Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Post-Intervention Quasi-Experimental Study.
BACKGROUND: Rectourethral fistulas are a rare yet severe complication of prostate surgery, pelvic irradiation, or both. Multiple surgical repairs exist with widely varying success rates. OBJECTIVE: To present our institution's multidisciplinary algorithm for rectourethral fistula repair and its outcomes. DESIGN: This was a retrospective, pre- and post-intervention, quasi-experimental design, comparing frequency of fistula healing and reversal of urinary and fecal diversion before and after implementation of our algorithm. SETTING: All patients who presented to Duke with rectourethral fistula between 2002-2019 were included. PATIENTS: Seventy-nine patients were treated for rectourethral fistula; 36 pre-algorithm and 43 post-algorithm. INTERVENTIONS: Our multidisciplinary algorithm was implemented in 2012. Patients with fistulas <2 cm and no history of radiation underwent York-Mason repair while those with fistulas 2-3 cm or prior pelvic irradiation underwent transperineal repair with gracilis flap interposition. Those with non-repairable fistulas (>3 cm or fixed tissues) underwent pelvic exenteration. Prior to repair, the algorithm recommended all patients undergo urinary and bowel diversion. MAIN OUTCOME MEASURES: The two primary outcomes were rectourethral fistula healing, defined as both radiographic and clinical resolution, and reversal of urinary and fecal diversions. RESULTS: Frequency of fistula healing improved in the post- vs. pre-algorithm subgroups (93.1% vs. 71.9%, p = 0.04). Relative risk of fistula healing pre-intervention as compared to post-intervention was 0.77 (0.61-0.98, p = 0.04) among the overall cohort. Eighteen patients (22.8%) underwent pelvic exenteration for nonrepairable fistulas and were therefore not included in primary outcome measures. LIMITATIONS: This study's limitations include its retrospective nature, possible selection bias due to algorithmic patient selection, and a small sample size. CONCLUSIONS: Implementation of a multidisciplinary institutional algorithm improved rectourethral fistula repair success with high rates of ostomy reversal. Proper patient selection and multidisciplinary involvement are paramount to this success. See Video Abstract at http://links.lww.com/DCR/B955.
Hayden, Joshua P., William R. Boysen, Urszula Kowalik, Brian M. Inouye, John Migaly, Christopher R. Mantyh, Detlev Erdmann, and Andrew C. Peterson. “Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Post-Intervention Quasi-Experimental Study.” In Dis Colon Rectum, 2022. https://doi.org/10.1097/DCR.0000000000002467.