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Introduction

Rectourethral fistula (RUF) is a rare and challenging condition to manage. We report our experience to aid the management of patients who are candidates for repair with no resultant diversion (no stoma), either urinary or fecal diversion (1 stoma), or double diversion (2 stomas).

Methods

We identified patients presenting with RUF between 2005 and 2015. Demographics, follow up, RUF and surgical details, outcomes including diversion status, complications, resolution, recurrence, or persistence of RUF were collected through retrospective chart review. Suprapubic tube was considered a form of urinary diversion. Univariable and multivariable logistic regression models were used for statistical analyses.

Results

We identified 110 patients with RUF, 7 were lost to follow up early and excluded from our analyses. Median age was 63 (IQR 59-70) years. Mean follow up was 31 (IQR 6-42) months. 85 (83%) patients had RUF following PCa treatment (28 surgery alone, 10 surgery + radiation, 16 XRT + brachytherapy, 31 either type of radiation alone). In addition to these treatments, 30 had undergone secondary treatments (prostate cryotherapy, HIFU, TUNA, urethral or rectal instrumentation). The remainder were related to colorectal malignancy (9), inflammatory bowel disease (3), and other (6). 29 patients had prior failed RUF repair._x000D_ At last follow up, 53% of all 103 patients had no stoma. 17% and 12% had fecal and urinary diversion respectively, and 17% had 2 stomas. 78% had resolution while 8% had recurrence and 15% had persistence of RUF. _x000D_ 82 (80%) patients had undergone surgery for RUF repair at our institution (63 transperineal, 8 transanal, 6 abdominal, 5 cystectomy with diversion). 60% had no stoma, 15% and 17% had fecal or urinary diversion, 9% had 2 stomas. 25% of these 82 patients had complications (7 recurrences, 1 bowel anastomotic leak, 3 bowel obstruction, 1 cutaneous fistula, 1 ureteral injury, 6 infection, 2 deaths due to sepsis). Of the 75 patients with 1 or no stoma, 69 (92%) had resolution of RUF. Secondary treatments (as listed above) are associated with lower likelihood of &[Prime]no stoma&[Prime] (OR 0.28, p = 0.049)._x000D_

Conclusions

Although the rate of RUF resolution is high, patients should be counseled on the possibility of permanent diversion and carefully selected for the optimal surgical management. In our overall series, 53% patients had no stoma, 39% had 1 stoma, and 17% had 2 stomas at 31-month follow up. Those with secondary treatments are less likely to have no stoma. Careful evaluation of the rectal repair is necessary prior to takedown of fecal diversion, as most complications occurred after this maneuver.

Funding

none