title: Transperineal management for postoperative and radiation rectourethral fistulas.
abstract: OBJECTIVE
  The rectal sphincter preserving transperineal approach has been increasingly used successfully. We analyzed our experience with this surgical approach. A secondary aim was to evaluate the surgical outcome of energy ablative rectourethral fistulas without a concomitant interposition muscle flap.
  
  
  METHODS
  We identified all patients with rectourethral fistula who underwent rectal sphincter preserving transperineal repair from 1998 to 2011. Re-approximation of the urethral mucosa, posterior anastomotic urethroplasty or partial/total prostatectomy with urethrovesical anastomosis was performed for urinary closure. The fistula cohort was divided into 2 groups, including postoperative and energy ablative fistulas, respectively. Success after perineal rectourethral fistula repair was defined as resolution after the first attempt at repair.
  
  
  RESULTS
  A total of 23 patients underwent rectal sphincter preserving, transperineal rectourethral fistula repair. In the postoperative fistula cohort the fistula was successfully resolved in all 10 patients. A dartos interposition muscle flap was used in 2 of 10 patients. In the energy ablative cohort the fistula was successfully closed in 8 of 13 patients. An interposition muscle flap was not placed in 8 patients with an energy ablative fistula, of whom success was achieved in 5. Two of the 5 patients with an energy ablative fistula and a successful outcome without a concomitant interposition muscle flap had urinary extravasation, necessitating temporary catheterization.
  
  
  CONCLUSIONS
  Rectal sphincter preserving transperineal repair is a successful surgical method to repair postoperative and energy ablative rectourethral fistulas. An interposition muscle flap should be considered in the setting of energy ablative rectourethral fistulas to increase successful outcomes.
authors.affiliation: Department of Urology, University of California-San Francisco Medical Center, San Francisco, California, USA. voelzke@uw.edu
authors.forename: Bryan B
authors.initials: BB
authors.lastname: Voelzke
authors.forename: Jack W
authors.initials: JW
authors.lastname: McAninch
authors.forename: Benjamin N
authors.initials: BN
authors.lastname: Breyer
authors.forename: Allison S
authors.initials: AS
authors.lastname: Glass
authors.forename: Julio
authors.initials: J
authors.lastname: Garcia-Aguilar
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D011468:Prostatectomy / Q000009:adverse effects*; D011471:Prostatic Neoplasms / Q000532:radiotherapy / Q000601:surgery; D011832:Radiation Injuries / Q000150:complications* / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps; D014521:Urethra / Q000601:surgery*; D014522:Urethral Diseases / Q000209:etiology / Q000601:surgery*; D014548:Urinary Fistula / Q000209:etiology / Q000601:surgery*; D014945:Wound Healing