Rectourethral Fistula Induced by Localised Prostate Cancer Treatment: Surgical and Functional Outcomes of Transperineal Repair with Gracilis Muscle Flap Interposition

Abstract

Background

Transperineal repair of rectourethral fistula (RUF) following prostate cancer treatment with gracilis muscle flap interposition (GMFI) leads to favourable outcomes, but published data are still lacking, notably concerning functional aspects.

Objective

To assess surgical and functional outcomes of this treatment of RUF.

Design, setting, and participants

A retrospective study was conducted in two referral hospitals including 21 patients who underwent RUF transperineal repair with GMFI between 2008 and 2020.

Surgical procedure

The standard vertical perineal approach is performed for fistula dissection. Bladder and rectal defects are closed separately. After dissection from its facia, the flap is harvested, preserving its pedicle; it is brought to the perineum and placed between the urethra and the rectum to fully cover the sutures.

Measurements

Fistula closure (clinical data and postoperative cystography), digestive stoma closure, and complications graded according to the Clavien-Dindo classification were reviewed. Functional results were assessed using the Urinary Symptom Profile (USP) questionnaire, anal incontinence St Mark’s score, Patient Observer Scar Assessment Scale (POSAS) score, and a nonvalidated Likert scale questionnaire assessing issues with lower extremity functionality.

Results and limitations

The median (interquartile range) follow-up was 27 (8–47) mo. Fistula closure was successful for 20 patients (95% success). Digestive stoma was closed in 10/12 shunted patients (83%). Two (9%) Clavien-Dindo grade ≥3b complications were reported (one urinoma in a kidney transplant patient and one thigh haematoma evacuation). Eighteen patients (86%) completed the postoperative questionnaire; 11/18 (61%) had significant urinary incontinence. The mean (standard deviation) USP dysuria score was 1/9 (1.2), mean St Mark’s score was 5/24 (5), mean POSAS score was 19/70 (11), mean lower extremity functionality score was 2/20 (4), and mean procedure patient satisfaction score was 9/10 (2). The retrospective design and limited number of patients are the main limitations.

Conclusions

The present study found an excellent success rate and low morbidity for RUF transperineal repair with GMFI. Functional outcomes were satisfactory despite a high urinary incontinence rate.

Patient summary

We performed an analysis of the outcomes of perineal approach surgery with muscle interposition for closing abnormal communication between the bladder and the rectum after prostate cancer treatment. This surgical technique was found to be safe to perform and provides a high success rate, with patients being satisfied despite poor urinary continence outcomes.

Introduction

Rectourethral fistula (RUF) is a dreaded but fortunately rare complication of localised prostate cancer treatments, including surgery, radiation (radiotherapy and brachytherapy), or ablative energies (cryotherapy and high-intensity focused ultrasound [HIFU]) that can be combined or administered in succession. RUF following direct rectum injury during prostatectomy are now reported rarely (<1% of cases); this is less frequent with laparoscopic and robotic prostatectomy than with surgery [1], [2]. However, RUF is more frequent with combined treatment—for instance, the incidence is ten times higher after radiotherapy, brachytherapy, and/or HIFU than in nonirradiated patients [3], [4], [5]. In addition, with radiation or ablative energy, fistulas are of larger diameters, with active fibrosis remodelling and compromised tissue healing [4], [6], [7].

A wide variety of techniques have been developed to repair fistulas, from a conservative approach combining urinary and digestive diversion to surgical repair (transanal and trans-sphincteric repair with or without a mucosa flap, transabdominal repair with or without epiploon interposition, and transperineal repair with or without tissue interposition). A recent systematic review of surgical repair in acquired RUF suggested that transperineal repair with gracilis muscle flap interposition (GMFI) and trans-sphincteric repair may lead to more favourable outcomes than other techniques [8]; however, very few studies have evaluated the functional outcomes [9], [10], [11] that have led to a lack of consensus in the management of RUF. The present study therefore aimed to assess the surgical outcomes of transperineal repair with GMFI in patients treated for localised prostate cancer with a comprehensive analysis of functional outcomes.