Outcomes of an Algorithmic, Multidisciplinary Approach to Rectourethral Fistula Repair: A Pre- and Post-Intervention Quasi-Experimental Study.
BACKGROUND: Rectourethral fistulas are a rare yet severe complication of prostate surgery, pelvic irradiation, or both. Multiple surgical repairs exist with widely varying success rates. OBJECTIVE: To present our institution's multidisciplinary algorithm for rectourethral fistula repair and its outcomes. DESIGN: This was a retrospective, pre- and post-intervention, quasi-experimental design, comparing frequency of fistula healing and reversal of urinary and fecal diversion before and after implementation of our algorithm. SETTING: All patients who presented to Duke with rectourethral fistula between 2002-2019 were included. PATIENTS: Seventy-nine patients were treated for rectourethral fistula; 36 pre-algorithm and 43 post-algorithm. INTERVENTIONS: Our multidisciplinary algorithm was implemented in 2012. Patients with fistulas <2 cm and no history of radiation underwent York-Mason repair while those with fistulas 2-3 cm or prior pelvic irradiation underwent transperineal repair with gracilis flap interposition. Those with non-repairable fistulas (>3 cm or fixed tissues) underwent pelvic exenteration. Prior to repair, the algorithm recommended all patients undergo urinary and bowel diversion. MAIN OUTCOME MEASURES: The two primary outcomes were rectourethral fistula healing, defined as both radiographic and clinical resolution, and reversal of urinary and fecal diversions. RESULTS: Frequency of fistula healing improved in the post- vs. pre-algorithm subgroups (93.1% vs. 71.9%, p = 0.04). Relative risk of fistula healing pre-intervention as compared to post-intervention was 0.77 (0.61-0.98, p = 0.04) among the overall cohort. Eighteen patients (22.8%) underwent pelvic exenteration for nonrepairable fistulas and were therefore not included in primary outcome measures. LIMITATIONS: This study's limitations include its retrospective nature, possible selection bias due to algorithmic patient selection, and a small sample size. CONCLUSIONS: Implementation of a multidisciplinary institutional algorithm improved rectourethral fistula repair success with high rates of ostomy reversal. Proper patient selection and multidisciplinary involvement are paramount to this success. See Video Abstract at http://links.lww.com/DCR/B955.
Hayden, JP; Boysen, WR; Kowalik, U; Inouye, BM; Migaly, J; Mantyh, CR; Erdmann, D; Peterson, AC
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