Keady Conor, Hechtl Daniel, Joyce Myles
Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland.
World J Gastrointest Surg. 2020 May 27;12(5):208-225. doi: 10.4240/wjgs.v12.i5.208.
Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.
胃肠道与泌尿系统之间的瘘管虽罕见，但在当前外科实践中却日益常见。它们是一组异质性的病理实体，是良性和恶性疾病的罕见并发症。随着复杂性憩室病和结直肠癌发病率的上升，胃肠道与泌尿系统之间瘘管连接的范围也随之增加。由于人口老龄化和预期寿命延长，这些复杂问题将更为常见。憩室病是最常见的病因，占病例的80%，其次是结直肠癌，占20%。为了做出诊断，需要高度的怀疑指数，不断改进的成像技术在诊断算法中发挥着重要作用。管理策略各不相同，现在大多数外科医生主张对膀胱肠瘘采用一期手术方法，特别是在择期手术中。同时进行的膀胱管理技术也存在争议。传统上，开放技术是标准方法；然而，经验的增加和手术技术的进步有助于改进腹腔镜管理。不幸的是，由于这些实体相对罕见，尚未进行随机研究以确定最合适的管理策略。随着前列腺癌非手术治疗的进展，直肠尿道瘘的发病率急剧上升。放疗是这些复杂瘘管形成的主要因素，因此最佳手术方法和暴露方式也相应改变，以优化其管理。以转流治疗形式的保守管理对于缓解病情有效，如果存在相关的粪便污染、组织浸渍或合并症，可使粪便内容物转流。可以计划在后期进行确定性手术干预。如果有适当的专业知识，污染较轻且无纤维化的病例可直接进行确定性手术。一种经腹直接修复并在修复组织间置入网膜的方法已有详细描述。对于低位瘘管，患者处于俯卧折刀位的经会阴入路可提供最佳暴露，并允许使用置入肌瓣。根据最近的文献，它在复杂病例中成功率很高。
