Transperineal repair of persistent rectourethral fistulas using a porcine dermal
patch as interposition tissue: preliminary experience
Aims of the study: We aimed to describe, for the first time, the technique and results of
persistent rectourethral fistula (RUF) repair through a perineal approach using a porcine
dermal patch as interposition tissue.
Material & Methods: With the patient placed in the lithotomy position, a cystoscopy is
performed and the ureters are stented. The fistulous tract is stented to facilitate
recognition. The lithotomy position is exaggerated. An inverted U-shaped perineal incision
is made outside the anus and inside the ischial tuberosities. The subcutaneous tissue is
divided and the central tendon of the perineum transected, thus opening the ischiorectal
fossae and exposing the ventral rectal wall. The scarring between the urethra, the bladder
and the anterior rectal wall is dissected sharply and the fistulous tract, with the stent
passing through it, is identified. The fistula is excised at the level of the rectal wall with
the surrounding scarred tissue to create vital margins. The anterior rectal wall is closed in
two layers, using continuous 5-0 monofilament sutures. The bladder defect is repaired
with interrupted 3/0 suture. A porcine dermal patch is positioned to cover the defect and
sutured to the rectal wall ( Figure 1).
Results: Two patients with history of recurrent RUF after RP were treated with the
technique described at our institution. Mean patients’ age was 68.7 years. Patients had
history of previous transurethral resection of the prostate. All patients had undergone a
first attempt of trans-abdominal repair of the RUF and had a colonstomy. Operative time
was 105.6 minutes (range: 90-120). Mean intra-operative blood loss was 98.7mL (range:
80-110). No intra-operative complications occurred. A cystogram performed on postoperative day 15 excluded pathologic urinary leakages in all cases. The ureteral catheters
were removed 4 weeks after surgery and the bladder catheter was removed 2 weeks
later. No early- and late post-operative complications occurred. Re-establishment of
intestinal continuity was achieved after a mean of 6.5 months. No fistula recurrence
occurred at a mean follow-up of 1.1 years.
Discussion:
RUF is a rare major complication after radical prostatectomy (RP). Management of
persistent RUF that have failed previous attempts at repair is technically challenging. The
perineal approach provides good exposure of the surgical field. The use of interposition
flaps has been reported to enhance fistula healing and prevent fistula recurrence.
However, the use of autologous patchs is technically challenging and time consuming.
Previous studies have demonstrated favorable results, technical simplicity, safety and
efficacy of using a porcine dermal collagen patch as interposition tissue for
vesicovaginal fistula repair.
Conclusions: According to our initial experience, transperineal repair of persistent RUF
with porcine dermal patch interposition
is a simple, efficacious and safe procedure.
Figure1: Pre-operative, intraoperative and post-operative details