• Etiology
  • Radical prostatectomy
    • During radical prostatectomy, the anterior rectal wall injury can be injured during dissection of the apical portion of the prostate.
  • External beam radiotherapy for pelvic malignancy
  • Pelvic brachytherapy
  • Inflammatory diseases of the pelvis (prostatic abscess)
  • Penetrating pelvic trauma.
• Presentation
  • Recurrent UTI's
  • Fecaluria
  • Pneumaturia
  • Urine per rectum (rare)
  • Physical examination:
    • A defect may be palpable at the level of the vesicourethral anastomosis
    • If a Foley catheter is indwelling it can be palpable on rectal examination.
• Evaluation
  • Voiding cystourethrography will demonstrate a fistula between the rectum and urethra.
  • Intravenous urography may be used if there is concern for ureteral injury.
  • Barium enema can be helpful to rule out concurrent colonic malignancy.
  • Cystoscopy and/or colonoscopy.
  • CT or MRI of the pelvis can be utilized to evaluate for inflammatory collections or other pelvic masses (e.g., malignancy).
• Therapy
  • Staged repairs and one-stage repairs have been advocated
    • Fecal diversion should be performed as an initial measure
    • In staged repairs, the GI tract is reconstituted only after the fistula has been repaired
  • Surgical options include:
    • Colostomy and urethral catheter drainage.
      • An attempt at fecal diversion and urethral drainage is a reasonable option in most patients.
      • With prolonged fecal diversion, the fistula may close over the urethral catheter.
    • Colostomy followed by a combined abdominal and/or perineal approach.
      • The rectum is separated off the urethra and both are closed primarily.
      • Well-vascularized tissue such as omentum is interposed between the layers.
    • Colostomy followed by a transrectal approach (York-Mason or transphincteric approach).
      • The fistula is exposed using either anal dilation and a speculum, or by transecting the anal sphincters.
      • The fistula is then repaired in multiple layers by advancement and rotation of rectal wall flaps.
    • Postoperative complications:
      • Urinary and/or fecal incontinence postoperatively
      • Patient should be counseled extensively regarding this possibility prior to attempted repair.

References

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