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BackgroundFistulas are an abnormal connection between two or more epithelial surfaces. When fistulization between adjacent structures occurs in the pelvis, there is almost invariably significant associated morbidity and impact on a patient's quality of life. Imaging may aid in the diagnosis of pelvic fistulas and is essential to identify any associated pathology, define the course of the fistula, and aid in pre-surgical planning.PurposeThis article aims to review the wide array of clinical and imaging presentations of fistulas in the pelvis, with a focus on the radiologists' role in managing this challenging entity.MethodsThis article will review each classification type of fistula.ResultsPelvic fistula is a devastating condition that causes significant morbidity and evaluation can be challenging.ConclusionsImaging, and particularly MRI, plays a vital role in the diagnosis, characterizing the course of a fistula and demonstrating associated complications, which are essential to guide treatment decisions.

Uro-enteric fistula is a pathological communication between the urinary and digestive tract. Compromise of the appendix is infrequent and few cases of reno-appendicular fistulas have been described in the literature. The case of patient with symptoms of fever, low back pain and severe right hydronephrosis secondary to staghorn calculus on urinary tract tomography is presented. Initially managed with antibiotics and nephrostomy under fluoroscopy, subsequently suspended by passing contrast to the intestine. A contrasted tomography was performed which reported a fistula from the kidney to the intestine. A nephrectomy was carried out and a fistula was found to the appendix, for which a concomitant appendectomy was performed with evident clinical improvement. The pathology reported xanthogranulomatous pyelonephritis and secondary appendicitis. Reno-appendicular fistula has nonspecific symptoms, contrasted tomography is a diagnostic tool and most are detected as an intraoperative finding. Treatment is usually surgical, with nephrectomy and intestinal segment repair., La fístula uro-entérica es una comunicación patológica entre la vía urinaria y digestiva. El compromiso del apéndice es infrecuente y son pocos los casos de fístulas reno-apendiculares en la literatura. Se presenta el caso de un paciente con clínica de fiebre, dolor lumbar e hidronefrosis derecha severa secundaria a cálculo coraliforme en la tomografía de vías urinarias. Manejado inicialmente con antibióticos y nefrostomía bajo fluoroscopia, posteriormente suspendida por paso de contraste al intestino. Se realizó una tomografía contrastada que reportó fístula del riñón al intestino. Se llevó a nefrectomía y se encontró fistula hacía el apéndice, por lo cual se realizó apendicectomía concomitante con mejoría clínica evidente. La patología reportó pielonefritis xantogranulomatosa y apendicitis secundaria. La fístula reno-apendicular posee una clínica inespecífica, la tomografía contrastada es una herramienta diagnóstica y la mayoría se detectan como un hallazgo intraoperatorio. El tratamiento usualmente es quirúrgico, con nefrectomía y reparación del segmento intestinal.

ObjectiveTo describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair.MethodsPatients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire).ResultsTwenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion.ConclusionRUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients.

ObjectiveTo describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair.MethodsPatients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire).ResultsTwenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion.ConclusionRUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients.

PurposeRectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi-institutional setting.Materials and methodsWe retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California-San Francisco, University College London Hospitals, Lahey Clinic and Devine-Jordan Center for Reconstructive Surgery, in a 15-year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes.ResultsAfter prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success.ConclusionsRectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

PurposeRectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi-institutional setting.Materials and methodsWe retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California-San Francisco, University College London Hospitals, Lahey Clinic and Devine-Jordan Center for Reconstructive Surgery, in a 15-year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes.ResultsAfter prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success.ConclusionsRectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

PurposeThe rectal sphincter preserving transperineal approach has been increasingly used successfully. We analyzed our experience with this surgical approach. A secondary aim was to evaluate the surgical outcome of energy ablative rectourethral fistulas without a concomitant interposition muscle flap.Materials and methodsWe identified all patients with rectourethral fistula who underwent rectal sphincter preserving transperineal repair from 1998 to 2011. Re-approximation of the urethral mucosa, posterior anastomotic urethroplasty or partial/total prostatectomy with urethrovesical anastomosis was performed for urinary closure. The fistula cohort was divided into 2 groups, including postoperative and energy ablative fistulas, respectively. Success after perineal rectourethral fistula repair was defined as resolution after the first attempt at repair.ResultsA total of 23 patients underwent rectal sphincter preserving, transperineal rectourethral fistula repair. In the postoperative fistula cohort the fistula was successfully resolved in all 10 patients. A dartos interposition muscle flap was used in 2 of 10 patients. In the energy ablative cohort the fistula was successfully closed in 8 of 13 patients. An interposition muscle flap was not placed in 8 patients with an energy ablative fistula, of whom success was achieved in 5. Two of the 5 patients with an energy ablative fistula and a successful outcome without a concomitant interposition muscle flap had urinary extravasation, necessitating temporary catheterization.ConclusionsRectal sphincter preserving transperineal repair is a successful surgical method to repair postoperative and energy ablative rectourethral fistulas. An interposition muscle flap should be considered in the setting of energy ablative rectourethral fistulas to increase successful outcomes.

PurposeThe rectal sphincter preserving transperineal approach has been increasingly used successfully. We analyzed our experience with this surgical approach. A secondary aim was to evaluate the surgical outcome of energy ablative rectourethral fistulas without a concomitant interposition muscle flap.Materials and methodsWe identified all patients with rectourethral fistula who underwent rectal sphincter preserving transperineal repair from 1998 to 2011. Re-approximation of the urethral mucosa, posterior anastomotic urethroplasty or partial/total prostatectomy with urethrovesical anastomosis was performed for urinary closure. The fistula cohort was divided into 2 groups, including postoperative and energy ablative fistulas, respectively. Success after perineal rectourethral fistula repair was defined as resolution after the first attempt at repair.ResultsA total of 23 patients underwent rectal sphincter preserving, transperineal rectourethral fistula repair. In the postoperative fistula cohort the fistula was successfully resolved in all 10 patients. A dartos interposition muscle flap was used in 2 of 10 patients. In the energy ablative cohort the fistula was successfully closed in 8 of 13 patients. An interposition muscle flap was not placed in 8 patients with an energy ablative fistula, of whom success was achieved in 5. Two of the 5 patients with an energy ablative fistula and a successful outcome without a concomitant interposition muscle flap had urinary extravasation, necessitating temporary catheterization.ConclusionsRectal sphincter preserving transperineal repair is a successful surgical method to repair postoperative and energy ablative rectourethral fistulas. An interposition muscle flap should be considered in the setting of energy ablative rectourethral fistulas to increase successful outcomes.

PurposeAdults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.Materials and methodsWe reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.ResultsA total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).ConclusionsManaging problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

PurposeAdults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging.Materials and methodsWe reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment.ResultsA total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50).ConclusionsManaging problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.

Two patients with the rare entity of arterio-ureteral fistula are presented. Both highlight the predisposing factors of radiation, major surgery in the region, history of vascular surgery and presence of double-J-stent. Both patients presented with the clinical sign of intermittent gross hematuria. Both patients were successfully treated by endovascular intervention using graft covered stent.

Two patients with the rare entity of arterio-ureteral fistula are presented. Both highlight the predisposing factors of radiation, major surgery in the region, history of vascular surgery and presence of double-J-stent. Both patients presented with the clinical sign of intermittent gross hematuria. Both patients were successfully treated by endovascular intervention using graft covered stent.