!illi i!iIiii iii
!i;!iii?
SINGLE-STAGE TRANSRECTAL TRANSSPHINCTERIC (MODIFIED YORK-MASON) REPAIR OF RECTOURINARY FISTULAS
i!ilili~~ii~!i ~i!! THOMAS W. WOOD, M.D. RICHARD G. MIDDLETON, M.D. From the Division of Urology, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah
C T--Over the past eleven years we have repaired seven rectourinary fistulas using a modi,Mason transrectaI transsphincteric approach. The simplicity of this one-stage procedure mstrated its cost effectiveness compared with the standard three-stage procedure (colost cystotomy, fistula repair, and colostomy takedown).
ry fistula is a rare complication ofoperation for either benign or mase. Repair of these fistulas is dfffi~sulting in multiple operations with ~spitalization. We have successfully e-staged transrectal, transsphinc~h as described by York-Mason 1 for : of the rectourinary fistula. We 5 a colostomy, but rather an exten[ca1 and antibiotic bowel prepara~ort on 2 patients treated with a tion consisting of cystotomy and transsphincteric fistula closure usfled York-Mason technique. Case Reports ght-year-old white man with Stage adenocarelnoma had undergone bie lymph node dissection and radical prostatectomy. He was referred 'ostoperatively with his Foley eatheHistologic examination of the spec~d rectal mucosa along with prosiarcinoma. The patient had watery ice his operation. A cystogram was ~hich showed leakage from the vesiunction per rectum (Fig. 1). JANUARY 1990 /
FIGURE 1.
Lateral cystogram demonstrating recto-
urinary fistula.
VOLUME XXXV, NUMBER 1
27
After a mechanical and antibiotic bob preparation, a cystotomy and direct York-M: son transrectal fistula repair were perform two weeks after his surgery. Postoperativelyi patient was given an elemental diet for ,i: week and then was started on a select diet. T eystotomy tube was removed two weeks post6 eratively. The patient voided well and has no recurrence of the fistula throughout the e suing two years.
Case 2 A sixty-two,year-old white man with a mote history of retropubic prostatectomy hai transurethral resection of the prostate pi formed for acute urinary retention, Watt diarrhea had developed postoperatively, anc cystogram demonstrated a prostatoreetal J!isti (Fig. g). Percutaneous cystotomy and a chanieal and antibiotic bowel preparation
FIGURE 2. Lateral cystogram demonstrating prostatorectal fistula.
a.
;ii
i
\ FIGURE 3. Modi]ied YorkMason transsphincteric transrectal repair o] rectourinary fistula. (From Henderson, Middleton, and Dah113 with permission o] Williams & Wilkins.)
\
,~ctal Wail
ErV Fistula 'Rectal Watt)
Vlusde
28
UROLOGY
JANUARY 1990
/
VOLUME XXXV,
,air of the fistula was underek p o s t o p e r a t i v e l y via t h e nssphineterie York-Mason ap~tient was given an elemental ~k postoperatively. Cystostomy red two weeks postoperatively. ted well with no recurrence of g the ensuing year.
TABLE I.
Procedures and Material Cystogram Cystoseopy Hospital (221 per day) Laboratory CBC SMA-7 SMA-20
mique on fically cleansed of all resyethylene glycol electro,owed by antibiotic prep3myein and neomycin. ~eetrum antibiotics are rive period. A preoperaotomy tube was used in
Lesia is administered, the ,' prone jacknife position. l and buttocks are spread After appropriate skin 1 is made from the tip of anal sphincter (Fig. 3A). :tended to the left of the hough the coccyx may be ae difficulty. The mueonarked with stay sutures le anal sphincter mecha0 chromic catgut sutures d with an appropriate tors inside the terminal ~, fistula on the anterior t and excised. The poste:then closed under direct pted chromic stitch as is anterior rectum. Rectal :ed with a running 3-0 The posterior rectal wall terrupted layer of 3-0 es. Repair of the anal ying the paired, tagged ter mechanism together, tches if necessary. Total oximately one hour. ]ment la is a devastating eomoperation. The afflicted ~ting distress which deFlective relief. Although
190 /
Cost comparison (dollars)
PT
PTT Polyethylene glycol electrolyte lavage solution Erythromyein/neomycin Cefoxitin (perioperative) Operating room time (1 hour) Anesthesia (1 hour) Intravenous solution TOTALS*
One-Stage York-Mason Repair 75 118 884
ThreeStage Repair Same Same 3x
8 24 26 12 9
Same
35 28 54
2x 2x 3x
250 173 63 $1,759
5x 5x 3x $5,516
*Neither anesthesiologist's nor surgeon's fees included.
