Abstract
PURPOSE: Acquired rectourinary fistulas, an infrequent complication of pelvic conditions, remain a therapeutic problem for which neither a widely accepted classification nor long-term outcome data are available. This study was designed to provide a new etiologic classification system and examine the success of various surgical therapies. It also looked at the need for permanent fecal or urinary diversion or radical excision depending on the cause of the fistula,i.e., benignvs. malignancy-related. METHODS: A retrospective analysis was made of 41 patients treated for acquired rectourinary fistulas between 1980 and 1995. Acquired rectourinary fistulas were classified as 1) benign but caused by Crohn's disease, trauma, perirectal sepsis, or iatrogenic injury; and 2) malignancy-related fistulas secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects. Surgical interventions were classified as repair, excision, fecal diversion, and urinary diversion. RESULTS: Thirty-seven males and 4 females with acquired rectourinary fistula were identified with a mean age of 62 (range, 28–90) years. Nineteen patients had fistulas involving their urethras, and 22 patients had fistulas involving the bladder. Eight patients were not treated surgically; one was not treated because of an advanced malignancy, three because of patient preference, three because of sepsis, and one because of a poor general condition. Of the remaining 33 patients, nine had benign fistulas of which two were the result of Crohn's disease, two were the result of trauma, two were from an iatrogenic response, and three were from perirectal sepsis. Twenty-four patients had malignancy-re-lated fistulas, and five patients had neoplasm at their fistula sites. The remaining 19 patients had malignancy-related fistulas that were the result of cancer treatments. Of the 19 malignancy-related fistulas, 5 were from radiation, 9 were from surgical trauma, and 5 were from radiation and surgical trauma. Forty-nine percent of the patients had undergone attempts at fistula treatment before referral. A resolution of symptoms after initial and reoperative surgery occurred more often in patients with benign fistulas (44 and 100 percent; mean, 1.8 surgeries per patient) compared with malignancy-related fistulas (21 and 88 percent; mean, 2.1 surgeries per patient). The rates of permanent fecal, urinary, and fecal plus urinary diversion were also lower for benign fistulas (11, 0, and 33 percent) compared with malignancy-related fistulas (13, 8, and 54 percent). Permanent diversion was avoided in 56 percent of the benign fistulas but in only 25 percent of the malignancy-related fistulas. The rates of excisional and radical (ileal conduit) surgery were lower for benign fistulas than for malignancy-related fistulas (44 and 11 percentvs. 50 and 54 percent). CONCLUSION: Successful management of rectourinary fistulas typically requires aggressive reoperative therapy with permanent diversion more often required for malignancy-related fistulas. Better outcomes can be anticipated for benign fistulas.
Similar content being viewed by others
References
Lewis LG. Repair of recto-urethral fistulas. J Urol 1947;57:1173–81.
Smith AM, Veenema RJ. Management of rectal injury and rectourethral fistulas following radical retropubic prostatectomy. J Urol 1972;108:778–9.
Massoudnia N. Vesicorectal fistula following abdominal hysterectomy. Int Surg 1975;60:96–7.
Dahl DS, Howard PM, Middleton RG. The surgical management of rectourinary fistulas resulting from a prostatic operation: a report of 5 cases. J Urol 1974;111:514–7.
Stamler JS, Bauer JJ, Janowitz HD. Rectourethroperineal fistula in Crohn's disease. Am J Gastroenterol 1985;80:111–2.
Fazio VW, Jones IT, Jagelman DG, Weakley FL. Rectourethral fistulas in Crohn's disease. Surg Gynecol Obstet 1987;164:148–50.
Kyle J. Urinary complications of Crohn's disease. World J Surg 1980;4:153–60.
Buck AC, Chisholm GD. Rectovesical fistula secondary to prostatic carcinoma. J Urol 1979;121:831–2.
King RM, Beart RW Jr, McIlrath DC. Colovesical and rectovesical fistulas. Arch Surg 1982;117:680–3.
Okaneya T, Ogawa A, Wajiki M. Tuberculous rectourethral fistula. Urology 1988;31:424–6.
Bukowski TP, Chakrabarty A, Powell IJ, Frontera R, Perlmutter AD, Montie JE. Acquired rectourethral fistula: methods of repair [Review]. J Urol 1995;153:730–3.
Culp OS, Calhoon HW. A variety of rectourethral fistulas: experiences with 20 cases. J Urol 1964;91:560–71.
Hemal AK, Sharma SK, Goswami AK. Urethrorectal fistulas complicated by posterior urethral stricture: an appraisal of management by transpubic approach. Urol Int 1991;46:329–33.
Gecelter L. Transanorectal approach to the posterior urethra and bladder neck. J Urol 1973;109:1011–6.
