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Brush E, Hernandez JA, Flusché AM, Oleck NC, Naga HI, Wickenheisser V, Hayden JP, Mantyh CR, Peterson AC, Erdmann D. The Uroplastic Approach to Complex Rectourethral Fistula Repair: Indications, Technique, Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2025; 13:e6662. [PMID: 40182296 PMCID: PMC11964384 DOI: 10.1097/gox.0000000000006662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 02/03/2025] [Indexed: 04/05/2025]
Abstract
Background Rectourethral fistulae are complex pathologies with significant morbidity that warrant multidisciplinary care. Although gracilis muscle interposition for fistula repair has been reported, specific indications and techniques for this mode of reconstruction remain unclear. Methods A retrospective quasi-experimental study was previously conducted to assess outcomes of rectourethral fistula management before and after the implementation of a multidisciplinary treatment algorithm. Patients with complex rectourethral fistulae and repair with gracilis muscle flap interposition were further investigated. Plastic surgery involvement for gracilis muscle interposition was indicated for (1) radiated rectourethral fistulae less than 3 cm and (2) nonradiated rectourethral fistulae more than 2 cm. Our preferred technique for gracilis muscle flap harvest, transposition, and inset is described in detail. Primary outcomes included healing of rectourethral fistulae and secondary reversal of urinary or fecal diversions. Results Twenty-three patients with complex rectourethral fistulae underwent gracilis muscle flap interposition between 2001 and 2022 before (n = 12) and after (n = 11) algorithmic implementation. The frequency of definitive rectourethral fistula healing improved in the postalgorithm group by 33%. There was no significant difference in fistula healing time or the rate of urinary or fecal diversions after algorithm implementation. The technique of gracilis muscle flap interposition is also described. Conclusions The gracilis muscle interposition flap is a valuable reconstructive option for complex rectourethral fistula repair. Implementation of a multidisciplinary treatment algorithm including plastic surgery involvement and refinement of the operative approach was associated with improved frequency of definitive healing of rectourethral fistulae.
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Affiliation(s)
- Erin Brush
- From the Duke University School of Medicine, Durham, NC
| | - J. Andres Hernandez
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | | | - Nicholas C. Oleck
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | - Hani I. Naga
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
| | | | - Joshua P. Hayden
- Division of Urology, Lahey Hospital and Medical Center, Urology, Burlington, MA
| | | | - Andrew C. Peterson
- Department of Surgery, Division of Urologic Surgery, Duke University, Durham, NC
| | - Detlev Erdmann
- Department of Surgery, Division of Plastic Surgery, Duke University, Durham, NC
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Rinebold E, Huang AL, Hahn SJ. How to Approach the Difficult Perineum in Crohn's Disease. Clin Colon Rectal Surg 2025; 38:148-159. [PMID: 39944307 PMCID: PMC11813606 DOI: 10.1055/s-0044-1786377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2025]
Abstract
Crohn's disease (CD) is a chronic, inflammatory bowel disease with a wide range of presentations, including perianal disease. Presentation is variable, ranging from skin tags to complex fistulas, strictures, and nonhealing wounds. Symptoms of perianal CD can be devastating and may impact quality of life. Optimal management requires coordinated medical and surgical therapy. When possible, conservative treatment of perianal disease should be attempted. However, surgical treatment is often required, and some patients may ultimately require total proctocolectomy with permanent diversion due to the severity of disease. Even with close attention and treatment, disease can be recurrent, and complications of treatment are sometimes worse than the initial presentation. Novel treatments, including use of mesenchymal stem cells and autologous fat grafting, hold some promise, but are not yet widely available. Thorough knowledge of treatment options, careful patient selection, coordination between medical and surgical providers, and setting realistic expectations are important in the successful treatment of difficult perineal CD.
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Affiliation(s)
- Emily Rinebold
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Alex L. Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Sue J. Hahn
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
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Strassmann V, Silva-Alvarenga E, Emile SH, Garoufalia Z, DaSilva G, Wexner SD. Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience. Am Surg 2023; 89:6366-6369. [PMID: 37216694 DOI: 10.1177/00031348231175481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. METHODS A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. RESULTS Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. CONCLUSIONS Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.
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Affiliation(s)
- Victor Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Emanuela Silva-Alvarenga
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Cleveland Clinic Florida, Martin Health, Port St. Lucie, Florida
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Maspero M, Otero Piñeiro A, Steele SR, Hull TL. Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis. Dis Colon Rectum 2023; 66:631-645. [PMID: 36735766 DOI: 10.1097/dcr.0000000000002739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established, and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, which is the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulas, but literature on the subject is scarce, mainly consisting of small case series. OBJECTIVE This study aimed to assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula. DATA SOURCES MEDLINE, Embase, Cochrane Library, and Web of Science. STUDY SELECTION Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions was applied. INTERVENTION Gracilis muscle interposition. MAIN OUTCOME MEASURES The primary outcome is the fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, and sexual function. RESULTS Twenty studies were included for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53%-74%; range, 33%-100%). Risk factors for failure were smoking, underlying Crohn's disease, and more than 2 previous repairs, whereas stoma formation was associated with improved outcomes. Postoperative complications ranged from 0% to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, but impairment of sexual function was common. LIMITATIONS Most of the included studies were small case series. CONCLUSIONS Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent rectovaginal fistula. REGISTRATION NO CRD42022319621.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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5
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Garoufalia Z, Gefen R, Emile SH, Silva-Alvarenga E, Horesh N, Freund MR, Wexner SD. Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature. Colorectal Dis 2023; 25:549-561. [PMID: 36413086 DOI: 10.1111/codi.16427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/09/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
AIM Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF. METHOD PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data. RESULTS Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I2 = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I2 = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I2 = 61%). CONCLUSION The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.
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Affiliation(s)
- Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Emanuela Silva-Alvarenga
- Cleveland Clinic Martin Health at Tradition Health Park Two, Cleveland Clinic Florida, Port St Lucie, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantations, Sheba Medical Center, Sheba Tel Hashomer, Ramat Gan, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Schoene MI, Schatz S, Brunner M, Fuerst A. Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases. Int J Colorectal Dis 2023; 38:16. [PMID: 36652018 PMCID: PMC9849283 DOI: 10.1007/s00384-022-04293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies. METHODS A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula. RESULTS A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1). CONCLUSION Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.
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Affiliation(s)
- Milla Isabelle Schoene
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
- University of Regensburg, Regensburg, Germany
| | - Sabine Schatz
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Marion Brunner
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Alois Fuerst
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany.
