MANAGEMENT OF ACQUIRED RECTOURINARY FISTULAS - OUTCOME ACCORDING TO CAUSE

Acquired rectourinary fistulas, an infrequent complication of pelvic c onditions, remain a therapeutic problem for which neither a widely acc epted classification nor long-term outcome data are available. This st udy was designed to provide a new etiologic classification system and examine the success of various surgical therapies. It also looked at t he need for permanent fecal or urinary diversion or radical excision d epending on the cause of the fistula, i.e., benign vs. malignancy-rela ted. METHODS: A retrospective analysis was made of 41 patients treated for acquired rectourinary fistulas between 1980 and 1995. Acquired re ctourinary fistulas were classified as 1) benign but caused by Crohn's disease, trauma, perirectal sepsis, or iatrogenic injury; and 2) mali gnancy-related fistulas secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects;Surgical interventions were class ified as repair, excision, fecal diversion, and urinary diversion. RES ULTS: Thirty-seven males and 4 females with acquired rectourinary fist ula were identified with a mean age of 62 (range, 28-90) years. Ninete en patients had fistulas involving their urethras, and 22 patients had fistulas involving the bladder. Eight patients were not treated surgi cally; one was not treated because of an advanced malignancy, three be cause of patient preference, three because of sepsis, and one because of a poor general condition. Of the remaining 33 patients, nine had b enign fistulas of which two were the result of Crohn's disease, two we re the result of trauma, two were from an iatrogenic response, and thr ee were from perirectal sepsis. Twenty-four patients had malignancy re lated fistulas, and five patients had neoplasm at their fistula sites. The remaining 19 patients had malignancy-related fistulas that were t he result of cancer treatments. Of the 19 malignancy-related fistulas, 5 were from radiation, 9 were from surgical trauma, and 5 were from r adiation and surgical trauma. Forty-nine percent of the patients had u ndergone attempts at fistula treatment before referral. A resolution o f symptoms after initial and reoperative surgery occurred more often i n patients with benign fistulas (44 and 100 percent; mean, 1.8 surgeri es per patient) compared with malignancy-related fistulas (21 and 88 p ercent; mean, 2.1 surgeries per patient). The rates of permanent fecal , urinary and fecal plus urinary diversion were also lower for benign fistulas (11, 0, and 33 percent) compared with malignancy-related fist ulas (13, 8, and 54 percent). Permanent diversion was avoided in 56 pe rcent of the benign fistulas but in only 25 percent of the malignancy- related fistulas. The rates of excisional and radical (ileal conduit) surgery were lower for benign fistulas than for malignancy-related fis tulas (44 and 11 percent vs. 50 and 54 percent). CONCLUSION: Successfu l management of rectourinary fistulas typically requires aggressive re operative therapy with permanent diversion more often required for mal ignancy-related fistulas. Better outcomes can be anticipated for benig n fistulas.