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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 14-45 The tunnel must be wide enough to easily accept a finger in order to
avoid compression of the flap that could lead to necrosis.
Bleeding may be encountered, and external pressure on the skin for 5
minutes usually controls this. Orientation is meticulously observed to
avoid twisting the flap. Using the long end of the tie (Fig. 14-46), it is
brought through the tunnel into the perineal wound and oriented (Fig. 14-
47).
FIGURE 14-46 The graft is brought through the tunnel and oriented.
FIGURE 14-47
The suture in the cephalad aspect (left with the needle from the internal
opening closure) is now used to anchor the graft taking small bites. Other
sutures are placed as needed to maintain orientation and stability.
If the fistula is in the mid-rectum, we would use the gracilis as the Martius
typically does not reach easily to that level. We perform this with our
plastic surgery colleagues. They harvest the muscle and bring it through
the tunnel. We assist to ensure it is oriented and sutured securely in place.
The skin is loosely re-approximated (Fig. 14-48). If there is a lot of
drainage, a Penrose ¼ in can be placed laterally. However, the skin is
again only loosely approximated as there will be drainage as this healed.
FIGURE 14-48 Closure of skin. Top: The suction drain is seen.
A suction drain is placed in the bed of the labial wound (seen at very top
of Fig. 14-48) and the skin closed over the surface. Patients typically go
home with the suction drain as we do not remove until it is about 30 mL
per day or less.
PEARLS AND PITFALLS
The use of a stoma does not guarantee success, but we prefer to use one
if there is less than ideal conditions or if there have been multiple
previous repairs.
For patients without a stoma, we keep them in the hospital overnight
and continue IV antibiotics.
We will then typically feed them and send them out the next day if they
are doing OK.
We will give them a total of 1 week of antibiotics (IV and oral).
For patients without a stoma, we advise they avoid constipation by
taking an ounce of mineral oil orally daily. If they do not move their
bowels by 3 days after they start to eat, Milk of Magnesia, 1 oz is given
nightly until there is a stool.
We allow them to take a shower but avoid a bath as that seems to
macerate the tissue.
They are advised to sit on a pillow if needed, but not a doughnut (this
will pull apart the buttocks and may stress a repair).
We also advise them to avoid lifting anything heavier than a gallon of
milk for 6-8 weeks or doing activity that forces them to grunt or push on
their pelvis. When stress is placed on their pelvis with activity that leads
to forces pushing on the perineum, it can stress the repair.
We encourage gentle walking.
Hyperbaric oxygen is ordered when tissue seemed to be less pliable, and
we have found it extremely helpful with healing.
For patients with a stoma, and examination under anesthesia is done at
about 8 weeks to assess for healing. A gastrografin enema is then done
prior to stoma closure.
Suggested Readings
Hull TL. Expert commentary on the evaluation and management of rectovaginal fistulas. Dis Colon
Rectum. 2018;61(1):24-26.
Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in Crohn’s disease.
World J Gastrointest Pathophysiol. 2014;5(4):487-495.
Chapter 15
Rectourethral Fistulas
NICHOLAS HAUSER
HADLEY WOOD
KENNETH ANGERMEIER
Perioperative Considerations
Rectourethral fistula (RUF) is a challenging problem encountered by
urologic and colorectal surgeons and may result from radiation to the
pelvis, prostate cryotherapy, prior surgery, inflammatory conditions,
trauma, or congenital defects.
Although transanal or transanosphincteric (York Mason) repair may be
considered for small fistulas following surgery alone, perineal repair with
gracilis interposition is favored for complex RUFs. This category includes
fistulas that develop in the setting of prior radiation therapy or ablative
procedures, such as cryotherapy or high-intensity focused ultrasound, and
defects that are large or have failed prior reconstruction.
Prior to repair of complex RUF, it is critical to perform fecal diversion
(loop colostomy or ileostomy) and selective urinary diversion (suprapubic
catheter) for 3-6 months to decrease inflammation in the perineum and
surrounding tissues before surgery.
Careful endoscopic evaluation (Fig. 15-1A-C) and examination under
anesthesia should be performed following a period of diversion to assess
the external urethral and anal sphincters, size and location of the fistula,
quality of the rectum and tissues surrounding the fistula, the urethra for
evidence of stricture, and the approximate capacity and quality of the
bladder. Consideration of these factors will aid in generating the ultimate
surgical plan.