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Takahashi H, Potretzke TA, Kawashima A, Cheville JC, Masuoka S, Kim B. Imaging of the Bulbourethral (Cowper) Gland: Abnormalities and Differential Diagnosis. Radiographics 2022; 42:2037-2053. [PMID: 36149823 DOI: 10.1148/rg.220099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Normal Cowper glands and ducts are imperceptible at imaging. However, abnormalities of the Cowper glands and ducts are increasingly seen owing to increasing use of cross-sectional imaging. In this article, the authors present a comprehensive review of the normal anatomy of the Cowper glands and ducts and the clinical and imaging findings of conditions that affect them in an effort to help lead to appropriate diagnosis and management. A Cowper duct syringocele is a congenital or acquired dilatation of the Cowper duct in the bulb of the corpus spongiosum. Retrograde urethrography is the standard test to diagnose a communicating (open) Cowper duct syringocele, and MRI is used for further morphologic assessment. Cowperitis refers to inflammation of the gland and/or duct, and recurrent cowperitis is usually associated with an underlying syringocele, a urethral fistulous connection to the Cowper gland, or a perianal fistula. MRI allows detection of the underlying structural abnormality and the superimposed inflammation. Cowper stones are typically radiopaque and are found in both the Cowper gland and duct. A Cowper gland HHhemorrhagic cyst may be incidentally detected at MRI of the prostate, and follow-up MRI may be required to ensure evolution of hemorrhage and exclude an underlying neoplasm. Cowper gland carcinoma is rare and includes adenocarcinoma and adenoid cystic carcinoma subtypes. Transperineal US may be used for initial evaluation and CT and/or MRI are necessary for further characterization and staging. Cowper gland hyperplasia is a rare entity with few previous reports that may be incidentally detected at imaging and may mimic malignancy. ©RSNA, 2022.
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Affiliation(s)
- Hiroaki Takahashi
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Theodora A Potretzke
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Akira Kawashima
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - John C Cheville
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Sota Masuoka
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
| | - Bohyun Kim
- From the Department of Diagnostic Radiology (H.T., T.A.P., B.K.) and Department of Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (A.K.); and Department of Diagnostic Radiology, University of Tsukuba, Tsukuba, Japan (S.M.)
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Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg 2022; 22:304. [PMID: 35933336 PMCID: PMC9357311 DOI: 10.1186/s12893-022-01755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. Methods A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. Results The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. Conclusions A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
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Affiliation(s)
- Chen Zhang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsen Bi
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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10
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Singh P, Kumar S, Panaiyadiyan S, Singh P, Dogra P, Seth A. Repair of Rectourethral Fistula Using Gracilis Muscle Flap Interposition—a Tertiary Care Center Experience. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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11
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Kazi MK, Gori J, Engineer R, Ankathi SKK, Bhuta P, Patel S, Sukumar V, Desouza A, Saklani AP. Incidence and Treatment Outcomes of Rectovaginal Fistula After Rectal Cancer Resection. Female Pelvic Med Reconstr Surg 2022; 28:115-120. [PMID: 35084372 DOI: 10.1097/spv.0000000000001063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rectovaginal fistulas (RVFs) are an uncommon and disturbing complication with limited success in treatment. This study was aimed at determining the incidence of RVFs after rectal resections in the era of neoadjuvant radiation therapy and the outcomes of their treatment. METHODS This was a retrospective study of female patients who underwent sphincter-preserving total mesorectal excision for rectal cancer and developed RVF. RESULTS Four hundred eighty-eight patients underwent rectal resections between January 2013 and December 2019, and 9 developed RVF (1.8%). Average time to presentation was 280 days (range, 6-540 days). The median time to onset for those presenting prior to stoma reversal was 90 days, whereas the duration between stoma reversal and RVF detection in those presenting after stoma closures was 115 days. Success rates of fecal diversion and local procedures for treatment of RVF were 20% (2/10 procedures) and 40% (2/5 procedures), respectively. Redo coloanal anastomosis was performed for 2 patients with successful outcome. An average of 2.1 procedures were performed per patient (19/9) with a per-procedure success rate of 31.6% (6/19 procedures) and a per-patient success rate of 66.7% (6/9). At median follow-up of 64 months, 50% (3/6) of patients with a healed fistula were free of stoma, and all of them were continent. Four patients were sexually active. CONCLUSIONS The incidence of RVF after rectal resection is low, but treatment outcomes are disappointing. Diversions and local repairs had high failure rates in our patients where the majority received preoperative radiation therapy. After successful healing, sexual function and continence are acceptable.
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Affiliation(s)
| | - Jayesh Gori
- From the Departments of Colorectal Surgical Oncology
| | | | | | - Prajesh Bhuta
- Department of Colorectal Surgery, Jaslok Hospital, Mumbai, Maharashtra, India
| | - Swapnil Patel
- From the Departments of Colorectal Surgical Oncology
| | - Vivek Sukumar
- From the Departments of Colorectal Surgical Oncology
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12
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Meyer J, Ris F, Parkes M, Davies J. Rectovaginal Fistula in Crohn's Disease: When and How to Operate? Clin Colon Rectal Surg 2022; 35:10-20. [PMID: 35069026 PMCID: PMC8763467 DOI: 10.1055/s-0041-1740029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rectovaginal fistula (RVF) occurring during the course of Crohn's disease (CD) constitutes a therapeutic challenge and is characterized by a high rate of recurrence. To optimize the outcome of CD-related RVF repair, the best conditions for correct healing should be obtained. Remission of CD should be achieved with no active proctitis, the perianal CD activity should be minimized, and local septic complications should be controlled. The objective of surgical repair is to close the fistula tract with minimal recurrence and functional disturbance. Several therapeutic strategies exist and the approach should be tailored to the anatomy of the RVF and the quality of the local supporting tissues. Herein, we review the medical and surgical management of CD-related RVF.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
- Medical School, University of Geneva, Genève, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
- Medical School, University of Geneva, Genève, Switzerland
| | - Miles Parkes
