Algorithm-based multidisciplinary treatment approach for rectourethral fistula

Purpose: The purpose of this study is to report the outcomes of an algorithm-based multidisciplinary treatment approach to rectourethral fistula. Methods: This study is a retrospective review of a prospectively collected database at a tertiary center of all consecutive patients treated between 2003 and 2013. Results: Thirty males (mean age 63 years) were reviewed. Prostate cancer treatment was the most common fistula etiology (97 %). Urinary drainage consisted of urethral catheter in all patients and suprapubic catheter in 14 (47 %). The rate of fecal diversion was 67 %. During a mean follow-up of 72 months, healing rate was 90 % and recurrence rate 0 %. Spontaneous healing was achieved in 14 patients (47 %): 8 (27 %) without fecal diversion and 6 (20 %) following fecal diversion. Thirteen patients (43 %) required definitive intervention. The majority of operated patients underwent transanal or transperineal flap (endorectal, dartos, or gracilis) successfully. Only 2 patients (7 %) required an abdominal approach (positive oncologic margins or non-functioning bladder). Fifteen out of the 20 patients (75 %) who underwent fecal diversion had stoma closure with an overall permanent stoma rate of 17 %. Long-term urinary incontinence was noted in 11 patients (37 %). Six patients (20 %) required permanent urinary diversion or drainage catheters. Conclusions: Algorithm-based treatment approach for rectourethral fistula is useful in the management of this rare condition. Selective fecal diversion is possible, and majority of patients who require definitive intervention can be treated with a transanal or transperineal approach. The rate of permanent stoma is low, but long-term urinary dysfunction is frequent.