V10-07: COMPLEX ROBOTIC RECONSTRUCTION FOR LARGE RADIATION RECTOURETHRAL FISTULA AND URETHRAL STRICTURE: SALVAGE PROSTATECTOMY, POSTERIOR URETHROPLASTY, LOW ANTERIOR RESECTION, WITH REANASTOMOSIS
Radiation rectourethral fistula (RUF) is a devastating iatrogenic complication of prostate cancer treatment. Traditional perineal approaches incorporating various techniques including buccal mucosal graft onlay, gracilis muscle flap interposition, primary rectal closure have excellent success rates. However, occasional cases will not be amenable to this approach, in particular very large defects or cases with significant radionecrosis of the prostate. These patients most frequently undergo both urinary and fecal diversion.
We present a 53 year-old man who received combination IMRT and brachytherapy for Gleason 8 prostate cancer 2 years ago and was cancer free. He developed a wide 4 cm RUF fistula with extensive prostate radionecrosis, and a transsphincteric urethral stricture, but a normal bladder and intact external anal sphincter. He had severe pelvic and perineal pain. Colostomy and SP tube placement provided no resolution of his symptoms._x000D_ Robotic assisted salvage prostatectomy was performed, with bladder neck reconstruction. There was a dense 2 cm transphincteric bulbomembranous urethral stricture. Colon and Rectal surgery did a robotic low anterior resection and coloanal anastomosis. A perineal, posterior urethroplasty was performed with stricture excision and urethral mobilization. The urethra was reintroduced intraperitoneally and traditional robotic urethrovesical anastomosis performed. A gracilis muscle interposition flap was placed between the suture lines. The case took 14h._x000D_
At 6 months, the patient had no fistula recurrence. His perineal pain resolved. His colostomy was reversed, restoring fecal continuity. As expected, he had total incontinence managed with interval placement of a transcorporal artificial urinary sphincter.
When there is a clinical suspicion that highly complex radiation RUF might fail traditional perineal repair, a multidisciplinary approach combining a robotic abdominal salvage prostatectomy, perineal urethroplasty and rectal fistula closure affords restoration of continuity of both the fecal and urinary streams. For the appropriate patient, this avoids permanent dual diversion and, though surgically challenging, may be attractive. A series is ongoing.