V01-06: Turnbull-Cutait Coloanal pull-through: A Salvage reconstructive option in the management of refractory rectourethral fistulae
Rectourethral fistula (RUF) is a devastating complication of prostate cancer treatment. RUF repair is one of the most complex reconstructions in urologic surgery, especially when associated with pelvic radiation or energy ablative treatments. Preoperative endoscopic evaluation of both the urinary and gastrointestinal tract, assessment for radiation damage, fistula size, location and continence status are essential. Fecal diversion is key for RUFs associated with prior radiation, especially with fecaluria, UTIs, or severe rectal pain. Radiated RUF repair typically employs a transperineal approach with muscle interposition; when this fails, trans-abdominal surgery can be effective. Turnbull-Cutait (TC) coloanal pull through with a delayed coloanal anastomosis (DCA), was traditionally described for management of rectal cancer, Hirschsprung's and chagasic megacolon. Herein, we present our unique technique of a staged TC coloanal pull-through to salvage a refractory radiated RUF.
52-year-old man with hypertension and tobacco dependency with Gleason 9 prostate cancer and external beam radiation in 2014. In 2016, he underwent a salvage robotic prostatectomy complicated by a rectal injury and subsequent 1.5 cm RUF. He underwent loop colostomy and SP tube, and delayed transperineal RUF repair with dartos flap. This surgery failed and he was referred to our center. We performed a transperineal RUF repair with buccal graft and gracilis muscle interposition. His course was complicated by a perineal wound infection, recurrent RUF and severe incontinence. A salvage RUF repair by distal proctectomy, TC coloanal pull through with DCA, omental flap interposition and loop ileostomy was performed. Key steps are preservation of marginal artery, mobilize splenic flexure, colon pulled through the anus ("tail"), mesentery facing urinary fistula, and coloanal anastomosis performed 1 week later.
Total operative time for the first and second stage were, 415 minutes and 106 minutes respectively, with blood loss of 500mL. The patient had an uneventful course, was able to ambulate, but restricted from sitting. On post-operative day number 7, the colon hanging out of the anus was transected, and the coloanal anastomosis performed, utilizing 8 pre-placed sutures from the first stage procedure. VCUG and gastrograffin enema at 6 weeks revealed no leak and the Foley and SP tubes were removed. 3 months later the loop ileostomy was taken down with good results.
A coloanal pullthough with DCA is infrequently utilized, yet highly effective salvage method to repair refractory RUFs. Long-term functional outcomes evaluation of our patient will be performed.