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Objective: The aim of this study was to establish an evidence-based best clinical practice consensus for the management of urethral stricture disease in the UK. Methods: A systematic review of optimal management of urethral stricture generated a base document which was endorsed by the British Association of Urological Surgeons (BAUS) section of Andrology and Genito-Urinary Reconstructive Surgeons (AGUS). A two-round electronic mail modified Delphi survey of 43 consultant reconstructive urologists, members of the British Association of Genito-Urinary Reconstructive Surgeons (BAGURS), was then performed. The panel’s views about the base document was sought in seven domains: definition, diagnosis, investigation, conservative, endoscopic and reconstructive treatments, and follow up. Responses were collated and used to modify the base to achieve a consensus statement. Results: In round one of the Delphi process four panel members commented on the base document and seven in round two. Consensus was thereby reached on 38 statements regarding definition (one), diagnosis (three), investigation (two), conservative/endoscopic (five) and reconstructive (24) treatments and follow up (three) for the management of urethral stricture disease. Conclusion: This consensus statement will help standardise care, provide guidance on the management of urethral stricture disease, and assist in clinical decision-making for healthcare professionals of all grades.

We present the case of a 66-year-old male with a history of iatrogenic bladder injury and radiation therapy for colon adenocarcinoma 20 years prior. A computed tomography of the thorax, abdomen and pelvis, reported a presacral mass with invasion to the bladder, ureters and lymph nodes. An initial bladder biopsy was histologically inconclusive. A later biopsy taken during emergency bypass surgery for small bowel obstruction, while the patient was positive for coronavirus disease of 2019, concluded that the mass was a peritoneal mesothelioma of epithelioid origin. The combination management of cytoreductive surgery with intraperitoneal chemotherapy has been a near universal standard of care for epithelioid peritoneal mesothelioma provided that the patient is an appropriate candidate for surgical interventions. To the best of our knowledge, this is the first case report of malignant peritoneal mesothelioma as a second primary carcinoma, many years after exposure to radiation therapy for colon adenocarcinoma.

INTRODUCTION AND OBJECTIVE:Recurrence after URF repair usually occurs from the urinary side of the fistula. This study evaluates the clinical significance of a radiological leak on pericatheter ure...

Penile urethral strictures have been managed by a staged surgical approach. In selected cases, spongiofibrosis can be excised, a neo-urethral plate created using buccal mucosa graft (BMG) and tubularized during the same procedure, performing a “two-in-one” stage approach. We aim to identify stricture factors which indicate suitability for this two-in-one stage approach. We assess surgical outcome and compare with staged reconstruction. We conducted an observational descriptive study. The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017. The minimum follow-up was 6 months. Outcomes were assessed clinically, radiologically, and by flow-rate analysis. Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention. Descriptive analysis of stricture characteristics and statistical comparison was made between groups. Of 425 penile urethroplasties, 139 met the inclusion criteria: 59 two-in-one stage and 80 staged. The mean stricture length was 2.8 cm (single stage) and 4.5 cm (staged). Etiology was lichen sclerosus (LS) 52.5% (single stage) and 73.8% hypospadias related (staged). 40.7% of patients had previous failed urethroplasties in the single-stage group and 81.2% in the staged. The most common stricture locations were navicular fossa (39.0%) and distal penile urethra (59.3%) in the single-stage group and mid or proximal penile urethra (58.7%) in the staged group. Success rates were 89.8% (single stage) and 81.3% (staged). A trend toward a single-stage approach for select penile urethral strictures was noted. We conclude that a single-stage substitution penile urethroplasty using BMG as a “two-in-one” approach is associated with excellent functional outcomes. The most suitable strictures for this approach are distal, primary, and LS-related strictures.

Cowper's syringoceles are uncommon, usually described in children and most commonly limited to the ducts. We describe more complex variants in an adult population affecting with varying degrees of severity, the glands themselves, and the complications they may lead to. One hundred consecutive urethrograms of patients with unreconstructed strictures were reviewed. Twenty-six patients (mean age: 41.1 years) with Cowper's syringoceles who were managed between 2009 and 2016 were subsequently evaluated. Presentation, radiological appearance, treatment (when indicated), and outcomes were assessed. Of 100 urethrograms in patients with strictures, 33.0% demonstrated filling of Cowper's ducts or glands, occurring predominantly in patients with bulbar strictures. Only 1 of 26 patients with non-bulbar strictures had a visible duct/gland. Of 26 symptomatic patients, 15 presented with poor flow. In four patients, a grossly dilated Cowper's duct obstructed the urethra. In the remaining 11 patients, a bulbar stricture caused the symptoms and the syringocele was identified incidentally. Eight patients presented with perineal pain. In six of them, fluoroscopy and magnetic resonance imaging (MRI) revealed complex multicystic lesions within the bulbourethral glands. Four patients developed perineoscrotal abscesses. In the 11 patients with strictures, the syringocele was no longer visible after urethroplasty. In three of four patients with urethral obstruction secondary to a dilated Cowper's duct, this resolved after transperineal excision (n = 2) and endoscopic deroofing (n = 1). Five of six patients with complex syringoceles involving Cowper's glands were excised surgically with symptomatic relief in all. In conclusion, Cowper's syringocele in adults is more common than previously thought and may cause lower urinary tract symptoms or be associated with serious complications which usually require surgical treatment.

