Intersphincteric approach for rectourethral fistulas following radical prostatectomy

Rectourethral fistula is a challenging complication of radical retropubic prostatectomy. Several treatments have been proposed, with varying outcomes. The available data are difficult to interpret, because patient and disease characteristics differ significantly among reports. Details of long-term follow-up and functional status are rarely provided. We describe a technique of rectourethral fistula repair via an intersphincteric route.

Preoperative workup included proctoscopy and urethrocystography. All patients already had a stoma at the time of fistula repair. Mechanical cleansing of the bowel distal to the colostomy was routinely performed, and perioperative antibiotic prophylaxis was administered. Patients were placed in the lithotomy position. Under spinal anesthesia, a curvilinear anteanal incision was made, to expose the external sphincter. The anterior portion of the external sphincter was gently displaced along half of its circumference. The anterior rectal wall was sharply dissected free from the urethra, approximately up to 2 cm above the fistula level through the intersphincteric plane. The fistula was identified. The surrounding tissues were mobilized to obtain a tension-free repair of the urethral defect, using a single row of 4-0 polyglactin transverse, interrupted sutures. Transanally, a U-shaped full-thickness rectal flap was advanced and sutured with 3-0 monofilament interrupted sutures to cover the rectal opening, and care was taken to ensure that the two suture lines were in different planes. The catheter was left in place for 4 weeks. Patients were evaluated at 3-month follow-up for stoma closure.

We successfully treated five patients. Only one minor complication was observed (surgical site infection). Stomas were taken down uneventfully. After a median follow-up duration of 2 years (range 2-3 years), no patients had fistula recurrence or impaired continence.

Intersphincteric repair should be considered as an effective option in patients with iatrogenic rectourethral fistulas. This technique offers several advantages over alternative procedures that require more extensive approaches or invasive manipulation of the anal sphincters.