Successful Repair of Iatrogenic Rectourinary Fistulas Using the Posterior Sagittal Transrectal Approach (York-Mason): 15-Year Experience

Introduction Rectourinary fistulas (RUFs) represent a challenging clinical problem. Most RUFs are secondary to lower urinary or intestinal tract surgery. Several surgical approaches have been proposed. The aim of this study was to review a 15-year experience using the York-Mason posterior sagittal transrectal approach to iatrogenic RUFs. Methods Seven patients with RUFs secondary to urologic surgery were operated on with the York-Mason technique at the Department of Urology, University of Padova, Italy between 1988 and 2003. The patients’ data have been collected and analyzed retrospectively. Results All the patients were treated successfully (100%). In one patient with Crohn’s disease the fistula recurred 11 years after the first surgery. One patient died for metastasis of prostate cancer 1 year after surgical repair of the RUF. A temporary colostomy was performed in five patients; the colostomies were subsequently closed, and the patients regained complete fecal continence with no postoperative anal strictures. The colostomy remained in place in one patient with Crohn’s disease and in another with ulcerative rectocolitis. Conclusions The posterior sagittal transrectal approach provided easy access and identification of RUFs and good surgical exposure, with no subsequent strictures or fecal incontinence. Our data show that the York-Mason technique alone is a highly effective option for treating an iatrogenic postoperative RUF.     

生物材料封堵治疗肛瘘的临床探讨

目的 观察脱细胞真皮基质(acellular dermal matrix,ADM)生物材料治疗肛瘘的有效性和安全性.方法 将102例肛瘘患者随机分成两组,每组51例,试验组采用ADM手术,对照组采用直肠黏膜瓣下移内口修补术,对两组患者的瘘管复发率、脓肿发生率、大便失禁率、肛门畸形率、术后疼痛时间、瘘管愈合时间等方面进行比较.采用卡方检验、秩和检验对数据进行分析.结果 试验组瘘管成功闭合者43例(84%),复发3例(6%),脓肿发生1例(2%),术后大便失禁1例(2%).对照组瘘管成功闭合者29例(57%),复发13例(25%),脓肿发生5例(10%),术后大便失禁4例(8%).试验组瘘管复发率低于对照组(x2=7.413,P＜0.05),差异有统计学意义;疼痛时间、瘘管愈合时间等方面,试验组均优于对照组(U值分别为28.600,15.100,P＜0.05),差异有统计学意义.结论 脱细胞真皮基质治疗肛瘘安全有效,可作为肛瘘的首选方法.     

Posterior sagittal approach: megasigmoid resection and anal reconstruction for severe constipation and fecal incontinence after anoplasty

PURPOSE: The aim of this study was to present the technique of megasigmoid resection and anal reconstruction by complete posterior sagittal approach for the children with severe constipation and fecal incontinence after anoplasty. METHODS: Six patients (age, 2 to 18 years) born with imperforate anus and originally treated with perineal anoplasty suffered from intractable constipation and fecal incontinence. Contrast enema showed massive dilated and aperistaltic rectosigmoid colon with fecal impaction. Resection of the dilated bowel and anal reconstruction were completely performed by posterior sagittal approach. RESULTS: The mean operating time was 205 minutes (range, 125 to 265 minutes) and the average length of resected colon was 23.3 cm (range, 10 to 40 cm). There were no intraoperative or postoperative complications. By 2 to 4 months after the operation, all patients obtained voluntary bowel movement. On follow-up at 6 to 24 months postoperative, no patient had constipation or required use of the laxatives again. Four of 6 patients suffered from grade 1 soiling, and the other 2 had grade greater than 1 soiling. None had urinary retention or incontinence after the procedure. CONCLUSION: Resection of dilated rectosigmoid colon and anal reconstruction for the patients with severe constipation and fecal incontinence after anoplasty can be performed successfully using a posterior sagittal approach.     

