surgical treatment of recto-urinary fistulas postprostate cancer treatment

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ORIGINAL ARTICLE

Mid term functional results following

surgical treatment of recto-urinary fistulas postprostate cancer treatment

Résultats à moyen terme des patients traités d’une fistule recto-urétrale après prise en charge d’un cancer de prostate

P.-E. Theveniaud

, N. Zafar

, A. El Hajj

,

A. Germain

, L. Brunaud

, P. Eschwege

, J. Hubert

, L. Bresler

aServiced’urologie,universitéHenri-PoincarédeLorraine,CHUNancy-Brabois,ruedu Morvan,54500Vandoeuvre-lès-Nancy,France

bDepartmentofUrology,RoyalDerbyHospital,Derby,UnitedKingdom

cDivisionofUrology,AmericanUniversityofBeirut,Lebanon

dServicedechirurgieviscérale,UniversitéHenri-PoincarédeLorraine,CHUNancy-Brabois, 54500Vandoeuvre-lès-Nancy,France

Received11December2017;accepted30July2018 Availableonline11September2018

KEYWORDS Qualityoflife;

YorkMason;

Graciloplastie;

Prostatecancer;

Recto-uretralfistula

Summary

Introduction.—ToevaluatethemidtermfunctionalresultsofpatientstreatedforRUFandto determineanoptimaltreatmentstrategytoimprovetheirqualityoflife.Recto-urinaryFistula (RUF)isararecomplicationfollowingprostatecancertreatment,andcanhaveamajorimpact onpatients’ qualityoflife.There isalack ofconsensusconcerning thebestapproach and differenttechniqueshavebeenproposed:endoscopic,transrectal,perinealandtransperitoneal (open,laparoscopicorrobotic).

Materialsandmethods.—Weretrospectivelyreviewedthechartsofpatientswhounderwent RUFrepairfromJanuary2001toDecember2010atourInstitute.16patientswhodevelopedRUF followingprostatecancertreatmentwereincludedinthestudy.Thefistulahadtobeconfirmed bothclinicallyandbyimaging.Allpatientshadfollowupconsultationevery3monthforthefirst yearandthenannually.Theywereaskedtofillquestionnairesevaluatingfunctionaloutcomes.

TheInternationalContinenceSociety(ICS)scorewasusedtoassessthepostoperativeurinary continence.Fecal continencewasevaluatedwiththeWexnerscoreandsexualfunctionwas assessedwiththeInternationalIndexforerectilefunction(IIEF-5)score.

∗Correspondingauthor.

E-mailaddresses:tpe018@gmail.com(P.-E.Theveniaud),maan814@hotmail.com(N.Zafar),alberthajj@gmail.com(A.E.Hajj), a.germain@chu-nancy.fr(A.Germain),l.brunaud@chu-nancy.fr(L.Brunaud),p.eschwege@chu-nancy.fr(P.Eschwege),

j.hubert@chu-nancy.fr(J.Hubert),l.bresler@chu-nancy.fr(L.Bresler).

https://doi.org/10.1016/j.purol.2018.07.286 1166-7087/©2018PublishedbyElsevierMassonSAS.

Results.—Eighty-sevenpercentpatients(14/16)inourseriesdevelopedRUFasaconsequence ofprostatecancersurgeryand13%(2/16)postbrachytherapy(BT).Allpatientsinitiallyhada diversioncolostomyandasuprapubiccatheter.69%(11/16)underwentprimaryYMrepairand 73%(8/11)weresuccessful.2/3primaryfailuresweresuccessfullyretreatedwithgraciloplasty.

Primarygracilisflapinterposition(GFI),on3non-irradiatedpatientsweresuccessful(100%).