spontaneous healing has been observed, surgical intervention has been necessary in the majority of reported cases. ~-4 Permanent closure of the fistula without direct repair has occurred after fecal and urinary diversion. T M Many surgical techniques have been proposed for repair of reetourinary fistulas, including the rectal pull-through operation of Young and Stone, 5-7 repair through the intact dilated anal sphincter, s direct exposure through a perineal incision, ° closure of the fistula posteriorly through a Kraske incision, ~0 and transreetal repair through the divided anal sphincter as described by York-Mason. 1,n-14 The York-Mason transreetal transsphincterie approach has the advantages of affording rapid exposure through fresh, unscarred tissues; excellent visualization of the fistula; and the space required to maneuver surgical instruments. This insures complete separation of the rectal and urinary components of the fistula. The concern for possible anal incontinence via the transsphincteric approach has been unfounded. Careful approximation of the anal sphincter mechanism has produced complete anal continence in the 4 patients reported on by Kilpatrick and York-Mason, 1 the 3 patients reported by Prasad, TM and in all 7 of our patients (5 in our previous reportsX2aa). Although some advocate delayed repair of the fistula after fecal diversion to evaluate the possibility o; spontaneous healing, this entails
VOLUME XXXV, NUMBER 1
29
at least one additional major operative procedure (i.e., colostomy takedown). This not only subjects the patient to the added risk of a second procedure but also burdens the patient with added costs (Table I). Racine Medical Clinic Racine, Wisconsin 53406
(DR. WOOD) References 1. Kflpatrick FR, and York,Mason A: Post-operative rectoprostatic fistula, Br J Urol 41:649 (1969). 2. Wilhelm SF: tlectourinary fistula, Surg Gyneeol Obstet 79. 427 (1944), 3. Goodwin WE, Turner RD, and Winter CC: Rectourinary fistula: principles of management and a technique of surgical closure, JUrQ1 80:246 (i958). 4. Weyrauch HM: A critical study of surgical principles used in repair of ure~roreetal fistula: presentation of a modern tecnique, Stanford Med Bull 9" 2 (1951).
30
5. Lewis LG: Repair of recto-urethral fistulas, J
(1947). 6. Parry WL: Prostate malignancies, in Glenn WH (Eds): Urologic Surgery, 2nd ed, New York, Publishers, Inc, 1977, p 546. 7. Young HH, and Stone HB: The operative urethrorectal fistula. Presentation of a method of 1 Urol 1:289 (1917). 8. VoseSN: A technique for the repair of recto-u: J Urol 61:799 (1949). 9. Beneventi FA, and Ca~ebaum WH: Rectal prostatorectal fistula, Surg Gynecol Obstet 133: 4~ 10. Culp OS, and Calhoon HW: A variety of re~ tulas: experiences with 20 cases, j Urol 91:560 (1c, 11. Kflpatrick Ftl, and York-Mason A: Post-ot prostatic fistula, Br J Urol 41:649 (1969). 12. Dalai DS, Howard PM, and Middleton RG management of rectourinary fistulas resulting frr operation: a report of 5 cases, J Urol 111:514 (19' 13. Henderson DJ, Middleton RG, and Daht D repair of rectourinary fistula, J Uroi 125:592 (19~ 14. Prasad ML, Ndson R, Hambrick E, and Abe Mason procedure for repair of postoperative urethral fistula, Dis Col Rectum 26:716 (1983).
UROLOGY / JANUARY1990 /
VOLUMEXXX'
!i;!iii?