- Division of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Gracilis Muscle Interposition for Treatment of Complex Anal Fistula: Experience With 119 Consecutive Patients. Dis Colon Rectum 2021; 64:881-887. [PMID: 33833143 DOI: 10.1097/dcr.0000000000001964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects. OBJECTIVE This study aims to report the results of gracilis muscle interposition for complex anal fistula, including prognostic factors for success. DESIGN This is a retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula from 2000 to 2018. SETTING Patient demographics, operative data, and postoperative outcome were obtained from medical records. Office visits were used for follow-up. PATIENTS All patients who underwent gracilis muscle interposition for complex anal fistula were included. Patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded. MAIN OUTCOME MEASURES The primary outcome measured was the healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed. RESULTS A total of 119 patients (60 men, 59 women; median age: 56 (21-85) years) were included. The initial success rate of gracilis muscle interposition was 42%; the final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in women and 51.6% in men. Univariate analysis revealed that sex (p = 0.0315) and bed rest >3 days (p = 0.0078) were significant poor prognostic factors for failure, whereas the multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, whereas in the male population there was no significant prognostic factor. LIMITATION This study was limited by its retrospective nature and the heterogeneity of patients. CONCLUSION Although initial success is <50%, the ultimate success after gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counseled that additional procedures will probably be required to achieve successful fistula closure. Furthermore, prolonged bed rest should be avoided after gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551. INTERPOSICIN DEL MSCULO GRACILIS PARA EL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA EXPERIENCIA CON PACIENTES CONSECUTIVOS ANTECEDENTES:El tratamiento de la fístula anal compleja es un desafío que a menudo requiere de múltiples procedimientos quirúrgicos. El músculo gracilis se ha utilizado para tratar fístulas y reparar defectos perineales.OBJETIVO:Informar los resultados de la interposición del músculo gracilis para la fístula anal compleja, incluyendo los factores pronósticos para un tratamiento exitoso.DISEÑO:Se efectuó un análisis retrospectivo obtenido de una base de datos prospectiva para pacientes sometidos a interposición del músculo gracilis por fístula anal compleja del 2000 al 2018.METODO:Los datos demográficos de los pacientes, la información del procedimiento quirúrgico y los resultados postoperatorios se obtuvieron de los expedientes clínicos; el seguimiento se llevó a cabo por medio de visitas al consultorio.PACIENTES:Se incluyeron todos los pacientes sometidos a interposición del músculo gracilis por fístula anal compleja; Se excluyeron los pacientes que se sometieron a interposición del músculo gracilis por motivos distintos a la fístula anal compleja.CRITERIOS DE EVALUACION DE LOS RESULTADOS:Curación de una fístula anal compleja después de la interposición del músculo gracilis y procedimientos adicionales, cuando fueron necesarios.RESULTADOS:Se estudiaron un total de 119 pacientes [60 hombres, 59 mujeres; con media de edad de 56 (21-85) años]. La tasa de éxito inicial de la interposición del músculo gracilis fue del 42%; La tasa de éxito final cuando realizaron procedimientos adicionales fue del 92%. La tasa de éxito global fue del 32,2% en mujeres y del 51,6% en hombres. El análisis univariado reveló que el género (p = 0,0315) y el reposo en cama > 3 días (p = 0,0078) en forma significativa fueron factores de pronóstico bajo para el fracaso, mientras que el modelo de regresión logística multivariable mostró que la duración del reposo en cama> 3 días fue un factor de pronóstico significativamente bajo para fracaso. En el subgrupo de mujeres, el análisis multivariado mostró que el reposo en cama ≥3 días fue un factor de pronóstico significativamente bajo, mientras que en la población masculina no hubo un factor pronóstico significativo.LIMITACIÓN:Carácter retrospectivo y heterogenicidad de los pacientes.CONCLUSIÓN:Aunque el éxito inicial es <50%, el éxito final después de la interposición del músculo gracilis y otros procedimientos posteriores es > 90%. Se debe aconsejar a los pacientes antes de la operación que probablemente se requieran procedimientos adicionales para lograr el cierre exitoso de la fístula. Además, debe evitarse el reposo prolongado en cama después de la interposición del músculo gracilis. Consulte Video Resumen en http://links.lww.com/DCR/B551.
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Britto C, Pfalzgraf D, Lima R, Medeiros P, Rebouças R, Passerotti C. Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair. Urol Int 2021; 105:1123-1127. [PMID: 34120106 DOI: 10.1159/000515614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/28/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. METHOD We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. RESULTS Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. DISCUSSION The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. CONCLUSION Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.
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Affiliation(s)
- Cesar Britto
- Hospital Universitário Onofre Lopes, UFRN, Natal, Brazil
| | - Daniel Pfalzgraf
- University Medical Mannheim, Mannheim, Germany.,Heilig Geist Hospital Bensheim, Bensheim, Germany
| | | | - Paulo Medeiros
- Hospital Universitário Onofre Lopes, UFRN, Natal, Brazil
| | - Rafael Rebouças
- Hospital da Policia Militar Edson Ramalho, João Pessoa, Brazil.,Universidade de João Pessoa, UNIPE, João Pessoa, Brazil
| | - Carlo Passerotti
- Laboratório de Investigação Médica-Urologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, Centro de Cirurgia Robótica, São Paulo, Brazil
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Abstract
INTRODUCTION Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. METHODS A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. RESULTS Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. CONCLUSIONS Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.
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Grott M, Rickert A, Hetjens S, Kienle P. Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period. Int J Colorectal Dis 2021; 36:569-580. [PMID: 33386945 DOI: 10.1007/s00384-020-03825-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term. METHODS This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function. RESULTS Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months). CONCLUSION GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.
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Affiliation(s)
- M Grott
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University, Röntgenstraße 1, 69126, Heidelberg, Germany
| | - A Rickert
- Department of Surgery, St. Josefskrankenhaus Heidelberg, Akademisches Lehrkrankenhaus der Medizinischen Fakultät Mannheim der Universität Heidelberg, Landhausstraße 25, 69115, Heidelberg, Germany
| | - S Hetjens
- Department for Medical Statistics and Biomathematics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Akademisches Lehrkrankenhaus der Universität Heidelberg, Heidelberg University, Bassermannstraße 1, 68165, Mannheim, Germany.
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Kanehira E, Tanida T, Kanehira AK, Takahashi K, Obana Y, Iwasaki M, Sagawa K. A New Technique to Repair Vesicorectal Fistula: Overlapping Rectal Muscle Plasty by Transanal Endoscopic Surgery. Urol Int 2021; 105:309-315. [PMID: 33429395 DOI: 10.1159/000512379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate clinical results of a novel surgical technique, we developed to repair vesicorectal fistula (VRF) occurring after prostatectomy, hospital records of the patients, who underwent the new surgical treatment, were assessed. METHODS The novel surgical technique is called "overlapping rectal muscle plasty," which is performed under transanal endoscopic microsurgery (TEM). During the new procedure, a complete fistulectomy was first performed, and then the proper muscle layer of the rectum was folded, overlapped, and sutured to create a thick wall between the rectum and urinary bladder. This operation was carried out in 15 patients with VRF following radical prostatectomy. RESULTS The operation was safely performed in all patients with an average time of 127.2 min. Fistula was corrected in 13 patients (86.7%), who were then freed from both urinary and intestinal diversions. CONCLUSIONS Overlapping rectal muscle plasty by TEM is a safe procedure. The success rate seems to be acceptable in selected patients. This new repair method may be considered as a minimally invasive option in the surgical treatment of VRF after prostatectomy.