PrimaryGFIpostbrachytherapy,nopatienthadrecoverurinaryanddigestivecontinuity.Intotal primaryGIFwassuccessfulin60%(3/5).Overalllongterm,successratewithaurinaryand digestivecontinuityandwithoutrecurrenceofthefistulawas81%(13/16).Midtermfunctional resultswereevaluatedatmeanfollowupof40months(14—92).13%(2/16)achievedcomplete urinarycontinence,48%(7/16)requiredsinglepad,25%(4/16)developedmajorincontinence, 7%(1/16)requiredurinarydiversionand13%(2/16)developedcompleteurethralclosurepost BTrequiringpermanentsuprapubic catheterization.Colostomywas reversedin93%(15/16) cases.75%(12/16)achievedcompletefaecal continence,minorincontinence(wexner score 3—4)wasseenin13%(2/16)andmajorincontinence(wexnerscore14)in7%(1/16)and7%

(1/16)requiredalongtermcolostomy.19%(3/16)developedcolostomyrelatedcomplications.

Only13%(2/16)achievedadequateerectionswiththeuseofintracavernosal prostaglandin injections.

Conclusions.—RUFfollowingprostatecancertreatmentisaseriouscomplicationwithsevere repercussiononpatients’qualityoflife.SurgicalrepairwiththeYorkMasontechniqueorGracilis Flapinterpositionisassociatedwithgoodsuccessrates.Ifavailablepediculedgracilismuscle shouldbeusedasitoffersbettersuccessrates.

Levelofevidence.— 3.

©2018PublishedbyElsevierMassonSAS.

MOTSCLÉS Qualitédevie; YorkMason; Graciloplastie; Cancerdeprostate; Fistulerecto-urétrale

Résumé

Introduction.—Évaluerlesrésultatsfonctionnelsàmoyentermedespatientstraitéspourune fistulerecto-urétraleetdéterminerunestratégiedetraitementoptimalepouraméliorerleur qualitédevie.Lafistulerecto-uréthrale(FRU)estunecomplicationraremaisfréquemmentcon- sécutiveautraitementducancerdelaprostateetpeutavoirunimpactmajeursurlaqualitéde viedespatients.Iln’yapasdeconsensusconcernantlameilleureapprocheetdifférentestech- niquesontétéproposées:endoscopique,transrectale,périnéaleettrans-péritonéale(ouverte, laparoscopiqueourobotique).

Matérielsetméthodes.—Nousavonsrevurétrospectivementlesdossiersdespatientsquiont subiuneréparationduFRUdejanvier2001àdécembre2010dansnotreinstitut.Seizepatients qui ont développé FRU après le traitement du cancer de la prostate ont été inclus dans l’étude.Lafistuledevaitêtreconfirméecliniquementetparimagerie. Touslespatientsont euuneconsultationdesuivitousles3moispendantlapremièreannéepuistouslesans.On leurademandé deremplir desquestionnairesévaluant lesrésultats fonctionnels.Le score del’International ContinenceSociety(ICS)aétéutilisé pourévaluerla continenceurinaire postopératoire.LacontinencefécaleaétéévaluéeaveclescoredeWexneretlafonctionsex- uelleaétéévaluéeaveclescoredel’indiceinternationaldelafonctionérectile(IIEF-5).Le critèrederéussiteàlongtermeétaitjugéparunrétablissementdelacontinuitéurinaireet digestivesansrécidivedelafistule.

Résultats.—Quatre-vingt-septpourcentdespatients(14/16)denotresérieontdéveloppéle FRUàlasuited’unechirurgieducancerdelaprostateet13%(2/16)aprèslacuriethérapie (BT).Touslespatientsavaientinitialementunecolostomieetuncathétersus-pubien.Onze patientsontbénéficiéenpremièreintentiond’unYork-Mason(YM).Le tauxdesuccèsaété de73%(8/11).Lagraciloplastie(GP)enpremièreintentiondespatientsnonirradiésaétéun succèspourles3patients(100%).Lespatientspostcuriethérapieprostatique,ontbénéficié d’unegraciloplastiepremière,l’unconserveuncystocathéteretl’autreunedoubledérivation urinaireetdigestive(0%desuccès).Autotal60%desgraciloplastiespremières(3/5)ontpermis unefermeturedelafistule.Les deuxtiersdeséchecsprimaires d’YMontétéretraitésavec succèspargraciloplastie(66%).Letauxderéussitedansnotreétudeétaitde81%(13/16).

