherapy and radiotherapy before rectal surgery has resulted in an increase rate of fistulas.

Laparoscopic and robotic rectourethral fistula management was described by Sotelo et al. For a fistula involving the prostatic capsule, the technique includes capsulotomy, excision of the prostate while preserving the seminal vesicles, and closing the rectum in two layers. The bladder is then mobilized distally, and urethrovesical anastomosis is performed in the standard running fashion, using an omental or peritoneal flap to interposition (4).

Rectovesical fistulas

Rectovesical fistulas are less common. They can occur at different locations, including the bladder dome, where diverticular disease (66% of cases) and colonic cancer (about 20% of cases) as more frequent etiologies (5); to the bladder neck, where it can follow extirpative or ablative procedures of the prostate for both benign and malignant conditions.

A review of complications after radical prostatectomy in the Medicare population revealed a 1% rate of RUF (6). For robot-assisted radical prostatectomies, the reported incidence of rectal injury is 0.17%, with most injuries detected intraoperative (7). There has been an increase in fistula rate as a result of an increase in the number salvage radical prostatectomies being performed.

Sotelo et al (8) was the first to report the use of a laparoscopic approach to the treatment of rectovesical fistula. He reported a transvesical approach, which reaches the fistulous tract through a vertical cystostomy, bivalving the trigone, which allows for a meticulous retrovesical dissection to separate the rectum from the bladder. Once the communication between the bladder and the rectum is identified, a careful dissection is performed to separate the rectum from the bladder. The rectum is then closed, and omentum can be brought down to serve as a tissue interposition to bolster the repair. The bladder closure is then performed. Parma et al (9) reported a similar case with the same success. The use of the robotic platform was first described by Sotelo et al (10) with shorter operative time and length of hospitalization, without fistula recurrence.

At USC we have performed pioneering work in laparoscopic and robotic surgery for complex urinary fistula management and repair. Our experience includes treatment of 100 cases rectourinary fistulas of all kinds. We have a dedicated team, including colorectal surgeons and urologic reconstructive surgeons, to offer the best collaborative treatment of this challenging condition.

References
1. Theodorescu D, Gillenwater JY, Koutrouvelis PG. Prostatourethral- rectal fistula after prostate brachytherapy. Cancer. 2000;89: 2085-2091.
2.Pisansky TM, Kozelsky TF, Myers RP, et al. Radiotherapy for isolated serum prostate specific antigen elevation after prostatectomy for prostate cancer. J Urol. 2000;163:845-850.
3. Netsch C., Bach T., Gross E., et al. Rectourethral fistula after high-intensity focused ultrasound therapy for prostate cancer and its surgical management. Urology 2011 Apr;77(4):999-1004
4. Sotelo R., Mirandolino M., Trujillo G., et al. Laparoscopic repair of rectourethral fistulas after prostate surgery. Urology 2007 Sep;70(3):515-8.
5. Venn S, Mundy T. Bladder reconstruction: urothelial augmentation, trauma, fistula. Curr Opin Urol 2002; 12:201–203
6. Benoit R., Naslund M., Cohen J. Complications after radical retropubic Prostatectomy in the medicare population. Urology 2000;56: 116–120
7. Wedmid A, Mendoza P, Sharma S et al. Rectal injury during robot-assisted radical prostatectomy: incidence and management. J Urol 2011; 186: 1928–33
8. Sotelo R, Garcia A.,Yaime H., et al. Laparoscopic rectovesical fistula repair. J Endou 2005; 19(6):603-606
*This is the first description of laparoscopic transvesical approach to a fistula.
9. Parma P., Samuelli A., DallOglio B., et al. Laparoscopic repair of rectovesical fistula after radical retropubic prostatectomy. Urologia 2011 Oct;78 Suppl 18:21-5
10. Sotelo R., De Andrade R., Carmona O., et al. Robotic repair of rectovesical fistula resulting from open radical prostatectomy. Urology 2008 Dec;72(6):1344-6