Management of acquired rectourinary fistulas: outcome according to cause

Acquired rectourinary fistulas, an infrequent complication of pelvic conditions, remain a therapeutic problem for which neither a widely accepted classification nor long-term outcome data are available. This study was designed to provide a new etiologic classification system and examine the success of various surgical therapies. It also looked at the need for permanent fecal or urinary diversion or radical excision depending on the cause of the fistula, i.e., benign vs. malignancy-related.

A retrospective analysis was made of 41 patients treated for acquired rectourinary fistulas between 1980 and 1995. Acquired rectourinary fistulas were classified as 1) benign but caused by Crohn's disease, trauma, perirectal sepsis, or iatrogenic injury; and 2) malignancy-related fistulas secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects. Surgical interventions were classified as repair, excision, fecal diversion, and urinary diversion.

Thirty-seven males and 4 females with acquired rectourinary fistula were identified with a mean age of 62 (range, 28-90) years. Nineteen patients had fistulas involving their urethras, and 22 patients had fistulas involving the bladder. Eight patients were not treated surgically; one was not treated because of an advanced malignancy, three because of patient preference, three because of sepsis, and one because of a poor general condition. Of the remaining 33 patients, nine had benign fistulas of which two were the result of Crohn's disease, two were the result of trauma, two were from an iatrogenic response, and three were from perirectal sepsis. Twenty-four patients had malignancy-related fistulas, and five patients had neoplasm at their fistula sites. The remaining 19 patients had malignancy-related fistulas that were the result of cancer treatments. Of the 19 malignancy-related fistulas, 5 were from radiation, 9 were from surgical trauma, and 5 were from radiation and surgical trauma. Forty-nine percent of the patients had undergone attempts at fistula treatment before referral. A resolution of symptoms after initial and reoperative surgery occurred more often in patients with benign fistulas (44 and 100 percent; mean, 1.8 surgeries per patient) compared with malignancy-related fistulas (21 and 88 percent; mean, 2.1 surgeries per patient). The rates of permanent fecal, urinary, and fecal plus urinary diversion were also lower for benign fistulas (11, 0, and 33 percent) compared with malignancy-related fistulas (13, 8, and 54 percent). Permanent diversion was avoided in 56 percent of the benign fistulas but in only 25 percent of the malignancy-related fistulas. The rates of excisional and radical (ileal conduit) surgery were lower for benign fistulas than for malignancy-related fistulas (44 and 11 percent vs. 50 and 54 percent).

Successful management of rectourinary fistulas typically requires aggressive reoperative therapy with permanent diversion more often required for malignancy-related fistulas. Better outcomes can be anticipated for benign fistulas.