Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas

Purpose We evaluate the impact of pelvic radiation and ablative therapy on the surgical repair of rectourethral fistula. Materials and Methods A total of 45 patients with rectourethral fistulas were identified from a prospective database. From 1998 to 2010 a total of 49 surgical reconstructive procedures were performed. Fistula formation was secondary to radiation (brachytherapy, external beam radiation) and ablative therapy (cryotherapy or high intensity focused ultrasound) in 29 patients. The approach for surgical repair and clinical outcomes were analyzed to identify the impact of radiation and ablative therapy on successful fistula repair. Results Median patient age was 68 years and mean followup was 42 months (IQR 7, 71). A primary repair was more frequently attempted (15 of 16 [94%] vs 6 of 29 [21%], p <0.0001) and successful in nonradiation/ablation cases (13 of 15 [87%] vs 1 of 6 [17%], p = 0.003). Patients with prior radiation/ablation were significantly more likely to require permanent colostomy (25 of 29 [86%] vs 0%, p <0.0001) and permanent urinary diversion as part of fistula management (27 of 29 [93%] vs 1 of 16 [6%], p <0.0001). Of the 6 patients with radiation/ablation induced fistula who underwent primary repair, 4 subsequently required urinary diversion for fistula recurrence, 1 is symptomatic with recurrence and 1 (who presented with a 0.5 cm fistula) has had no evidence of fistula recurrence. Conclusions Unlike the repair of a rectourethral fistula after surgical intervention, which is typically amenable to primary repair, most patients with severe radiation and ablation induced fistula will require urinary diversion with or without permanent colostomy. Thus, permanent urinary diversion should be considered early in the surgical management of these cases.