Urinary fistula, radiated and redo: what I need to know

What makes a fistula hard

Five things, and I want each of them in the records before the visit: radiation or energy ablation of the field; how many repairs have already failed; a stenosis next to the fistula, at the bladder neck, the anastomosis or the ureter; a large or trigonal defect; and whether healthy tissue will have to be brought in. Operative notes from the prior repairs, the radiation record, and current imaging and endoscopy answer most of it.

Repair, interposition, diversion

The repair closes the connection and, when the tissue needs it, brings in healthy tissue to support the closure and keep the two organs apart: omentum, a peritoneal flap, or muscle. I do most of this robotically, through the single-port da Vinci. A fistula that has failed a prior repair, or formed in radiated tissue, is harder, and it is often still fixable. A failed repair is a reason to be evaluated by someone who does this routinely, not a reason to stop.

The conversation before the operation

I ask whether the patient will accept a diversion if the repair fails, before I operate, not after. For a rectourethral fistula there is one stop I declare before the case: if taking the fistula down would leave him with fecal incontinence he has not accepted, I stop. It is declared in advance because a case that is going wrong does not announce itself early, and I am the one in the room who has to call it.

Fistula after phalloplasty

Urethral complications after phalloplasty and metoidioplasty, fistula included, are part of the practice. In phalloplasty itself, I do the vaginectomy robotically with a gracilis interposition to reduce fistula rates.

Videos by fistula

Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.

Papers

1. Mishra K, Mahran A, Abboud B, et al. Validating the Martini staging system for rectourethral fistula: a meta-analysis of postoperative outcomes. Urology. 2020. PubMed 32916190
2. Osterberg EC, Vanni AJ, Gaither TW, et al. Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from TURNS. World J Urol. 2016. PubMed 27928592
3. Xu AJ, Stair SL, Mishra K, Agocs C, Zhao LC. PATIO repair for treatment of urethrocutaneous fistula: updated technique and outcomes in a diverse adult population. Urology Video Journal. 2023. DOI 10.1016/j.urolvj.2022.100201
4. Cohen O, Stranix JT, Zhao L, Levine J, Bluebond-Langner R. Use of a split pedicled gracilis muscle flap in robotically assisted vaginectomy and urethral lengthening for phalloplasty. Plast Reconstr Surg. 2020. PubMed 32195856
5. Jun MS, Shakir NA, Blasdel G, et al. Robotic-assisted vaginectomy during staged gender-affirming penile reconstruction surgery: technique and outcomes. Urology. 2021. PubMed 33493507
6. Cohen OD, Dy GW, Nolan IT, et al. Robotic excision of vaginal remnant and urethral diverticulum for relief of urinary symptoms following phalloplasty in transgender men. Urology. 2019. PubMed 31790784
7. Nikolavsky D, Hughes M, Zhao LC. Urologic complications after phalloplasty or metoidioplasty. Clin Plast Surg. 2018. PubMed 29908632
8. Liu W, Shakir N, Zhao LC. Single-port robotic posterior urethroplasty using buccal mucosa grafts: technique and outcomes. Urology. 2021. PubMed 34624362

All my trauma and fistula papers

More

• Bladder neck reconstruction: how I choose the operation
• Distal ureteral stricture
• For patients: What is a urinary fistula? and Can radiation injury affect the urinary tract?

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