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Affiliation(s)
- Eiji Kanehira
- Department of Surgery, Medical Topia Soka, Soka City, Japan,
| | - Takashi Tanida
- Department of Surgery, Medical Topia Soka, Soka City, Japan
| | | | | | - Yuichi Obana
- Department of Surgery, Medical Topia Soka, Soka City, Japan
| | | | - Koji Sagawa
- Department of Urology, Medical Topia Soka, Soka City, Japan
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Incarbone GP, Palmisano F, Lorusso V, Granata AM, Romanò ALL, Marchesotti F, Ranzoni S, Gregori A. Repair of a rectovesical fistula following laparoscopic radical prostatectomy with Martius fat pad flap interposition: a proposal of a new technique. Turk J Urol 2021; 47:81-85. [PMID: 33112733 PMCID: PMC7815234 DOI: 10.5152/tud.2020.20356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
Rectovesical fistula (RVF) is defined as an abnormal communication between the rectum and the urinary bladder, most commonly after an iatrogenic injury during pelvic surgery. Patients with RVF may have various clinical presentations, ranging from fecaluria, pneumaturia, to urine leakage through the anus. The quality of life for patients with this pathology is adversely affected owing to the associated psychological burden. Surgery is the preferred treatment given the low success rates reported for conservative or minimally invasive approaches. Herein, we present a case of a 65-year-old man with RVF after radical prostatectomy successfully treated by a transperineal approach using a modified Martius procedure.
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Affiliation(s)
- Giacomo Piero Incarbone
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Franco Palmisano
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Vito Lorusso
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Antonio Maria Granata
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Ai Ling Loredana Romanò
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Federica Marchesotti
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Stefania Ranzoni
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Andrea Gregori
- Department of Urology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
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Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas. Eur Urol Focus 2020; 6:762-769. [PMID: 31402242 DOI: 10.1016/j.euf.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/04/2019] [Accepted: 07/25/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rectourethral fistulas (RUFs) are rare but devastating complications after surgery or radiation therapy to the urethra, prostate, or rectum. RUF repair is challenging, especially in irradiated patients. OBJECTIVE To evaluate the efficacy of the York Mason (YM) procedure with or without concomitant gracilis muscle interposition (graciloplasty) for RUF repair. DESIGN, SETTING, AND PARTICIPANTS Records of patients with an iatrogenic RUF who underwent the YM procedure between 2008 and 2018 in two university hospitals were reviewed. Data on etiology, diagnostic and operative procedures, urinary and fecal diversion, and postoperative follow-up were collected. INTERVENTION Twenty-eight patients underwent 33 YM procedures. Concomitant graciloplasty was performed in four (14%) primary repairs and two (7%) repairs for recurrent RUFs. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was successful RUF repair, defined as absence of symptoms and no leakage on control urethrocystography. The secondary endpoint was colostomy reversal rate. RESULTS AND LIMITATIONS Median follow-up was 24 mo. Ten patients (36%) were irradiated previously. The ultimate success rate was 75% after a maximum of three YM procedures. Success rates were 89% and 50% in patients with nonirradiated and irradiated fistulas, respectively. In irradiated patients, the success rates of the first YM procedure with and without graciloplasty were 100% and 29%, respectively. In recurrent cases, concomitant graciloplasty did not result in better outcomes. Colostomy reversal was possible in 15 patients after successful repair. In all patients, fecal continence was intact and no anal stenosis was reported. Limitations of the study include small sample size and the retrospective design. CONCLUSIONS Combination of the YM procedure with graciloplasty resulted in higher success rates of RUF repair in patients with irradiated fistulas. Fecal continence was preserved, and colostomy reversal is feasible. PATIENT SUMMARY We analyzed the outcomes, complications, and colostomy reversal rate of the York Mason procedure for the repair of rectourethral fistulas (RUFs). We found that concomitant graciloplasty increases success rates in case of prior radiation therapy. Colostomy reversal is feasible after RUF repair.
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Gilshtein H, Strassman V, Wexner SD. Redo gracilis interposition for complex perineal fistulas. Tech Coloproctol 2020; 24:475-478. [PMID: 32215768 DOI: 10.1007/s10151-020-02185-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Rectovaginal, pouch-vaginal, and recto-urethral fistulas are very challenging to treat. Gracilis muscle interposition was shown be an effective treatment for these complex fistulas. The aim of this study was to investigate the feasibility and outcomes of redo gracilis interposition for persistent and recurrent complex perineal fistulas. METHODS A retrospective analysis of all patients who had redo gracilis muscle interposition for complex perineal fistulas at our institution from 1995 to 2019 was performed. RESULTS Nine patients (5 males, mean age 55 years) were included for analysis. The types of fistulas were recto-urethral (n = 5), rectovaginal (n = 2) and pouch-vaginal (n = 2). The success rate was 56% with 5 patients achieving complete healing of the fistula. Only 1 patient (11%) experienced a postoperative complication. CONCLUSIONS Redo gracilis muscle interposition is feasible and safe with promising resultsin healing of complex perineal fistula.
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Affiliation(s)
- H Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - V Strassman
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Kersting S, Athanasiadis CJ, Jung KP, Berg E. Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas. Colorectal Dis 2019; 21:1429-1437. [PMID: 31245912 DOI: 10.1111/codi.14741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/10/2019] [Indexed: 12/12/2022]
Abstract
AIM Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients. METHOD The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination. RESULTS The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction. CONCLUSION GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.
