Presentation Authors: Urszula Kowalik*, Brian Inouye, Stephanie Sexton, Brian Gilmore, Durham, NC, Arman Kahokehr, Adelaide, Australia, Andrew Peterson, Christopher Mantyh, John Migaly, Durham, NC
Introduction: Recto-urethral fistulas are a devastating complication after treatment for prostate and rectal cancers and especially in radiated patients. These fistulas seldom spontaneously resolve and often require fecal and urinary diversion and surgical repair for the best chance of healing. Despite reports of excellent outcomes in the short term, often these repairs do not translate into ostomy reversal rates and long-term data is lacking. Anecdotally, we had experience with several patients presenting with delayed recurrence after a successful repair and hypothesized that the success rate of the fistula repair in the short-term does not always predict long-term success of the repair.
Methods: We performed a review of a prospective database of patients undergoing recto-urethral fistula repair from 2002 to 2017. Of the 65 patients in the database, 19 underwent repair of their fistula using a gracilis interposition flap. Half of the patients had a history of radiation therapy for either prostate or rectal cancer treatment and per our algorithm all had undergone urinary and bowel diversion prior to or at the time of repair.
Results: Of the 9 patients without a history of radiation, there was a 100% success rate of repair. Of the radiated group, 3/10 patients failed initial repair. Two more patients in the radiated group recurred in a delayed fashion after ostomy reversal (4.3 and 5.3 yrs after repair). Two of the five failures/recurrences had a repeat repair using a gracilis flap, one underwent pelvic exenteration, one was managed with permanent diversion and the last continued with a minimally symptomatic fistula without further intervention. Ostomy reversal rates were lower than objective success rates with 70% of the group undergoing reversal of their bowel diversion after fistula repair (excluding the 2 patients with rectal cancer not eligible for reversal).
Conclusions: Rectourethral fistulas can be difficult to repair. In our series, at an average follow-up of 45 months (median 61 months), initial success was 84% in our group (100% for the non-radiated and 70% for the radiated group). We have been successful in restoring continuity of bowel function to the majority of patients. In the long-term, we observed a 28% recurrence rate in the radiated group. Despite rigorous patient selection, failure and recurrence of rectourethral fistula remains significant. Even in light of initial successful repair, long-term follow-up of these patients is paramount as there can be delayed recurrence, especially in patients with a history of radiation.