Surgical management of acquired rectourethral fistula,emphasizing the posterior approach

Rectourethral fistula is an uncommon surgical entity having a variety of congenital and acquired causes. Although several surgical approaches have been proposed in the literature, successful repair is often difficult. The 2 patients described had rectourethral fistulas after radical prostatectomy. One patient failed previous transabdominal and perineal repairs. The authors propose a 3-step approach to management of acquired rectourethral fistulas. A diverting transverse colostomy with insertion of a suprapubic or indwelling silicone rubber Foley catheter for 3 to 6 months will allow for a decrease in the inflammatory response surrounding the involved area and possible spontaneous closure. If spontaneous closure does not occur within this time, the fistula should be closed operatively through a posterior approach (modified York–Mason procedure). This approach provides excellent exposure and allows the suture lines to be offset, which in turn allows for better healing, presents a minimal risk of impotence or incontinence and allows for complete separation of urinary and fecal streams. The third step involves closure of the colostomy followed by removal of the Foley or suprapubic catheter if there is no recurrence. Timing of this step is crucial and should be individualized according to the postoperative course.     

手术治疗后位内口高位肛瘘126例疗效观察

为探讨对肛门组织特别是括约肌功能影响小、痛苦轻、复发率低的手术方法，对126例后位内口高位肛瘘患者，根据其瘘道走向采用切开挂线、切开加双挂线和切开挂线加改良留桥方法，一次治愈115例，无肛门失禁等并发症发生。     

One-stage Correction of Rectovestibular Fistula by Transfistula Anorectoplasty (TFARP)

Background The present article details a new technique for the repair of rectovestibular fistula. Materials and Methods Twenty-five patients with rectovestibular fistula, between 13 days and 4 years of age underwent surgical correction by transfistula anorectoplasty (TFARP). The technique, described in detail, involves mobilization of the fistula and the rectum through the fistula and creation of a new anus in the anatomically normal site by preserving both the perineal skin bridge (skin between the neo-anus and the posterior fourchette) and the levator muscle. Results The mean operating time was 85 min, and the mean hospital stay was 5 days. Moderate anal stenosis developed in 1 patient and was treated successfully by anal dilatations using Hegar dilators. A diverting colostomy was not required in any patient, and none of the patients developed rectal prolapse. Eleven patients who are now 3 years of age or older have voluntary bowel movements with good fecal continence scores. The 14 neonates and infants, who are still too young to be evaluated for continence, have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination. The average number of bowel movements per day was three to five, without the need for any laxative or enema. Conclusions Transfistula anorectoplasty is a simple surgical procedure that does not divide the levator muscle or the perineal body. Preservation of these structures contributes significantly toward improvement of the aesthetic appearance of the perineum and of fecal continence.     

Posterior sagittal anorectoplasty for failed imperforate anus surgery: lessons learned from secondary repairs

PURPOSE: The aim of this study was to evaluate secondary operations using a posterior sagittal approach in patients with fecal incontinence and impaction after primary repair of anorectal malformations. METHODS: Twenty patients (14 boys, 6 girls) who had previous failed surgery for imperforate anus underwent secondary operations. The indications for surgery included fecal incontinence (n = 16) and fecal impaction (n = 4). Patients ranged in age from 2 to 30 years (mean, 11 years), with 4 over the age of 20 years. The primary procedures included abdominosacroperineal (n = 7), sacroperineal (n = 10), and perineal (n = 3) pull-throughs. At surgery, none of the patients underwent a diverting colostomy. The rectum was mobilized from the surrounding structures through a posterior sagittal approach. The surgical findings included anteriorly displaced anus (n = 17), laterally displaced anus (n = 3), mesenteric fat surrounding the rectum (n = 4), mega-rectosigmoid (n = 2), and others (n = 3). The rectum underwent reconstruction, which involved relocation of the rectum and anus to surround them with the muscle complex. RESULTS: Patients underwent follow-up for periods ranging from 8 months to 6 years after surgery (mean, 3 years). To evaluate the functional results, fecal continence scores (Templeton and Ditesheim) were calculated for incontinent patients. Of the 16 incontinent patients, 12 achieved continence and 4 some improvement. Of the 4 patients with fecal impaction, 2 achieved daily voluntary bowel movement, whereas the other 2 have mild constipation and need occasional enemas. CONCLUSIONS: Our study suggests that (1) a secondary operation through a posterior sagittal approach can restore fecal continence and is efficacious even in adolescents and adults and (2) a posterior sagittal procedure can be safely performed without a diverting colostomy.     