Les résultatsfonctionnels àmoyen terme ont étéévaluésavec un suivimoyen de 40 mois (14—92).13%(2/16)ontobtenuunecontinenceurinairecomplète,48%(7/16)ontnécessité

uneprotectionunique,25%(4/16)ontdéveloppéuneincontinencemajeure,7%(1/16)une dérivationurinaireestrequiseet13%(2/16)ontdéveloppéunesténoseurétralecomplètepost- curiethérapienécessitantuncathétérismesuspubienpermanent.Lacolostomieaétéinversée dans93%(15/16)descas.75%(12/16)ontobtenuunecontinencecomplètedesselles,une incontinencemineure(scoredeWexner3—4) chez13%(2/16)etuneincontinencemajeure (scoredeWexner14)chez7%(1/16)ainsique7%(1/16)anécessitéunecolostomieàlong terme.19 %(3/16) ontdéveloppédes complicationsliéesà lacolostomie. Seulement 13% (2/16)ontdesérectionsavecl’utilisationd’injectionsintracaverneusesdeprostaglandines.

Conclusion.—LesFRUfaisantsuiteàuntraitementducancerdelaprostateestunecompli- cation graveavecdesrépercussionsgraves surlaqualité deviedespatients.Laréparation chirurgicaleaveclatechniquedeYorkMasonoul’interpositiondemusclegracilisestassociée àdebonstauxderéussite.Siilestdisponible,lemusclegracilispédiculédoitêtreutilisécar iloffreunmeilleurtauxderéussite.

Niveaudepreuve.— 3.

©2018Publi´eparElsevierMassonSAS.

Introduction

Recto-urinaryFistula(RUF)isararecomplicationfollowing prostate cancer treatment, and can have a majorimpact onpatients’qualityoflife.ThereportedincidenceofRUF following brachytherapy (BT) in older series[1] has been reported to be 1%, however in recently published series its incidence has been reported to be 0.32% [2]. Symp- toms following brachytherapy can develop up to 3 years and, therefore, a longer follow up is required [3]. Of all fistula’s post radiotherapy 37% are postbrachytherapy, 20% post External beam Radiotherapy (EBRT) and 43% in combination of BT andEBRT [4].Primary-HIFU may cause recto-urethral fistulas and the risk is even greater when HIFUisusedtotreatprostatecancerrecurrence.Theinci- denceofthesepost-HIFUtreatmentfistulasarenotedtobe increasing[5,6].TheincidenceofrectalInjuryduringradical prostatectomyrangesfrom11%inolderseries[7]to0.34%

inrecentseries[8].Thereisalackofconsensusconcerning thebestapproachanddifferenttechniqueshavebeenpro- posedincludingendoscopic,transrectal,perinealandtrans peritoneal(open,laparoscopicorrobotic).TheYork-Mason (YM)posterior transsphincterictechnique[9]isusedsince itallowseasy andrapidaccesstotheanteriorrectalwall withminimalcomplications.Tissueinterpositionbyseveral typesofflapsorbioprosthesishasalsobeendescribedaspri- marytreatmentorinthemanagementofrelapsefollowing YMTheseincludegracilis[10],dartos[11]andevenbuccal mucosa[12] Regardless ofthe typeof surgical technique, thereportedsuccess rates aregood,however, theimpact of reconstruction onsexual function and continence (uri- naryandFecal)hasrarelybeenaddressed.Wedescribeour experienceof treatingRUFandtheimpactonUrinaryand digestiveQualityoflife.

Material and Method

Weretrospectivelyreviewedthechartsofourpatientswho underwentRUFrepairfromJanuary2001toDecember2010.

16 patientswhodeveloped RUFfollowing prostate cancer

treatmentwereidentified.Thefistulawasconfirmedboth clinicallyandbyimaginginallcases.Allpatientshadfol- lowup consultationevery 3month for the firstyear then annuallyandfilledquestionnairesevaluatingfunctionalout- comes.TheInternationalContinenceSociety(ICS)scorewas usedto assess the postoperativeurinary continence [13].

FecalcontinencewasevaluatedwiththeWexnerscore[14]

(Supplementary data,TableS1).Sexualfunctionwaseval- uated using the International Index for Erectile Function (IIEF-5)[15].