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Affiliation(s)
- S Kersting
- Department of General Surgery, Katharinen-Hospital Unna, Unna, Germany
| | - C-J Athanasiadis
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
| | - K-P Jung
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
| | - E Berg
- Department of Coloproctology, Prosper-Hospital Recklinghausen, Recklinghausen, Germany
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Gracilis muscle transposition for treatment of recurrent anovaginal, rectovaginal, rectourethral, and pouch-vaginal fistulas in patients with inflammatory bowel disease. Tech Coloproctol 2019; 23:43-52. [PMID: 30604248 PMCID: PMC6656797 DOI: 10.1007/s10151-018-1918-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 12/17/2018] [Indexed: 12/22/2022]
Abstract
Background The aim of this study was to evaluate the effectiveness of gracilis muscle transposition (GMT) to treat recurrent anovaginal, rectovaginal, rectourethral, and pouch–vaginal fistulas in patients with inflammatory bowel disease (IBD). Methods A retrospective study was conducted in patients with IBD who had GMT performed by a single surgeon between 2000 and 2018. Follow-up data regarding healing rate, complications, additional procedures, and stoma closure rate was collected. Results A total of 30 women and 2 men had GMT. In all patients fistula was associated with Crohn's disease. In 1 female patient, contralateral gracilis transposition was required after a failed attempt at repair. The primary healing rate was 47% (15/32) and the definitive healing rate (healed by the time of data collection and after secondary procedures) was 71% (23/32). Additional surgical procedures due to fistula persistence or recurrence were performed on 17 patients (53%).At least 7 patients (21%) suffered complications including one wound infection with ischemia of the gracilis muscle. Stoma closure was successful in 18 of 31 cases of patients with stoma (58% of the patients). Conclusions GMT for the treatment of recurrent and complex anorectal fistulas in patients with IBD patient is eventually successful in almost 2/3 of patients.
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Mid term functional results following surgical treatment of recto-urinary fistulas postprostate cancer treatment. Prog Urol 2018; 28:915-920. [PMID: 30213561 DOI: 10.1016/j.purol.2018.07.286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 07/19/2018] [Accepted: 07/30/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION To evaluate the mid term functional results of patients treated for RUF and to determine an optimal treatment strategy to improve their quality of life. Recto-urinary Fistula (RUF) is a rare complication following prostate cancer treatment, and can have a major impact on patients' quality of life. There is a lack of consensus concerning the best approach and different techniques have been proposed: endoscopic, transrectal, perineal and transperitoneal (open, laparoscopic or robotic). MATERIALS AND METHODS We retrospectively reviewed the charts of patients who underwent RUF repair from January 2001 to December 2010 at our Institute. 16 patients who developed RUF following prostate cancer treatment were included in the study. The fistula had to be confirmed both clinically and by imaging. All patients had follow up consultation every 3 month for the first year and then annually. They were asked to fill questionnaires evaluating functional outcomes. The International Continence Society (ICS) score was used to assess the postoperative urinary continence. Fecal continence was evaluated with the Wexner score and sexual function was assessed with the International Index for erectile function (IIEF-5) score. RESULTS Eighty-seven percent patients (14/16) in our series developed RUF as a consequence of prostate cancer surgery and 13% (2/16) postbrachytherapy (BT). All patients initially had a diversion colostomy and a supra pubic catheter. 69% (11/16) underwent primary YM repair and 73% (8/11) were successful. 2/3 primary failures were successfully retreated with graciloplasty. Primary gracilis flap interposition (GFI), on 3 non-irradiated patients were successful (100%). Primary GFI postbrachytherapy, no patient had recover urinary and digestive continuity. In total primary GIF was successful in 60% (3/5). Over all long term, success rate with a urinary and digestive continuity and without recurrence of the fistula was 81% (13/16). Mid term functional results were evaluated at mean follow up of 40 months (14-92). 13% (2/16) achieved complete urinary continence, 48% (7/16) required single pad, 25% (4/16) developed major incontinence, 7% (1/16) required urinary diversion and 13% (2/16) developed complete urethral closure post BT requiring permanent suprapubic catheterization. Colostomy was reversed in 93% (15/16) cases. 75% (12/16) achieved complete faecal continence, minor incontinence (wexner score 3-4) was seen in 13% (2/16) and major incontinence (wexner score 14) in 7% (1/16) and 7% (1/16) required a long term colostomy. 19% (3/16) developed colostomy related complications. Only 13% (2/16) achieved adequate erections with the use of intra cavernosal prostaglandin injections. CONCLUSIONS RUF following prostate cancer treatment is a serious complication with severe repercussion on patients' quality of life. Surgical repair with the York Mason technique or Gracilis Flap interposition is associated with good success rates. If available pediculed gracilis muscle should be used as it offers better success rates. LEVEL OF EVIDENCE 3.
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Rottoli M, Vallicelli C, Boschi L, Cipriani R, Poggioli G. Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study. Updates Surg 2018; 70:485-490. [DOI: 10.1007/s13304-018-0558-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/30/2018] [Indexed: 01/11/2023]
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Park SO, Hong KY, Park KJ, Chang H, Shin JY, Jeong SY. Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up. Int J Colorectal Dis 2017; 32:1029-1032. [PMID: 28210852 DOI: 10.1007/s00384-017-2784-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Rectovaginal fistulas are difficult to treat completely, especially when patients present with a history of multiple surgeries and radiation therapy. We aimed to evaluate the efficacy of gracilis muscle flap transposition to treat rectovaginal fistula. METHODS We performed a retrospective chart review of all gracilis muscle transposition cases and other procedures between January 2009 and July 2016. RESULTS Total 53 cases were reviewed. A total of 11 patients underwent gracilis muscle flap transposition for rectovaginal fistula repair, with 8 patients showing good results without recurrence (total success rate, 72.7%). Comparison of this patient group with patients who had undergone other surgical procedures for rectovaginal fistula repair showed that those who received a gracilis transposition flap had significantly higher average number of previous surgeries (2.18 ± 1.17 vs. 1.1 ± 1.25) and had previously undergone radiotherapy at a significantly higher rate (63.6 vs. 26.2%). Furthermore, none of our patients complained of donor site discomfort. CONCLUSIONS Based on these results, we recommend using the gracilis muscle flap for rectovaginal fistula repair in cases where there is a history of radiotherapy and had surgical failure more than twice.
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Affiliation(s)
- Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyo Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jin Yong Shin
- Department of Plastic and Reconstructive Surgery, Medical School of Chonbuk National University, Jeonju, South Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Abstract
Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.
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Affiliation(s)
- Mahmoud Abu Gazala
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
| | - Steven D Wexner
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
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Jai S, Ganpule A, Singh A, Vijaykumar M, Bopaiah V, Sabnis R, Desai M. Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula. F1000Res 2017; 5:2891. [PMID: 28299181 PMCID: PMC5310386 DOI: 10.12688/f1000research.10245.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 11/29/2022] Open
Abstract
High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni
et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the “first chance is the best chance”.