SINGLE-STAGE TRANSRECTAL TRANSSPHINCTERIC (MODIFIED YORK-MASON) REPAIR OF RECTOURINARY FISTULAS
i!ilili~~ii~!i ~i!! THOMAS W. WOOD, M.D. RICHARD G. MIDDLETON, M.D. From the Division of Urology, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah
C T--Over the past eleven years we have repaired seven rectourinary fistulas using a modi,Mason transrectaI transsphincteric approach. The simplicity of this one-stage procedure mstrated its cost effectiveness compared with the standard three-stage procedure (colost cystotomy, fistula repair, and colostomy takedown).
ry fistula is a rare complication ofoperation for either benign or mase. Repair of these fistulas is dfffi~sulting in multiple operations with ~spitalization. We have successfully e-staged transrectal, transsphinc~h as described by York-Mason 1 for : of the rectourinary fistula. We 5 a colostomy, but rather an exten[ca1 and antibiotic bowel prepara~ort on 2 patients treated with a tion consisting of cystotomy and transsphincteric fistula closure usfled York-Mason technique. Case Reports ght-year-old white man with Stage adenocarelnoma had undergone bie lymph node dissection and radical prostatectomy. He was referred 'ostoperatively with his Foley eatheHistologic examination of the spec~d rectal mucosa along with prosiarcinoma. The patient had watery ice his operation. A cystogram was ~hich showed leakage from the vesiunction per rectum (Fig. 1). JANUARY 1990 /
FIGURE 1.
Lateral cystogram demonstrating recto-
urinary fistula.
VOLUME XXXV, NUMBER 1
27
After a mechanical and antibiotic bob preparation, a cystotomy and direct York-M: son transrectal fistula repair were perform two weeks after his surgery. Postoperativelyi patient was given an elemental diet for ,i: week and then was started on a select diet. T eystotomy tube was removed two weeks post6 eratively. The patient voided well and has no recurrence of the fistula throughout the e suing two years.
Case 2 A sixty-two,year-old white man with a mote history of retropubic prostatectomy hai transurethral resection of the prostate pi formed for acute urinary retention, Watt diarrhea had developed postoperatively, anc cystogram demonstrated a prostatoreetal J!isti (Fig. g). Percutaneous cystotomy and a chanieal and antibiotic bowel preparation
FIGURE 2. Lateral cystogram demonstrating prostatorectal fistula.
a.
;ii
i
\ FIGURE 3. Modi]ied YorkMason transsphincteric transrectal repair o] rectourinary fistula. (From Henderson, Middleton, and Dah113 with permission o] Williams & Wilkins.)
\
,~ctal Wail
ErV Fistula 'Rectal Watt)
Vlusde
28
UROLOGY
JANUARY 1990
/
VOLUME XXXV,
,air of the fistula was underek p o s t o p e r a t i v e l y via t h e nssphineterie York-Mason ap~tient was given an elemental ~k postoperatively. Cystostomy red two weeks postoperatively. ted well with no recurrence of g the ensuing year.
TABLE I.
Procedures and Material Cystogram Cystoseopy Hospital (221 per day) Laboratory CBC SMA-7 SMA-20
mique on fically cleansed of all resyethylene glycol electro,owed by antibiotic prep3myein and neomycin. ~eetrum antibiotics are rive period. A preoperaotomy tube was used in
Lesia is administered, the ,' prone jacknife position. l and buttocks are spread After appropriate skin 1 is made from the tip of anal sphincter (Fig. 3A). :tended to the left of the hough the coccyx may be ae difficulty. The mueonarked with stay sutures le anal sphincter mecha0 chromic catgut sutures d with an appropriate tors inside the terminal ~, fistula on the anterior t and excised. The poste:then closed under direct pted chromic stitch as is anterior rectum. Rectal :ed with a running 3-0 The posterior rectal wall terrupted layer of 3-0 es. Repair of the anal ying the paired, tagged ter mechanism together, tches if necessary. Total oximately one hour. ]ment la is a devastating eomoperation. The afflicted ~ting distress which deFlective relief. Although
190 /
Cost comparison (dollars)
PT
PTT Polyethylene glycol electrolyte lavage solution Erythromyein/neomycin Cefoxitin (perioperative) Operating room time (1 hour) Anesthesia (1 hour) Intravenous solution TOTALS*
One-Stage York-Mason Repair 75 118 884
ThreeStage Repair Same Same 3x
8 24 26 12 9
Same
35 28 54
2x 2x 3x
250 173 63 $1,759
5x 5x 3x $5,516
*Neither anesthesiologist's nor surgeon's fees included.