INTRODUCTION AND OBJECTIVE:Urethro-cutaneous fistula (UCF) originating from the anterior urethra in adult men is an uncommon presentation. We describe our experience in managing this problem.METHOD...

INTRODUCTION AND OBJECTIVES:This study evaluates the outcome of redo-urethroplasty in patients with recurrent penile, bulbar or posterior urethral strictures with a particular view to identifying a...

INTRODUCTION AND OBJECTIVES:Problematic urethral catheterization before or immediately after complex genitourinary reconstructive surgery (GURS) can be a difficult scenario even for expert surgeons...

Fistulation is a relatively uncommon complication resulting from the treatment of pelvic malignancy but one which is associated with significant patient morbidity. Fistulae complicating treatment with radiation, when compared to those arising from surgical management alone, are usually more difficult to treat by virtue of tissue ischaemia and fibrosis. They are also commonly associated with other complications resulting from the effect of radiation on adjacent organs such as the bladder, lower intestinal tract and pelvic bones as well as the frequent occurrence of intervening cavitation and chronic pelvic sepsis, all of which render these fistulae complex. Complex radiotherapy fistulae necessitate a change in the standard approach to fistula management. In a non-tertiary setting, they are often treated by urinary or bowel diversion (or both). Surgical correction of complex fistulae following radiotherapy is nonetheless possible in experienced hands but commonly requires extensive reconstructive procedures via an abdominoperineal approach with a protracted recovery and reduced potential for return to complete functional normality.

To investigate the concept of 'urethral atrophy', which is often cited as a cause of recurrent incontinence after initially successful implantation of an artificial urinary sphincter (AUS); and to investigate the specific cause of the malfunction of the AUS in these patients and address their management.Between January 2006 and May 2013, 50 consecutive patients (mean age 54.3 years) with recurrent incontinence had their AUS explored for malfunction and replaced with a new device with components of exactly the same size, unless there was a particular reason to use something different. Average time to replacement of the device was 10.1 years. The mean follow-up after replacement of the device was 24.7 months. All patients without an obvious cause for their recurrent incontinence had preoperative urodynamic evaluation, including measurement of the Valsalva leak point pressure (VLPP) and the retrograde cuff occlusion pressure (RCOP). After explantation of the AUS in patients without any apparent abnormality of the device at the time of replacement, the pressure generated by the explanted pressure-regulating balloon (PRB) was measured manometrically, when this was possible. In a select group of six consecutive patients of this type, the fibrous capsule surrounding the old cuff was incised then excised to expose and evaluate the underlying corpus spongiosum.In 31 of the 50 patients (62%) undergoing exploration, a specific cause for the malfunction of their AUS was defined. In the other 19 patients (38%) no cause was found, either preoperatively or at the time of exploration, other than a low VLPP and RCOP. A typical 'waisted' or 'hour-glass' appearance of the underlying corpus spongiosum was demonstrable, to some degree, on explanting the cuff in all cases. In the six patients in whom the restrictive sheath surrounding the cuff was excised, the urethral circumference immediately returned to normal after the compressive effect of the sheath was released. Manometry of the explanted PRBs, when this was possible, showed a loss of pressure in all instances. Replacement of the explanted AUS with a new device with the same size cuff and PRB in 14 of these 19 patients was successful in 12 (85.7%).These results, and other theoretical considerations, suggest that recurrent incontinence, years after initially successful implantation of an AUS, is because of material failure of the PRB, probably attributable to its age and consequent loss of its ability to generate the pressure it was designed to produce, and that urethral atrophy does not occur. Simply replacing the old device with a new one with the same characteristics, unless there is a particular reason to do otherwise, is usually successful and avoids the complications of alternatives such as as cuff downsizing, implanting a PRB with a higher pressure range, implantation of a second cuff or transcorporeal cuff placement, all of which have been advocated in these patients.

