Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy

Purpose: Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience.

Materials and methods: From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy.

Results: Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3).

Conclusions: The therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.