Specific complications of radical perineal prostatectomy: a single institution study of more than 600 cases

PURPOSE: Although groups at several institutions have long experience with radical perineal prostatectomy (RPP), only few reports of larger series describe associated complications, mostly without reporting management options in detail. We analyzed specific perioperative and postoperative complications of the perineal approach and management strategies thereof. MATERIALS AND METHODS: The medical records of 630 patients who underwent RPP between January 1997 and May 2003 were retrospectively reviewed in regard to complications and their management. Median followup was 8 months (range 1 to 68). RESULTS: Major complications requiring open surgical intervention were noted in 11 patients (1.7%) for a total surgical revision rate of 2.4% (15 of 630). Two patients with persistent urinary fistula required fistula excision and closure. Two patients with a rectocutaneous fistula needed temporary diverting colostomy. Three patients with a combined urinary and fecal fistula were treated with protective colostomy, fistula excision and the interposition of a tunica vaginalis graft. No further morbidity was observed in these patients. In 7 patients a subvesical hematoma was drained surgically, including 3 mentioned in whom a hematoma expanded into the urethral anastomosis. Minor complications, which could be successfully managed conservatively or with endoscopic interventions only, developed in 124 patients for a total rate of 19.7%. In the long term 9% of the patients experienced postoperative de novo changes in stool habits after RPP but only 2.7% reported distressing anal sphincter incompetence. CONCLUSIONS: RPP is a safe and reproducible procedure with low major complication and reintervention rates even in a training center setting with many involved surgeons. A subvesical hematoma should be revised early since it can be the origin of subsequent major complications.     

Gracilis muscle transposition for iatrogenic rectourethral fistula

OBJECTIVE: To assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula. SUMMARY BACKGROUND DATA: Iatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors' experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula. METHODS: A retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions. RESULTS: Eleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients. CONCLUSIONS: Gracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.     

EFFECTIVENESS OF THE LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) IN THE TREATMENT OF ANAL FISTULA: INITIAL RESULTS

Background

The abscesses and anal fistulas represent about 70% of perianal suppuration, with an estimated incidence of 1/10000 inhabitants per year and representing 5% of queries in coloproctology.

Aim

To evaluate the effectiveness of the interesphincteric ligation technique of the fistulous tract in the treatment of anal fistula.

Methods

The records of eight patients who underwent this technique, evaluating age, gender and presence of incontinence were studied. Was named technical first-step the passage of cotton thread to promote the correct individualization of the fistula and, as the second, the surgical procedure.

Results

Two patients were men and eight women. The mean age was 42.8 years. Of these, seven (87.5%) had complete healing of the fistula; six were cured only with this procedure and one required additional operation with simple fistulotomy. Only one patient developed fecal incontinence which was documented by anorectal manometry. There were no deaths in this series.

Conclusion

The interesphincteric ligation technique of the fistulous tract proved to be effective for the treatment of anal fistula and should not be discouraged despite the occurrence of eventual fecal incontinence.     

Posterior sagittal anorectoplasty for adults. A sphincter-saving operation

We performed posterior sagittal anorectoplasty to treat two adult patients. One patient had an idiopathic stricture extending from the proximal sigmoid colon to the anus. The second patient was born with a high imperforate anus and, following a pull-through procedure as an infant, remained totally incontinent of feces. Both patients now have excellent fecal continence following this operation. The posterior sagittal anorectoplasty may be used to preserve rectal continence in selected adults.     

Combined abdominal and posterior sagittal approach for redo pull-through operation in Hirschsprung's disease

