Login to Access Video or Poster Abstract: MP79-07
Sources of Funding: none

Introduction

Recto-urinary fistula (RUF) is a rare complication following pelvic surgery, radiation or trauma. We report our experience using a perineal approach with a cremasteric myocutaneous interposition flap (CIF) for the treatment of symptomatic RUF and sought to compare their outcomes with patients undergoing repair with other interpositions. _x000D_ _x000D_ _x000D_

Methods

We identified all patients undergoing RUF repair at a single institution from January 2001 to June 2014. Demographics, fistula etiology, surgical approach and outcomes were reviewed. Successful RUF repair was defined based on a post-operative voiding cystourethrogram without evidence of contrast extravasation.

Results

26 patients underwent RUF repair by a single surgeon at our institution. All patients underwent colonic diversion prior to repair. Initial repair was performed at the median age of 63 (21-83) years using a cremasteric interposition flap (CIF) in 12 patients, gracilis interposition flap (GIF) in 13 and a rectus myocutaneos flap (RMF) in one. Median follow-up was 8.8 (1-44) months. Fistulas were categorized as complex where radiation therapy, salvage cryoablation or APR was performed (69.2%), and simple when they occurred in the setting of radical prostatectomy, hemorrhoidectomy or trauma (30.8%). Pre-repair hyperbaric oxygen was performed in 57.7% of patients and was not associated with improved success in initial closure for either complex or simple fistulas (p=0.16, 0.69). In the CIF group, 9 (75%) patients failed the initial repair with 2 subsequently undergoing successful second CIF, 4 with successful subsequent GIF and 2 lost to follow-up. One patient failed a repeat CIF. The majority of patients (88%) who failed initial repair with CIF had radiation-induced fistulas, whereas only 33% of patients with a successful initial repair had prior radiation exposure (p=0.12). In the GIF group, 11(84.6%) had successful repair with initial surgery. Initial repair of simple fistulas was more successful than complex fistulas (p=0.04). The use of GIF or rectus myocutaneous flap resulted in improved success in complex fistula repair as compared to CIF (p=0.004). There was no difference seen in success of simple fistula repair when comparing GIF and CIF (p=0.17).

Conclusions

Perineal repair of RUF using CIF is a novel approach with potentially less morbidity than larger muscle interposition flaps. However, the CIF is less effective in complex fistulas and thus should only be considered in patients with simple fistulas. For complex fistulas, a more vascularized flap such as GIF or rectus myocutaneous flap is effective.

Funding

none