Zimmern PE, Cukier J. Prostatic and membranous urethrorectal fistulas: a new technique of surgical closure. J Urol 1985;134:355–7.
Venable DD. Modification of the anterior perineal transanorectal approach for complicated prostatic urethrorectal fistula repair. J Urol 1989;142:381–4.
Kelemen Z, Lehoczky G. Closure of severe vesicovagino-rectal fistulas using Lehoczky's island flap. Br J Urol 1987;59:153–5.
Ryan JA Jr, Beebe HG, Gibbons RP. Gracilis muscle flap for closure of rectourethral fistula. J Urol 1979;122:124–5.
Young HH, Stone HB. The operative treatment of urethro-rectal fistula. Presentation of a method of radical cure. J Urol 1917;1:289–317.
Campbell MF. Urethrorectal fistula. J Urol 1956;76:411–8.
Young HH, Stone HB. An operation for urethro-rectal fistula: report of three cases. Trans Am Assoc Genitourin Surg 1913;8:270–8.
Talarico RD, Fernandes M. Transrectal closure of urethrorectal fistula: a case report. J Urol 1969;101:332–4.
Vose SN. A technique for the repair of recto-urethral fistula. J Urol 1949;61:790–4.
Tiptaft RC, Motson RW, Costello AJ, Paris AM, Blandy JP. Fistulae involving rectum and urethra: the place of Parks's operations. Br J Urol 1983;55:711–5.
Jones IT, Fazio VW, Jagelman DG. The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum. Dis Colon Rectum 1987;30:919–23.
Parks AG, Motson RW. Peranal repair of rectoprostatic fistula. Br J Surg 1983;70:725–6.
Kraske P. Extirpation of high carcinomas of the large bowel. Dis Colon Rectum 1984;27:499–503.
Kilpatrick FR, Mason AY. Post-operative recto-prostatic fistula. Br J Urol 1969;41:649–54.
Wiseman NE, Decter A. The Kraske approach to the repair of recurrent rectourethral fistula. J Pediatr Surg 1982;17:342–6.
Martelli A, Bercovich E, Lo Cigno M, Laria G, Beghelli R. Transcoccygeal approach for rectourethral fistula repair. Urol Int 1984;39:292–7.
Sweeney WB, Deshmukh N. Modified Kraske approach for disease of the mid-rectum. Am J Gastroenterol 1991;86:75–8.
Morgan C Jr. Dorsal rectotomy and full thickness skin graft for repair of prostatic urethrorectal fistula. J Urol 1975;113:207–9.
Wood TW, Middleton RG. Single-stage transrectal transsphincteric (modified York-Mason) repair of rectourinary fistulas. Urology 1990;35:27.
Beneventi FA, Cassebaum WH. Rectal flap repair of prostatorectal fistula. Surg Gynecol Obstet 1971;133:489–92.
Prasad ML, Nelson R, Hambrick E, Abcarian H. York Mason procedure for repair of postoperative rectoprostatic urethral fistula. Dis Colon Rectum 1983;26:716–20.
Tveter KJ, Mathisen W. Recto-urethral fistula: treatment by abdomino-perineal pull-through resection of the rectum. Eur Urol 1978;4:303–5.
Antony J. A method of repair of recurrent recto-vesico-prostatic fistula following prostatectomy. J Urol 1980;124:936–7.
Tang N. A new surgical approach to traumatic rectourethral fistulas. J Urol 1978;119:693–5.
Miller W. A successful repair of a recto-urethral fistula: a case report. Br J Surg 1977;64:869–71.
Trippitelli A, Barbagli G, Lenzi R, Fiorelli C, Masini GC. Surgical treatment of rectourethral fistulae. Eur Urol 1985;11:388–91.
Thompson JS, Engen DE, Beart RW Jr, Culp CE. The management of acquired rectourinary fistula. Dis Colon Rectum 1982;25:689–92.
Sarr MG, Fishman EK, Goldman SM, Siegelman SS, Cameron JL. Enterovesical fistula. Surg Gynecol Obstet 1987;164:41–8.
Wesolowski S, Bulinski W. Vesico-intestinal fistulae and recto-urethral fistulae. Br J Urol 1973;45:34–8.
Goodwin WE, Turner RD, Winter CC. Rectourinary fistula: principles of management and a technique of surgical closure. J Urol 1958;80:246–54.
Hampton JM, Bacon HE. Diagnosis and surgical management of rectourethral fistulas. Dis Colon Rectum 1961;4:177–80.
Author information
Authors and Affiliations
About this article
Cite this article
Muñoz, M., Nelson, H., Harrington, J. et al. Management of acquired rectourinary fistulas. Dis Colon Rectum 41, 1230–1238 (1998). https://doi.org/10.1007/BF02258219
Issue Date:
DOI: https://doi.org/10.1007/BF02258219