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Affiliation(s)
- Shrikant Jai
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Arvind Ganpule
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Abhishek Singh
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | | | - Vinod Bopaiah
- Staten Island University Hospital, Staten Island, USA
| | - Ravindra Sabnis
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
| | - Mahesh Desai
- Dept. of Urology, Muljibhaipatel Urological Hospital, Gujarat, India
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Singh M, Kinsley S, Huang A, Ricci JA, Clancy TE, Irani J, Goldberg J, Breen E, Bleday R, Talbot SG. Gracilis Flap Reconstruction of the Perineum: An Outcomes Analysis. J Am Coll Surg 2016; 223:602-10. [DOI: 10.1016/j.jamcollsurg.2016.06.383] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/16/2016] [Accepted: 06/23/2016] [Indexed: 11/15/2022]
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Abstract
Rectovaginal fistulae are abnormal epithelialized connections between the rectum and vagina. Fistulae from the anorectal region to the posterior vagina are truly best characterized as anovaginal or very low rectovaginal fistulae. True rectovaginal fistulae are less common and result from inflammatory bowel disease, trauma, or iatrogenic injury. A very few patients are asymptomatic, but the symptoms of rectovaginal fistula are incredibly distressing and unacceptable. Diagnostic approach, timing, and choice of surgical intervention, including sphincteroplasty, gracilis flaps, Martius flaps, and special circumstances are discussed.
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Affiliation(s)
- Bidhan Das
- Division of Colon and Rectal Surgery, Department of Surgery, University of Texas-Houston, Houston, Texas
| | - Michael Snyder
- Department of Surgery, University of Texas-Houston, Houston, Texas
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Hokenstad ED, Hammoudeh ZS, Tran NV, Chua HK, Occhino JA. Rectovaginal fistula repair using a gracilis muscle flap. Int Urogynecol J 2016; 27:965-7. [PMID: 26811111 DOI: 10.1007/s00192-015-2942-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/18/2015] [Indexed: 01/18/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula. METHODS We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient's prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula. CONCLUSION Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.
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Affiliation(s)
- Erik D Hokenstad
- Division of Gynecologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Ziyad S Hammoudeh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nho V Tran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Heidi K Chua
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - John A Occhino
- Division of Gynecologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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Subhas G, Alva S, Longo WE. Re-operative surgery for genitourinary fistulae to the colorectum. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Falavolti C, Sergi F, Shehu E, Buscarini M. York Mason procedure to repair iatrogenic rectourinary fistula: our experience. World J Surg 2015; 37:2950-5. [PMID: 24045963 DOI: 10.1007/s00268-013-2199-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. METHODS We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. RESULTS In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. CONCLUSIONS The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.
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Affiliation(s)
- Cristina Falavolti
- Department of Urology, Campus Bio-Medico University of Rome, Rome, Italy,
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[Surgical treatment of rectourinary fistulas: review of the literature]. Urologia 2015; 82:30-5. [PMID: 25744705 DOI: 10.5301/uro.5000111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation, or trauma. Retrospective studies and case reports have highlighted different approaches for surgical repair. OBJECTIVE The aim of this study was to review our experience with surgical management of RUF. DATA SOURCES MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms RUFs urethrorectal fistulas, and prostatourethral-rectal fistulas. STUDY SELECTION All studies were retrospective and in English. Of the records identified, 31 series were included. RESULTS Four hundred sixty-five patients were identified. Most patients underwent one of four categories of repair: transanal (4.7%), transabdominal (14.1%), transsphincteric (26.6%), and transperineal (57.6%). Tissue interposition flaps, predominantly gracilis muscle, were used in 56% of repairs. The fistula was successfully closed in 93.9% of patients. CONCLUSIONS Regardless of complexity, RUFs have an initial closure rate of 93.9%.
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Hotouras A, Ribas Y, Zakeri S, Murphy J, Bhan C, Chan CL. Gracilis muscle interposition for rectovaginal and anovaginal fistula repair: a systematic literature review. Colorectal Dis 2015; 17:104-10. [PMID: 25284745 DOI: 10.1111/codi.12791] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 07/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Repair of rectovaginal fistula (RVF) is associated with high recurrence. For this reason gracilis muscle interposition is increasingly being used. AIM To evaluate the efficacy of this procedure for RVF repair. METHOD/SEARCH STRATEGY A search of PubMed and Medline databases was performed in November 2013 using the text terms and MESH headings 'rectovaginal fistula/fistulation', and 'gracilis muscle', spanning 1980-2013. The search strategy was restricted to articles written in English with available abstracts. Sample size, aetiology of RVF, previous repair attempts, follow-up period, healing rates and complications were recorded and analysed. RESULTS Seventeen studies involving 106 patients were analysed. The cause of RVF included inflammatory bowel disease (n = 37 [34.9%]: Crohn's disease [34], ulcerative colitis [3]), pelvic surgery (37 [34.9%]), obstetric injury (9 [8.5%]), malignancy (7 [6.6%]), trauma (5 [4.7%]), miscellaneous (idiopathic, endometriosis, radiation: 11 [10.4%]). Patients had undergone a median number of two previous unsuccessful repairs. At a median follow-up of 21 months, healing had occurred in 33-100% (median 100%) with the largest studies reporting rates between 60% and 90%. Thirteen studies did not report any complications, with the remainder reporting only minor morbidity. CONCLUSION Gracilis interposition appears to have a reasonable success rate for RVF repair with acceptable morbidity. It may be considered as one of the first-line treatment options for recurrent RVF.
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Affiliation(s)
- A Hotouras
- Academic Surgical Unit, Barts Health NHS Trust, Queen Mary University of London, London, UK
| | - Y Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain
| | - S Zakeri
- Department of Colorectal Surgery, Whittington Health NHS Trust, London, UK
| | - J Murphy
- Academic Surgical Unit, Barts Health NHS Trust, Queen Mary University of London, London, UK
| | - C Bhan
- Department of Colorectal Surgery, Whittington Health NHS Trust, London, UK
| | - C L Chan
- Academic Surgical Unit, Barts Health NHS Trust, Queen Mary University of London, London, UK
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Abstract
BACKGROUND Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis. OBJECTIVE To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm. DESIGN AND SETTING A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012. PATIENTS Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16. MAIN OUTCOME MEASURES The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence. RESULTS There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group. LIMITATIONS This study was limited by the small sample size and the retrospective nature of the review. CONCLUSIONS Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.