Results

Atotalof16 patientswithameanageof 66(57—73)had RUFfollowing treatment for prostate cancer. In 14cases, RUFwasdiagnosed5.8days(1—21)followingradicalprosta- tectomy,6of which wereopen retro-pubic(RRP) andthe remaining8werelaparoscopicprostatectomy(LRP).In2of the8patientswhounderwentLRPaconversiontoanopen approachwasnecessary duetotechnicaldifficulties.Four patientshadrectalinjurydiagnosedandtreatedintraoper- ativelyandanimmediatecolostomywasperformedin2of thosepatients.

Inpostiodine125brachytherapytreatment,RUFoccurred in2ofourpatientsat26monthsfollowingseedimplanta- tion.In one patientthe fistula appeared following biopsy ofanteriorrectalwallulceration.Thesecond patientpre- sented with rectal bleeding and underwent hyperbaric oxygentherapyfor2monthwithoutimprovement.

All patients diagnosed with RUF had a colostomy for fecaldiversion,inourserie.Conservativemanagementwas attemptedforameantimeof9months(3—20)beforethe surgicaltreatmentoftheRUFwasperformed.(Table1).

Theposteriortrans-sphinctericYMtechniquewasthepri- mary treatment in 11 patients. The 5 remaining patients includingthetwobrachytherapypatients,hadperinealGra- cilisflaptransposition(GFI).(Table1).

The YM technique was successful in 8 patients (73%), while relapse of the fistula occurred in 3 patients within ameanof32days(5—81).

Table1 PatientscharacteristicsandWexnerscore.

Treatment Numberofdaysbetween prostatecancertreatment anddiagnosticofRUF

First intervention

Second intervention

Wexner score

1 BT 672 GFI^a 0

2 BT 883 GFI^a Fecaldiversion

3 ORP 4 GFI 0

4 ORP 5 GFI 4

5 ORP 6 YM 0

6 ORP 2 GFI 0

7 ORP 42 YM 0

8 LRP 19 YM^a GFI^a 0

9 LRP 19 YM 0

10 LRP 8 YM 0

11 LRPcO 3 YM 3

12 LRP 6 YM 0

13 ORP 5 YM^a GFI 14

14 LRP 1 YM^a GFI 0

15 LRP 6 YM 0

16 LRPcO 8 YM 0

BT:brachytherapy;GFI:Graciloplastyflapinterposition;YM:YorkMason;ORP:openradicalprostatectomy;LRPcO:laparoscopicradical prostatectomyconversiontoopen.

aFailureofsurgicaltreatment.

GracilisPrimary GFIonnon-irradiatedpatientwassuc- cessful in 3 patients (100%). Complication (grade IIIB Clavien)occurredinthetwobrachytherapypatients.Early flap necrosis occurred in one patient while the second patienthadaperiprostatic abscessanddevelopedavesic- ocutaneous fistula one year following surgery. Surgical drainage of the abscess allowed healing of the vesicocu- taneous fistula, there was no RUF relapse but he had a suprapubic catheter.These 2patients were considered as afailure of surgical repair (0%). In total primaryGFI was successfulin3cases(60%).

Gracilis flap interposition was also performed in the 3 patients that relapsed following YM. RUF healing was obtainedin2ofthe3patients(66%).Onepatientpresented with a urinary peritonitis that required urinary diversion withbilateralureterostomies.TheRUFsubsequentlyhealed after2yearsoffecalandurinarydiversion.Inthispatient, thecolostomywasclosed,howevertheurinarydiversionwas leftinplace.

In total, 13 of the 16 patients had successful surgical repair of their fistula (81%) with a urinary and digestive continuityandwithoutrecurrenceofthefistula.Therewas no significant difference in mean hospital stay for both techniques (9.3 days for YM vs. 10.2 days for GFI). Mean bladdercatheterizationtimefromthetimeofthediagno- sistothehealingoftheRUFwas11monthfor13patients.

Midtermfunctionalresultswereevaluatedwithameanfol- low up of 40 months (14—92). The mean catheterization time(diagnosis to fistulaclosure n=13 pts) was 338 days (11months).

