title: Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.
abstract: OBJECTIVE
  The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation.
  
  
  METHODS
  Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up.
  
  
  RESULTS
  Mean age was 60 years (50-73) with median follow-up of 28.7 months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p = 0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2 months (3.5-24.9). In irradiated patients, 18/20 (90 %) developed BOD compared with 1/7 (14 %) who were not radiated (p = 0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p = 0.0458).
  
  
  CONCLUSIONS
  Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.
authors.affiliation: Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. vraup@partners.org.
authors.forename: Valary T
authors.initials: VT
authors.lastname: Raup
authors.affiliation: Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Jairam R
authors.initials: JR
authors.lastname: Eswara
authors.affiliation: Division of Urology, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: Julio
authors.initials: J
authors.lastname: Geminiani
authors.affiliation: Division of Urology, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: Kerry
authors.initials: K
authors.lastname: Madison
authors.affiliation: Division of Urology, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: Avory M
authors.initials: AM
authors.lastname: Heningburg
authors.affiliation: Division of Urology, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: Steven B
authors.initials: SB
authors.lastname: Brandes
mesh_terms: D000368:Aged; D015179:Colorectal Neoplasms / Q000532:radiotherapy; D017577:Cutaneous Fistula / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007049:Iatrogenic Disease; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000637:transplantation*; D010388:Pelvis; D011183:Postoperative Complications / Q000453:epidemiology*; D011471:Prostatic Neoplasms / Q000532:radiotherapy; D011788:Quality of Life; D011878:Radiotherapy / Q000009:adverse effects / Q000706:statistics & numerical data*; D019651:Plastic Surgery Procedures; D012003:Rectal Fistula / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D001749:Urinary Bladder Neoplasms / Q000532:radiotherapy; D014548:Urinary Fistula / Q000209:etiology / Q000601:surgery*; D014549:Urinary Incontinence / Q000453:epidemiology*
keywords: Fistula repair; Gracilis flap; Quality of life; Radiation; Urinary diversion