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Amin K, Dempsey M, Ghali S, Grobbelaar A. Saving grace: distally pedicled gracilis muscular flap in lower limb salvage. BMJ Case Rep 2014; 2014:bcr-2014-205486. [PMID: 25085952 DOI: 10.1136/bcr-2014-205486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.
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Affiliation(s)
- Kavit Amin
- Plastic & Reconstructive Surgery Department, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Marlese Dempsey
- Plastic & Reconstructive Surgery Department, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Shadi Ghali
- Plastic & Reconstructive Surgery Department, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Adriaan Grobbelaar
- Plastic & Reconstructive Surgery Department, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, UK
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40
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Takano S, Boutros M, Wexner SD. Gracilis Muscle Transposition for Complex Perineal Fistulas and Sinuses: A Systematic Literature Review of Surgical Outcomes. J Am Coll Surg 2014; 219:313-23. [DOI: 10.1016/j.jamcollsurg.2014.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/15/2014] [Indexed: 02/07/2023]
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Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO. The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study. Dis Colon Rectum 2014; 57:888-98. [PMID: 24901691 DOI: 10.1097/dcr.0000000000000147] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear. OBJECTIVE A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas. DATA SOURCES Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles. STUDY SELECTION Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results. INTERVENTION(S) Any surgical intervention for the closure of rectovaginal fistulas was included. MAIN OUTCOME MEASURES The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning. RESULTS Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable. LIMITATIONS The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis. CONCLUSIONS No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.
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Affiliation(s)
- Kevin W Göttgens
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
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Abstract
BACKGROUND Rectourethral fistula is a rare but significant complication that often requires operative intervention. OBJECTIVE A new perineal approach using the medial aspect of the puborectalis muscles as a double-breasted rotational interposition flap to repair the rectourethral fistula is hereby described. PROCEDURE With the patient in a modified Lloyd-Davies position, a vertical midline incision from the base of the scrotum to 2 cm anterior to the anal verge is made. The dissection continues along the anterior rectal wall through the Denonvilliers fascia until the rectourethral fistula is reached. The dissection through the fused Denonvilliers fascia continues a further 1 to 2 cm above the fistula. The openings in the rectum and the urethra are then closed vertically (urethra) and horizontally (rectum) with interrupted 3/0 and 4/0 polyglactin sutures. The puborectalis muscles are then mobilized as a 1-cm strip bilaterally and released posteriorly at the level of the anorectum. The 2 strips of the puborectalis muscles are then rotated medially and superiorly along its anterior attachments, forming a double -breasted overlapping flap overlying the fistula openings. The flaps are anchored into the superior and contralateral aspect of the surgical field with the use of 2/0 polyglactin sutures. RESULTS From November 2011 to December 2012, 4 patients underwent this procedure. No perioperative complications, including those related to the harvesting of the puborectalis muscles, were identified. Subsequent radiological studies confirmed the success of the procedure. After a median follow-up of 8 (6-18) months, 3 patients had their colostomy reversed and remained continent, whereas the last patient had a permanent ileostomy. None of the patients reported any urinary leakage through the perineum. CONCLUSIONS The double-breasted puborectalis interposition flap is an alternative transperineal procedure in the management of rectourethral fistula. It avoids a laparotomy and is rectum sparing.
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Affiliation(s)
- Michael J Solomon
- 1Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia 2Surgical Outcomes Research Centre (SOuRCe), Central Sydney Area Health Service, Sydney, New South Wales, Australia 3University of Sydney, Sydney, New South Wales, Australia 4Department of Urology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Beddy D, Poskus T, Umbreit E, Larson DW, Elliott DS, Dozois EJ. Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula. Colorectal Dis 2013; 15:1515-1520. [PMID: 23841640 DOI: 10.1111/codi.12350] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 05/20/2013] [Indexed: 02/08/2023]
Abstract
AIM Most patients presenting with rectourethral fistula acquire it as a complication of radiotherapy for prostate cancer, as a result of injury to the rectum during prostatectomy, through trauma or from Crohn's disease. This study examined whether choice of operation and results of surgery for rectourethral fistula are influenced by prior radiotherapy. METHOD Male patients undergoing surgery for rectourethral fistula were identified from a prospectively maintained database. Data regarding aetiology, surgical treatment and outcomes were analysed. RESULTS Fifty patients (median age = 65.5 years) were identified. Radiation was received by 29 patients for prostate or rectal cancer, and 21 patients developed a fistula following prostatectomy, Crohn's disease or pelvic fracture (without radiation). Prior to definitive surgery, 30 patients underwent fecal diversion and 37 underwent urinary diversion. In total, 57 repairs were performed (44 patients had one repair, five patients had two and one patient had three). Definitive surgery was approached predominantly abdominally in radiated patients (90.6 vs 9.3%, P < 0.001) and perineally in nonradiated patients (80 vs 20%, P < 0.001). Successful primary fistula repair was more frequent in the nonradiated group compared with the radiated group (80.9 vs 0%, P < 0.001). Permanent colostomy and urinary diversion were more often required in radiated patients than in nonradiated patients (colostomy: 83 vs 0%, P < 0.001; urorostomy: 100 vs 19%, P < 0.001). CONCLUSION Few patients with radiation-induced rectourethral fistula avoid permanent colostomy and urostomy. In contrast, most patients with nonradiation-related fistulae undergo successful perineal repair without permanent faecal and urinary diversion.
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Affiliation(s)
- D Beddy
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Pfalzgraf D, Isbarn H, Reiss P, Meyer-Moldenhauer WH, Fisch M, Dahlem R. Outcomes after recto-anastomosis fistula repair in patients who underwent radical prostatectomy for prostate cancer. BJU Int 2013; 113:568-73. [PMID: 24053507 DOI: 10.1111/bju.12254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To assess fistula recurrence rate and health-related quality of life (HRQL) after repair, as well as the impact on continence and erection in patients with recto-anastomotic fistula after radical prostatectomy (RP). In recent publications, the numbers of cases of recto-urinary fistulae after RP are relatively small. Success rates at fistula closure are good; however, data about functional outcomes and HRQL are more restricted. PATIENTS AND METHODS A retrospective study of patients treated for recto-urethral fistulae after RP between 1993 and 2008. All 17 patients were assessed for fistula recurrence in 2007 and received a standardised non-validated questionnaire to assess HRQL in 2011; furthermore, a patient's chart review was performed. SURGICAL TECHNIQUE fistula closure was abdominal in 10 patients, perineal in five and combined abdominal and perineal in two, some with tissue interposition. RESULTS In 2007, follow-up was available for 14 patients, one was deceased and two were lost to follow-up. The mean follow-up was 73.3 months and the mean patient age was 63 years. In two of the 17 patients, rectal injury during the initial surgery was reported; another three had undergone adjuvant radiation therapy (18%). In 2011, another two patients were deceased; the mean (range) follow-up was 99.5 (44-184) months. There was a great improvement in HRQL as compared with before surgery in seven of the 12 evaluable patients, a slight improvement in one and no change in three. In all, eight of the 12 patients were very satisfied with the surgery and four were satisfied. CONCLUSION Perineal or abdominal fistula repair yields excellent success rates and high patient satisfaction. However, urinary incontinence can be found in some patients postoperatively, requiring further treatment.