spontaneous healing has been observed, surgical intervention has been necessary in the majority of reported cases. ~-4 Permanent closure of the fistula without direct repair has occurred after fecal and urinary diversion. T M Many surgical techniques have been proposed for repair of reetourinary fistulas, including the rectal pull-through operation of Young and Stone, 5-7 repair through the intact dilated anal sphincter, s direct exposure through a perineal incision, ° closure of the fistula posteriorly through a Kraske incision, ~0 and transreetal repair through the divided anal sphincter as described by York-Mason. 1,n-14 The York-Mason transreetal transsphincterie approach has the advantages of affording rapid exposure through fresh, unscarred tissues; excellent visualization of the fistula; and the space required to maneuver surgical instruments. This insures complete separation of the rectal and urinary components of the fistula. The concern for possible anal incontinence via the transsphincteric approach has been unfounded. Careful approximation of the anal sphincter mechanism has produced complete anal continence in the 4 patients reported on by Kilpatrick and York-Mason, 1 the 3 patients reported by Prasad, TM and in all 7 of our patients (5 in our previous reportsX2aa). Although some advocate delayed repair of the fistula after fecal diversion to evaluate the possibility o; spontaneous healing, this entails
VOLUME XXXV, NUMBER 1
29
at least one additional major operative procedure (i.e., colostomy takedown). This not only subjects the patient to the added risk of a second procedure but also burdens the patient with added costs (Table I). Racine Medical Clinic Racine, Wisconsin 53406
(DR. WOOD) References 1. Kflpatrick FR, and York,Mason A: Post-operative rectoprostatic fistula, Br J Urol 41:649 (1969). 2. Wilhelm SF: tlectourinary fistula, Surg Gyneeol Obstet 79. 427 (1944), 3. Goodwin WE, Turner RD, and Winter CC: Rectourinary fistula: principles of management and a technique of surgical closure, JUrQ1 80:246 (i958). 4. Weyrauch HM: A critical study of surgical principles used in repair of ure~roreetal fistula: presentation of a modern tecnique, Stanford Med Bull 9" 2 (1951).
30
5. Lewis LG: Repair of recto-urethral fistulas, J
(1947). 6. Parry WL: Prostate malignancies, in Glenn WH (Eds): Urologic Surgery, 2nd ed, New York, Publishers, Inc, 1977, p 546. 7. Young HH, and Stone HB: The operative urethrorectal fistula. Presentation of a method of 1 Urol 1:289 (1917). 8. VoseSN: A technique for the repair of recto-u: J Urol 61:799 (1949). 9. Beneventi FA, and Ca~ebaum WH: Rectal prostatorectal fistula, Surg Gynecol Obstet 133: 4~ 10. Culp OS, and Calhoon HW: A variety of re~ tulas: experiences with 20 cases, j Urol 91:560 (1c, 11. Kflpatrick Ftl, and York-Mason A: Post-ot prostatic fistula, Br J Urol 41:649 (1969). 12. Dalai DS, Howard PM, and Middleton RG management of rectourinary fistulas resulting frr operation: a report of 5 cases, J Urol 111:514 (19' 13. Henderson DJ, Middleton RG, and Daht D repair of rectourinary fistula, J Uroi 125:592 (19~ 14. Prasad ML, Ndson R, Hambrick E, and Abe Mason procedure for repair of postoperative urethral fistula, Dis Col Rectum 26:716 (1983).
UROLOGY / JANUARY1990 /
VOLUMEXXX'