Background/Purpose: In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and retained aganglionosis after a previous operation. Duhamel or Swenson method is used commonly for redo operations. The pelvic dissection may be difficult, especially in Swenson's type of operation, because of fibrosis resulting from previous surgery or its complications. To overcome this, the authors used a combined abdominal and posterior sagittal approach to perform redo pull-through of Swenson's type in 4 children. Methods: Four boys (2.5 to 12 years) underwent redo pull-through for failed endorectal pull through (n = 2), persistent symptoms after 2 myectomies (n = 1) and late anastomotic disruption after Swenson's PT (n = 1). Abdominal dissection was done first to mobilize colon and resect aganglionic segment as far as the mid pelvis. The mobilized ganglionic colon was tacked to the pelvic rectal stump, hemostasis checked, and the abdomen closed. The lower pelvic dissection was done through the posterior sagittal route, under direct vision. The remainder of diseased rectum was excised, and the pull-through colon was retrieved and anastomosed to the anal stump. No covering colostomy was done. Results: A rectocutaneous fistula developed in one patient, which healed spontaneously. All patients had increased stool frequency in the early postoperative period but improved with time. All patients have attained normal voluntary bowel actions, but one child has infrequent minor soiling. There was no anastomotic narrowing in any case. Conclusions: Posterior sagittal approach is a useful alternative in difficult redo pull-through surgery. It offers excellent exposure, precise dissection, and direct anastomosis. There are minimal chances of complications, and continence is retained. J Pediatr Surg 37:1156-1159.     

主灶切开支管剥离缝合治疗蹄铁型肛瘘82例疗效观察

为探讨蹄铁型肛瘘的治疗方法,采用主灶切开、支管剥离缝合治疗蹄铁型肛瘘82例。结果显示,82例全部治愈,术后无肛门失禁,随访2年无复发。结果表明,主灶切开、支管剥离缝合治疗蹄铁型肛瘘,对瘘管进行充分剥离,术中对肛门括约肌分层缝合,达到了治疗目的,保证了肛门括约肌的完整性,防止了肛门失禁,提高了疗效。     

两种术式治疗后半蹄铁型肛瘘的疗效对比分析

为探讨治疗后半蹄铁型肛瘘的手术方式及疗效,我们采用隧道式瘘管剔除对口引流术治疗后半蹄铁型肛瘘38例（A组）,隧道式拖线术治疗34例（B组）,并对两组疗效进行对比分析。结果显示,两组治愈率均为100％,其中B组4例经二次扩创后治愈,随访3年无复发。两组均无肛门畸形、肛门失禁等并发症。A组平均疗程为（26．2±3．4）d,B组平均疗程为（28．3±3．1）d。术后2级以上疼痛A组为89．5％（34／38）,平均持续时间（7．3±3．2）d;B组为94．1％（32／34）,平均持续时间（12．8±3．8）d。结果表明,隧道式瘘管剔除对口引流术治疗后半蹄铁型肛瘘疗效显著。     

后正中位纵切横缝术治疗陈旧性肛裂46例疗效观察

为探讨后正中位纵切横缝术治疗陈旧性肛裂的临床疗效,对46例陈旧性肛裂采用后正中位纵切横缝术治疗。结果显示,缝线脱落时间为（10±2）d;创面愈合时间为14-22d;本组术后无继发性感染、大便失禁及肛门漏气病例;术后随访0．5～1．0年无复发。结果表明,后正中位纵切横缝术治疗陈旧性肛裂操作简单、出血少、感染少、并发症少、复发率低,可一次性根治肛裂。     

A decade of selective use of adjustable cutting seton combined with fistulotomy for anal fistula

Previous studies have demonstrated that the division of sphincter muscle in the treatment of anal fistula may precipitate fecal incontinence. Cutting setons may pose a particular risk of unrecoverable injury to the sphincter apparatus. To evaluate if the use of an adjustable cutting seton mitigates this risk, we performed a retrospective review of all patients operated on for anal fistulae in a 10-year period by a single surgeon. Adjustable cutting setons (consisting of heavy silk ligature with patient-controllable tension) were used selectively. Forty-seven patients met the study criteria. Ninety-four per cent of the fistulae treated were transsphincteric. All of the fistulae were treated with at least partial fistulotomy. Ninety-nine per cent of patients were followed to completion of treatment. One (2%) patient subsequently developed fecal incontinence, and four (9%) developed a recurrent or persistent fistula in the same location. Adjustable cutting setons have been used in our practice with a high success rate and low risk of complications. Our data support adjustable cutting setons as a useful tool in the surgeon's repertoire for treating fistulae that involve the anal sphincter complex.     