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Affiliation(s)
- Daniel Pfalzgraf
- Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Chen XB, Wang YX, Jiang H, Liao DX, Yu JH, Luo CH. Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas. World J Gastroenterol 2013; 19:6625-6629. [PMID: 24151391 PMCID: PMC3801378 DOI: 10.3748/wjg.v19.i39.6625] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/16/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas (RVFs) and rectourethral fistulas (RUFs).
METHODS: Between May 2009 and March 2012, 11 female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled. Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage. Efficacy was assessed in terms of the success rate and surgical complications. SF-36 quality of life (QOL) scores and Wexner fecal incontinence scores were compared before and after surgery.
RESULTS: The fistulas healed in 14 patients after gracilis muscle transposition; the initial healing rate was 73.7%. Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5 patients: 4 healed and 1 failed, and postoperative fecal diversions were performed for the patient whose treatment failed. At a median follow-up of 17 mo, the overall healing rate was 94.7%. Postoperative complications occurred in 4 cases. Significant improvement was observed in the quality outcomes framework scores (P < 0.001) and Wexner fecal incontinence scores (P = 0.002) after the successful healing of complex RVFs or RUFs. There was no significant difference in SF-36 QOL scores between the initial healing group and irrigation-suction-assisted healing group.
CONCLUSION: Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs. QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.
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Hwang JH, Kang MH, Lee YT, Park DS, Lee SR. Clinical factors that predict successful posterior urethral anastomosis with a gracilis muscle flap. Korean J Urol 2013; 54:710-4. [PMID: 24175047 PMCID: PMC3806997 DOI: 10.4111/kju.2013.54.10.710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/31/2013] [Indexed: 12/03/2022] Open
Abstract
Purpose We evaluated the preoperative clinical factors that affect the surgical outcome of posterior urethral anastomosis (PUA) with a gracilis muscle flap (GMF) to determine which factors predict benefit from the use of the GMF. Materials and Methods This was a retrospective analysis of 49 patients who underwent a delayed PUA with a GMF. A successful clinical outcome was defined as achieving a peak urinary flow rate greater than 15 mL/s at 3 and 12 months postoperatively without evidence of stricture recurrence on a retrograde urethrogram or cystourethroscopy at 3 months postoperatively. Multiple clinical factors were evaluated by use of univariate and multivariate analyses. Results The outcome of 21 of 49 patients (42.9%) was deemed successful. The mean age of the 49 patients was 37.2±13.5 years and the mean follow-up duration was 43.4±28.0 months. The length of the urethral defect was significantly shorter in patients with a successful outcome than in patients with an unsuccessful outcome (p=0.010). The outcome differed significantly depending on whether the patients had a previously successful urethroplasty (p=0.036) or whether they had suffered a pelvic bone injury (p=0.012). Multivariate logistic regression analyses revealed that a previous urethroplasty was the only preoperative clinical factor that significantly affected the surgical outcome in PUA with a GMF (odds ratio, 0.218; 95% confidence interval, 0.050 to 0.947; p=0.042). Conclusions A history of previous urethroplasty is a preoperative clinical factor that significantly affects the surgical outcome in PUA with a GMF; the procedure is more likely to be successful in patients who have not previously undergone urethroplasty.
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Affiliation(s)
- Jin Ho Hwang
- Department of Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Kaoutzanis C, Pannucci C, Sherick D. Use of gracilis muscle as a “walking” flap for repair of a rectovaginal fistula. J Plast Reconstr Aesthet Surg 2013; 66:e197-200. [DOI: 10.1016/j.bjps.2013.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/01/2013] [Indexed: 11/26/2022]
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Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes. Dis Colon Rectum 2013; 56:374-83. [PMID: 23392154 DOI: 10.1097/dcr.0b013e318274dc87] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rectourethral fistulas are uncommon. Retrospective studies and case reports have highlighted various approaches for surgical repair. Because clinical presentations and technical expertise vary widely, no single procedure has been universally adopted. OBJECTIVE We sought to qualitatively analyze studies describing surgical techniques and outcomes in adult acquired rectourethral fistulas to outline universal approaches for evaluation and management. DATA SOURCES MEDLINE (PubMed, Ovid) and the Cochrane Library were searched by using the terms rectourethral fistulas, recto-urethral fistulas, urethrorectal fistulas, and prostatourethral-rectal fistulas. STUDY SELECTION All studies were retrospective, in English, and reported at least 4 cases. Any series with >50% congenital cases or <50% adults (19+ years) was excluded. Of the 569 records identified, 26 articles were included. INTERVENTION The intervention was surgical repair of rectourethral fistula. MAIN OUTCOME MEASURES The main outcome measures were successful fistula closure, fistula recurrence or persistence, and permanent fecal and/or urinary diversion. RESULTS Four hundred sixteen patients were identified, including 169 (40%) who had previous pelvic irradiation and/or ablation. Most patients (90%) underwent 1 of 4 categories of repair: transanal (5.9%), transabdominal (12.5%), transsphincteric (15.7%), and transperineal (65.9%). Tissue interposition flaps, predominantly gracilis muscle, were used in 72% of repairs. The fistula was successfully closed in 87.5%. Overall permanent fecal and/or urinary diversion rates were 10.6% and 8.3%. Most high-volume centers (≥25 patients) performed transperineal repairs with tissue flaps in 100% of cases. LIMITATIONS This review was limited by the heterogeneity of repairs and bias toward preferred surgical approaches in single-center studies. CONCLUSIONS Regardless of complexity, rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems.
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Evaluation and Management of Rectourethral Fistula Following Radiation Treatment for Prostate Cancer. CURRENT BLADDER DYSFUNCTION REPORTS 2012. [DOI: 10.1007/s11884-012-0154-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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