V1-08: Surgical Correction of Urorectal Fistula (URF) following Radical Prostatectomy for the Treatment of Prostate Cancer.
Urorectal fistula is the least common, but probably the most incapacitating complication associated with the surgical treatment of localised prostate cancer. There has been a considerable rise in the reported incidence of URF after the treatment of prostate cancer, presumably due to new and evolving multimodal treatments. The majority of patients with URF present with urine leakage through the rectum as the flow gradient is predominantly from the urinary to the intestinal tract.
This video describes a transperineal approach for surgical correction of URF following radical prostatectomy for the treatment of prostate cancer. We explain in detail the surgical technique and emphasise the key steps. The essential anatomical landmarks are identified including access via an inverted U-shaped, peri-anal incision, exposure of the perineal body, fistula exposure and division with independent closure of both sides of the fistula.
Over the past 10 years we have repaired URF transperineally in 62 patients with a minimum of 1 year follow-up (these exclude abdomino-perineal repairs). 44 (71%) were purely post-surgical fistulae while the remaining 18 (29%) had adjuvant radiotherapy. There were 10 failures (5 in each group), 8 of which were salvaged by an abdomino-perineal repair, giving an overall fistula closure rate of 96.8%._x000D_ _x000D_ Via a transperineal approach the rectum can be accessed easily, and the rectal defect closed in two layers, with relatively few problems. The bladder defect is more difficult to close because there is less mobility and flexibility of the tissues, and is therefore usually closed in one layer. Preservation of the levator ani muscles allows them to be interposed between the urinary and rectal suture lines longitudinally, closing the space between them and doing away with the need for a gracilis interposition flap._x000D_
URF at the level of the anastomosis or bladder base can be managed via a transerineal approach without the need for a trans-anorectal sphincter-splitting approach, a covering colostomy or an interposition flap when the circumstances are appropriate, and the surgeon is sufficiently experienced.