Posterior sagittal anorectoplasty for reoperation in children with anorectal malformations

A prospective study was carried out in 12 consecutive patients (7 boys and 5 girls), to evaluate posterior sagittal anorectoplasty for patients incontinent of faeces after anorectal reconstruction. Examination revealed anatomical problems such as: recurrent fistula (two), massive urethral diverticulum (one), absent vagina (one), and a missed urogenital sinus (one). Preliminary electromyography showed the external sphincter to be displaced from the anus in nine patients. Posterior sagittal anorectoplasty, with correction of anatomical defects and precise reconstruction of bowel within the sphincters, was carried out after the formation of a loop colostomy. No postoperative complications were observed. Contrast studies confirmed healed suture lines before stoma closure. Follow-up, between 4 and 46 months, revealed good faecal control in only two patients, with a significant improvement in two others. The rest remained incontinent although sensation was improved. These disappointing results, at variance with other published reports, lead us to conclude that posterior sagittal anorectoplasty, when used as a secondary procedure, is good for correcting anatomical defects but not for improving faecal continence.     

Primary anorectoplasty in females with common anorectal malformations without colostomy

Background/Purpose

The objective of this study is to assess the feasibility of primary posterior sagittal anorectoplasty in vestibular fistula without a covering colostomy.

Methods

Girls presenting from July 1997 to July 2005 with vestibular fistula were included prospectively in the study, in a nonrandomized manner, after excluding those with megarectosigmoid and pouch colon. All underwent primary posterior sagittal anorectoplasty after total gut irrigation with normal saline. They were kept nil per oral until the fifth postoperative day. No patient was started on anal dilatation. Patients were assessed for immediate and delayed complications as well as voluntary bowel movements and continence.

Results

A total of 72 patients with an age range of 1.5 months to 8 years (median, 9 months) were studied after excluding 7 with pouch colon and 3 with megarectosigmoid. Of the 72, 3 had undergone previous surgery. Follow-up ranged from 7 months to 8 years. No wound dehiscence or recurrence of fistula was noted. There were 5 mild wound infections. At 1 month postoperative, all patients had 1 to 3 stools per day with no episodes of soiling. None required anal dilatations, laxatives, or enemas.

Conclusions

Primary posterior sagittal anorectoplasty in vestibular fistula can be performed without a covering colostomy provided fecal contamination of the wound can be kept to the minimum in the first postoperative week. We achieve this by thorough total gut irrigation preoperatively and keeping the child nil per oral for the first 5 postoperative days. Continence rates are excellent and postoperative constipation is unlikely if megarectosigmoid and pouch colon are ruled out before surgery. Anal dilatation is not required after surgery.     

复杂性肛瘘64例手术治疗体会

为总结复杂性肛瘘的手术治疗体会,回顾分析接受手术治疗的64例复杂性肛瘘患者资料。对其中低位复杂性肛瘘采用单纯切开法治疗,外口距肛门较近的高位复杂性肛瘘采用切开挂线法治疗。外口距肛门较远的高位复杂性肛瘘采用开窗加切开挂线法治疗,蹄铁型肛瘘采用皮桥旷置法或切开缝合法治疗,术后给予全面护理。结果显示,1次手术治愈63例（98．4％）,2次手术治愈1例。术后随访半年,均无复发．无肛门失禁和肛门畸形等后遗症发生。结果表明,复杂性肛瘘以手术治疗为主,术式选择应根据患者具体病情而定,术后全面护理是于术成功的保障。     

One-stage repair of colovaginal fistula complicating acute diverticulitis

Fourteen patients with colovaginal fistula secondary to sigmoid diverticulitis were seen between 1964 and 1988. Thirteen had undergone prior hysterectomy. Three different operative approaches were used. Three patients were treated with colostomy alone; one died and the fistula persisted in one. Five patients underwent staged procedures. One patient died of complications after the second stage of a planned three-stage procedure. Four patients underwent a two-stage procedure (fistula takedown, colectomy with colostomy and colostomy closure), all with good results. Six patients were treated with one-stage fistula takedown, colectomy and primary anastomosis, without major complication. We advocate this as the procedure of choice and emphasize the following principles of epidemiology and management: 1) colovaginal fistula complicates diverticulitis in elderly women usually following hysterectomy; this association may be a factor in etiology; 2) vaginography is useful in diagnosis; and 3) planned one-stage repair is the best surgical approach.