Major incontinence requiring urinary sphincter was present in 4 patients, this was although not performed, 7 patients had mild incontinence requiring a single pad per day, and 2 patients regained complete continence. 2

patients required long term suprapubic catheter drainage forcompleteurethralstenosisfollowingbrachytherapy.One patientrequired urinary diversionwith bilateralureteros- tomies.

Closureofthecolostomywaspossibleinallpatientsafter ameandiversiontimeof15months(3—46).Fistulareacti- vationandfecalincontinenceoccurredinonepatientafter colostomyclosure,andthusrequireddefinitivefecaldiver- sion. Parastomal hernia repair with mesh placement was requiredin3patients.

Twopatientshadminorfecalincontinence(Wexnerscore 3and4)while12patientswerecompletelycontinent.One patienthadseverefecalincontinence(Wexner14) follow- ingclosureofthecolostomy.Onepatientrequireddefinitive fecaldiversion.(Table1).

Noneofthepatientscomplainedofrectalstenosisorwas noticedondigitalrectalexamination.

Sexualfunctionassessmentrevealedthatonly2patients regained sexual activity andpotency withintracavernosal prostaglandineE1injections.

Discussion

Fecal continence/issues with colostomy

Manysmallcaseserieshavebeenpublishedintheliterature, these publications describe different surgical techniques and outcomes. Recently Pfalzgraf et al. [16] studied the impactofRUFrepaironsexualandurinarycontinencebut our study to our knowledge is the only study specifically addressingtheissueoffaecalcontinenceaswell.

Colostomy performed after the diagnosis of RUF has a majorimpact onpatient’s qualityof life and is asubject

ofdebatewhen managingthesepatientssincethereisno consensusintheliteratureabouttheneedforit.20ofthe36 patientsinWexneretal.series[17],andhalfthepatientsin Kasraeianseries[18]hadacolostomy(Table1).Inourstudy allpatientshadacolostomyfollowingdiagnosisofRUF.When these3studiesarecomparedwefindsimilarhealingtimes andcomplicationsrates.Furthermore3ofourpatients(20%) hadcolostomyrelatedcomplicationi.e.parastomalhernia that requiredsurgical repair withmesh placement.Based onthese findings, it can be argued that the colostomyis notadeterminingfactorforRUFhealingandpreventionof infections.

The latest publishedresults fromHadley etal. (2012) [19]whichincludeoutcomesfrom27morecasescompared totheirseriespublishedin2003(n=24)showsimilarresults (93%vs.91%success rate).Intheirlatest seriesonly7/27 hadboweldiversionpreoperativelywithidenticalsuccess rates.

IntheseriesofWexner,Ulrich[10],andVanni[20]almost all patients underwent bowel diversion preoperatively. In theseriesfromVannithough,thedecisiontoperformbowel diversion was made at the time of fistula surgery. Vanni etal. also divided hiscases between Irradiated and non- irradiatedgroup and found thatmost failures occurredin theirradiatedgroup.Hannaetal.[21]intheirseriesof37 patientsdescribedfailuretoreversecolostomytobe45%in Irradiatedgroup,comparedtoonly9%inthenon-irradiated group.

Accordingtothemainseries,theincidenceofanalsteno- sisandfecalincontinencefollowinggracilisinterpositionor York Mason repair is reportedto bevery low.In the York Masontechnique,analsphincteriscutwithoutmorbidity,as shownbyKasraeianetal.[18],whoachieved100%success ratesevenwithredoYMrepairsasnoneofthe12patients theytreated with YM repair developed any fecal inconti- nenceoranalstenosis.

Irradiated pelvis appears a poor prognosticmarker for reversalofboweldiversionas50%patientsinourseriesand 33%inVanni’sseriespostradiotherapyhadlongtermbowel diversion after RUF fistula repair. As we know, no series hadevaluatedanalcontinenceusingtheWexnerScore.Our study found 20% (3/15) postoperative minor anal inconti- nencewhichisnotnegligible.

Hechenbleikner [22] et al recently published a review articleinwhich416patientswereidentified,including169 (40%)whohadprevious pelvicirradiationand/orablation.

