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Introduction: The repair of complex urethrorectal fistulas, which can be the result of treating prostate cancer with radical prostatectomy, is a big problem in urology and its final result is not always satisfactory. There are no universally accepted methods for repairing such fistulas. In our work we present a retrospective analysis of patients treated for urethrorectal fistulas after previous radical prostatectomy. The methods used were the initial excision and suture of the fistula, or a gracilis muscle flap interposition., Material and Methods: In the years 2000-2012, four patients were treated because of urethrorectal fistulas after radical prostatectomy. In two patients, open radical prostatectomy had been performed. Two other patients had been operated laparoscopically. Two patients had a primary fistula repair. They were operated using anterior perineal access. Two others were treated with the use of a gracilis muscle flap., Results: During the follow up, there was no recurrence of fistulas. Medium follow up for the first two patients was 120 and 156 months, and follow up of two other patients was 16 and 23 months. Until now, there were no final postoperative complications., Conclusions: Repair of the fistulas requires an individual approach to each case. Excision and suturing of the fistula gives a very good final result, especially when the primary reconstruction is performed. Repair of urethrorectal fistula using a gracilis muscle flap appears to be an excellent option in cases of complex recurrent fistulas. It is also associated with low morbidity in patients and a high success rate.

Elevated shear stress within the skeletal muscle microvasculature is implicated in the induction of a longitudinal splitting form of angiogenesis, which is characterized by the lack of basement membrane breakage. We investigated whether the transcriptional regulator, Ets-1, is responsive to changes in hemodynamic forces and if so, whether Ets-1 controls microvascular endothelial cell integrity by inducing the expression of inhibitors of matrix degrading proteases. Rats were treated with prazosin for 2, 4, and 7 days to increase in microvascular shear stress in hindlimb skeletal muscles. In complimentary in vitro experiments, rat microvascular skeletal muscle endothelial cells were exposed to laminar shear stress (15 dyne/cm(2)) for 0.5, 2, and 24 h. TaqMan PCR analysis of laser microdissected capillaries isolated from EDL muscles demonstrated transient (after 2 days) induction of Ets-1 gene expression. In cultured cells, a transient up-regulation of Ets-1 mRNA was observed after 2 h shear stimulation, accompanied by increased phosphorylation of Ets-1 and enhanced Ets-1 DNA binding activity. This response was modulated by ERK1/2 and p38 MAP kinases, but was not dependent on NOS or COX-2 activity. PAI-1, TIMP-1 and TIMP-3 mRNA were elevated significantly in prazosin treated EDL, and in response to shear stimulation in vitro. In cultured endothelial cells, Ets-1 RNA interference abolished the shear-induced increases in Ets-1, PAI-1, TIMP-1, and TIMP-3 mRNA expression. These results suggest that enhanced laminar shear stress may act to preserve the integrity of microvascular walls in part through Ets-1-dependent induction of protease inhibitors., ((c) 2008 Wiley-Liss, Inc)

Angiogenesis, which is essential for the physiological adaptation of skeletal muscle to exercise, occurs in response to the mechanical forces of elevated capillary shear stress and cell stretch. Increased production of VEGF is a characteristic of endothelial cells undergoing either stretch- or shear-stress-induced angiogenesis. Because VEGF production is regulated by hypoxia inducible factors (HIFs), we examined whether HIFs play a significant role in the angiogenic process initiated by these mechanical forces. Rat extensor digitorum longus (EDL) muscles were overloaded to induce stretch, or exposed to the dilator prazosin to elevate capillary shear stress, and capillaries from these muscles were isolated by laser capture microdissection for RNA analysis. HIF-1alpha and HIF-2alpha transcript levels increased after 4 and 7 days of stretch, whereas a transient early induction of HIF-1alpha and HIF-2alpha transcripts was detected in capillaries from prazosin-treated muscles. Skeletal muscle microvascular endothelial cells exposed to 10% stretch in vitro showed an elevation in HIF-1alpha and HIF-2alpha mRNA, which was preceded by increases in HIF-binding activity. Conversely, HIF-1alpha and HIF-2alpha mRNA were reduced significantly, and HIF-alpha proteins were undetectable, after 24 h exposure to elevated shear stress (16 dyn cm(-2) (16 x10(-5) N cm(-2)). Given the disparate regulation of HIFs in response to these mechanical stimuli, we tested the requirement of HIF-alpha proteins in stretch- and shear-stress-induced angiogenesis by impeding HIF accumulation through use of the geldanamycin derivative 17-DMAG. Treatment with 17-DMAG significantly impaired stretch-induced, but not shear-stress-induced, angiogenesis. Together, these results illustrate that activation of HIF-1alpha and HIF-2alpha contributes significantly to stretch- but not to shear-stress-induced capillary growth.