Hanna Jennifer M, Turley Ryan, Castleberry Anthony, Hopkins Thomas, Peterson Andrew C, Mantyh Christopher, Migaly John
1Department of Surgery, Section of Colon and Rectal Surgery, Duke University Medical Center, Durham, North Carolina 2Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 3Division of Urology, Duke University Medical Center, Durham, North Carolina.
Dis Colon Rectum. 2014 Sep;57(9):1105-12. doi: 10.1097/DCR.0000000000000175.
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.
To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm.
A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012.
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.
The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence.
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.
This study was limited by the small sample size and the retrospective nature of the review.
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.
直肠尿道瘘在前列腺癌治疗或创伤后虽不常见，但后果严重，其手术治疗在历史上一直未标准化。据传闻，接受过放疗的直肠尿道瘘预后较差。
回顾接受过放疗和未接受过放疗的患者直肠尿道瘘手术治疗后的结果，以构建合理的手术方案。
对1996年至2012年在杜克大学就诊并被诊断为直肠尿道瘘的所有患者进行回顾性研究。
37例患者因直肠尿道瘘就诊并接受治疗：21例接受过放疗，16例因创伤或医源性损伤出现直肠尿道瘘。
比较两组患者的功能结局，包括愈合情况、愈合时间、控尿能力及复发情况。
两组患者的特征无显著差异。接受过放疗的直肠尿道瘘患者经直肠排尿和伤口感染的发生率显著更高，晶体液输注和输血需求率更高，造口回纳时间比未接受过放疗的患者更长。接受过放疗的直肠尿道瘘患者接受更复杂的手术修复，包括股薄肌插入瓣修复（38%）和盆腔脏器清除术（19%），而未接受过放疗的患者最常接受约克-梅森修复术（50%）。直肠尿道瘘愈合情况以及术后和功能结局方面无统计学显著差异。仅55%接受过放疗的患者造口得以回纳，而未接受过放疗组为91%。
本研究受样本量小及回顾性研究性质的限制。
与非放疗引起的直肠尿道瘘相比，放疗导致的直肠尿道瘘修复术后伤口感染率显著更高、愈合中位时间更长，总体造口回纳率更低。接受过放疗的直肠尿道瘘患者需要更复杂的手术，这可能导致更高的发病率、死亡率及更低的瘘管闭合率。我们基于病因提出了一种处理直肠尿道瘘的方案。