Mostpatients(90%)underwent1of4categoriesofrepair:

transanal(5.9%), transabdominal(12.5%), transsphincteric (15.7%), and transperineal (65.9%). Tissue interposition flaps, predominantly gracilismuscle, wereused in 72%of repairs.Thefistulawassuccessfullyclosedin87.5%.Overall permanentfecaland/orurinarydiversionrateswere10.6%

and8.3%.

Forselectedpatients withoutassociatedcomorbidities, absenceof sepsisand anon-irradiated field,boweldiver- sioncanbeavoidedthusavoidingatleasttwounnecessary surgeries.

For certain complex fistulas post radiation treatment, presenceofsepsisandpatientswithsignificant comorbidi- ties,abowel diversionmay berequiredthus delaying the definitivesurgery.

About the urinary function

Urinary functional result is another important factor for patients’qualityoflifeafterfistularepair.

In our series, 4 out of 16 patients had severe urinary leakthatwould have requiredthe placementofan artifi- cialsphincter.Howeverthis procedure wasdeemedtobe complexinthissetting,andthuswasnotperformed.Artifi- cialsphincterwasusedin7/74patientsintheseriesfrom Vannietal.Nospecialmeshfortheurethrahasbeenused in any of the published series. It is almost impossible to know the possible reasons for Incontinence in our series;

thiscould be multifactorial either due to the treatment ofprostatecancerorabsenceofdetrusor-sphincterphysio- therapywhichcouldnotbeachieved.Itisalsoimpossibleto knowwhetheraperinealincisionwithplacementofagra- cilismuscleinducesmoreurinaryincontinencecomparedto thetechniqueofYorkMason.

The two patients who presented with RUF following brachytherapyhadcompleteurethralstenosisandrequired lifetimeurinarydiversionwithasuprapubiccatheter.Addi- tionofabuccalmucosagrafttothegracilisflapinterposition asdescribedbyVanni etal.might haveresultedinamore favorable outcome in those patients. Vanni et al. used a combinationofgracilismuscleandbuccalmucosalgraftin irradiatedpatientsandreportedasatisfactoryurinaryconti- nencein90%cases.

About the sexual function

Following these multiple surgeries, patients’ sexual func- tionwas severely damaged. In addition to the effects of theinitialprostatecancertreatment,longtermurinaryand fecaldiversion can leadto alteredself-image andhave a negativeimpactonthe sexualdrive. Pfalzgrafet al.[16]

reportedthatfor10/12patientspostRUFrepaircouldnot achieve erections.All patients reported that the erectile dysfunctionwasunchanged comparedwithbeforethefis- tularepair.Erectile dysfunctiondoesnot appeartobean importantissueduringthecourseoftreatmentofRUFrepair butwesuggest initiatingtherehabilitationprocessearlier duringtherepair processwiththeuse ofintracavernosal prostaglandininjectionsasoncetheRUFrepairissuccess- ful mostof these patients wereinterested in recovery of theirsexualfunction.Telokenetal.[23]suggestedstarting therehabilitation processwithintracavernosal injections intheirseriesduringthecourse oftreatment ofRUFpost radicalprostatectomy.Urinarydrainage witha suprapubic insteadof a Foley catheter can alsohelp enhance sexual functioninthesepatients.

Conclusion

RUFfollowingprostatecancertreatmentisaseriouscompli- cationwithsevererepercussiononpatients’qualityoflife.

Graciloplastyshouldbeuseforallfistulas,irradiatedornon- irradiatedpatientbecausethereisaflapoftissuethatgives abetterrateofsuccess.YorkMasontechniquecanbeper- formedtonon-irradiatedpatientsbyteamsdidn’tperform

glaciloplasty,asitiseasier,fasterandassociatedwithlow morbidity.

Avoiding fecal diversion with a colostomy, urinary drainagewithasuprapubiccatheterandearlyintracaver- nosalProstaglandininjectionscanimprovepatients’quality oflifefollowingsurgery.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

Appendix A. Supplementary data

Supplementary data associated with this article can be found in the online version, at http://www.

sciencedirect.com and https://doi.org/10.1016/j.purol.

2018.07.286.

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