Complex Urinary Fistulas of the Posterior Urethra and Bladder

Abstract

The management and reconstruction of complex rectourinary and vesicoperineal fistulas are some of the most difficult problems to treat in urology. To decide on the proper management, a detailed knowledge of the fistula etiology, integrity of the anal and external urethral sphincters, functional status of the bladder, extent of rectal radiation damage, size and location of the urinary fistula, and the overall performance and nutritional status of the patient is needed. Few surgeons have had a large experience with such fistulas and this explains why there is no clear standard surgical approach. Treatment needs to be tailored to the specifics of the fistula, the etiology, and the patient. Fistulas that result from radiation therapy are more complex and difficult to reconstruct than those developing after other forms of treatment, with the frequent concomitant problems of urinary and fecal incontinence and/or urethral stricture. Small, nonradiated fistulas are successfully managed by the transanal or York-Mason approach. Complex fistulas that are large, or of radiation or cryotherapy etiology, are often best managed by primary repair, buttressed with a gracilis interposition flap, or by proctectomy and colo-anal pull through, or supravesical urinary diversion. Herein we have detailed the varying surgical methods for fistula repair as well as for salvage.