FIGURE 15-1 Preoperative evaluation. A. Flexible sigmoidoscopic view of the
rectourethral fistula (RUF). B. Cystoscopic view of the RUF. C. Contrast study in a patient
with prior brachytherapy for prostate cancer, demonstrating fistula between the rectum
and the prostatic urethra.
If future urinary and bowel function are likely to be adequate based on the
above evaluation, repair the urethral defect, with selective use of a buccal
mucosa graft. Restore bowel function via primary rectal repair and then
interpose a gracilis muscle flap. In rare situations when the anal sphincter
is intact and the rectum cannot be closed primarily, proctectomy with
coloanal pull-through may be considered.
If future bowel function is not likely to be adequate or the anal sphincter is
clearly compromised, repair the urethral defect, with selective use of a
buccal mucosa graft, with transfer of a gracilis muscle flap to buttress the
repair. Continue with the current fecal diversion if a colostomy or convert
the ileostomy to a colostomy. Proctectomy or rectal closure will also be
needed depending on patient anatomy.
If future bowel function is likely to be adequate, but urinary function not
restorable due to contracted bladder, extensive radiation cystitis, or
devastated bladder outlet, perform a cystoprostatectomy with ileal conduit
urinary diversion. Bowel function can then be restored via primary rectal
repair or proctectomy with coloanal pull-through and later reversal of the
diverting colostomy or ileostomy. Omental pedicle flap to the pelvis
should be considered when feasible.
Finally, if neither bowel nor urinary function is likely to be adequate,
perform a pelvic exenteration with ileal conduit and colostomy.
Sterile Equipment
Modified Denis-Browne retractor with notched grooves or modified Scott
ring retractor with elastic stay hooks
Gelpi retractor
Handheld malleable retractors
Fiberoptic-lighted handheld retractor such as St. Mark or Deaver
Skin stapler
Doppler ultrasound probe
Patient Positioning and Draping (See Chapter 3)
High lithotomy position
The patient should be positioned on the bed such that the perineum is at
the level of the foot break.
Place legs in adjustable stirrups (such as Yellowfins); raise the stirrups
until the hips are flexed about 75-80 degrees and extend the legs until the
knees are flexed approximately 90-100 degrees (Fig. 15-2).
FIGURE 15-2 A. High lithotomy position. B. Draping. C. Close-up of surgical field and
marked incision. Note the sterile towels draped just posterior to the proposed incision.
Access to the rectum is possible through a slit between the paired towels.
If surgery is prolonged, consider dropping the stirrups for short periods of
time to allow for normal lower extremity perfusion to decrease the risk of
complications such as rhabdomyolysis or neuropraxia.
Padding of Pressure Points
Use a gel pad beneath the buttock to cushion the site bearing the majority
of the patient’s weight.
Egg crate foam may be used to pad the lateral portion of the knee within
the stirrups to prevent injury to the common peroneal nerve.
Similar foam cushion can be placed between the patient and any tubing for
sequential compression devices on the patient’s lower leg.
Prepping and Draping
In addition to shaving the perineum and external genitalia, shave the
medial and posterior thigh on the leg selected for gracilis muscle harvest.
Prep the entire thigh into the field, extending just beyond the knee.
Most patients will have a previously placed suprapubic catheter for urinary
diversion. Remove the catheter and include the lower abdomen in the
prepped surgical field.
A bulb syringe can be used to gently irrigate the rectum with povidone–
iodine solution prior to prepping the remainder of the surgical field.
When draping, isolate the selected thigh with individual stick-on drapes or
sterile towels prior to covering the leg and stirrup with the leg drape.
When access is needed, the top drape can be cut back to expose the
prepped thigh.
Take care to include access to the rectum while draping. This can be done
by placing adjacent sterile towels on either side of the rectum and stapling
them in place, leaving a midline slit through which a digital rectal
examination can be performed intraoperatively.
Technique
Perineal Approach with Gracilis Muscle Interposition
Advantages of the perineal approach include excellent exposure, access to
the urethra if concomitant repair of stricture is necessary, and ability to
harvest a gracilis muscle interposition flap without repositioning.
Replace a suprapubic catheter to drain the bladder during the initial
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