Minimally Invasive Transanal Repair of Rectourethral Fistulas

Background: Rectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk. Objective: To describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes. Design, setting, and participants: We retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5cm, sepsis, and/or faecaluria. Surgical procedure: After fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks' anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure. Measurements: Fistula closure, postoperative complications, and recurrence. Results and limitations: Median follow-up was 21 (range, 12-74) mo. Median operative time was 58 (range, 50-70) min. Median hospital stay was 1.5 (range, 1-4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas. Conclusions: MITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy. Patient summary: We studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications.