title: Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients.
abstract: BACKGROUND
  Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis.
  
  
  OBJECTIVE
  To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm.
  
  
  METHODS
  A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012.
  
  
  METHODS
  Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16.
  
  
  METHODS
  The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence.
  
  
  RESULTS
  There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group.
  
  
  CONCLUSIONS
  This study was limited by the small sample size and the retrospective nature of the review.
  
  
  CONCLUSIONS
  Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.
authors.affiliation: 1Department of Surgery, Section of Colon and Rectal Surgery, Duke University Medical Center, Durham, North Carolina 2Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 3Division of Urology, Duke University Medical Center, Durham, North Carolina.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Hanna
authors.forename: Ryan
authors.initials: R
authors.lastname: Turley
authors.forename: Anthony
authors.initials: A
authors.lastname: Castleberry
authors.forename: Thomas
authors.initials: T
authors.lastname: Hopkins
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Peterson
authors.forename: Christopher
authors.initials: C
authors.lastname: Mantyh
authors.forename: John
authors.initials: J
authors.lastname: Migaly
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D015897:Comorbidity; D006801:Humans; D008297:Male; D008875:Middle Aged; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D016896:Treatment Outcome; D014522:Urethral Diseases / Q000209:etiology / Q000601:surgery*; D014548:Urinary Fistula / Q000209:etiology / Q000601:surgery*