INTRODUCTION AND OBJECTIVES: Bulbo-prostatic anastomotic urethroplasty (BPA) for urethral injuries associated with traumatic disruption of the pelvic ring is notoriously a surgical challenge, often requiring various manouvres to straighten the course of the bulbar urethra and bridge the resulting defect. There are however other factors which may render the reconstructive procedure more complex. This study investigates these factors. METHODS: 360 BPAs were performed in a single tertiary referral centre between October 1996 and October 2014. 77 (21%) were revision procedures. Mean patient age was 37.9 years. Mean follow-up was 51 months (range 9-115 months). Recurrence was defined radiologically and/or by the need for any further surgical intervention including dilatation or urethrotomy. RESULTS: 286 (79%) procedures were carried out transperineally (Step 1-4) while 74 (21%) required additional abdominal exposure to mobilise the bladder bladder base (n1⁄416), repair associated injuries (n1⁄441) or perform an entero-urethroplasty (n1⁄417). 29 of 74 (39%) abdomino-perineal (AP) procedures were revisions. 48 of 77 revisions (62%) were performed via a transperineal approach. The restricture rate was higher for revision procedures compared to primary ones when approached transperineally (15% vs 8%) but not for AP procedures (21% in both primary and revision cases). Overall, the recurrence rate for AP procedures was 21% compared to 9% for the transperineal approach. Associated bladder neck injury (n1⁄418), uro-rectal/perineal fistulae (n1⁄415), perineal degloving injury (n1⁄46), anterior urethral stricture (n1⁄419) and osteomyelitis/pelvic sepsis (n1⁄410) were identified as factors adding complexity to the procedure. CONCLUSIONS: A longer defect and revisional surgery often require corporal separation, inferior wedge pubectomy and rerouting of the urethra around the crura in a stepwise fashion in order to guarantee a tension-free anastomosis. These render the procedure more difficult but do not necessarily imply increasing complexity. Factors necessitating a change in approach (usually but not exclusively requiring additional abdominal exposure) to deal with multiple pathologies such as the need for bladder neck reconstruction or concominant anterior urethral strictures are what render the procedure complex.

Excision and end-to-end anastomosis (EPA) has been the preferred urethroplasty technique for short bulbar strictures and is associated with an excellent functional outcome. Driven by concerns over the potential morbidity associated with dividing the urethra, therefore compromising spongiosal blood flow, as well as spongiofibrosis being superficial in the majority of non-traumatic bulbar strictures, the non-transecting technique for bulbar urethroplasty has been developed with the aim of achieving the same success as EPA without the morbidity associated with transection. This manuscript highlights the fundamental principles underlying the ongoing debate—transection or non-transection of the strictured bulbar urethra? The potential advantages of avoiding dividing the corpus spongiosum of the urethra are discussed. The non-transecting anastomotic procedure together with its various modifications are decribed in detail. Our experience with this technique is presented. Non-transecting excision of spongiofibrosis with preservation of well vascularised underlying spongiosum provides an excellent alternative to dividing the urethra during urethroplasty for short non-traumatic proximal bulbar strictures.

INTRODUCTION AND OBJECTIVES: Augmentation cystoplasty has been used for over 50 years as a surgical treatment for patients with dysfunctional bladder disorders. Some of these patients may require an artificial urinary sphincter (AUS) to maintain continence; and to perform clean intermittent self-catheterisation (CISC) to ensure bladder emptying. This study reviews outcomes of patients with neuropathic bladder disorders who have had both cystoplasty and AUS implantation. We compare the outcomes of those that regularly CISC with those that do not. METHODS: In this retrospective cohort study, 123 patients (77 male, 46 female) underwent augmentation cystoplasty, by a single surgeon, with implantation of an AUS. The cohort was divided into 2 groups. Group 1 (n1⁄467) performed CISC and group 2 (n1⁄456) did not. Mean age at time of initial surgery was 22 years (4.3-73 years). Mean follow up was 25 years (12-32 years). RESULTS: Of 123 patients, 85 (group 1 n1⁄442 vs. group 2 n1⁄443) had the AUS removed after a mean of 6.3 years (2 days 23.4 years). The mean time to explant was equal in groups 1 and 2 (6.4 years vs 6.2 years). In group 1, erosion occurred in 48.8%, infection in 2.4%, and malfunction 48.8%. The mean time to explant was 4.95 years (42 days 18 years) for erosion and 8.2 years (85 days 23.5 years) for malfunction. 1 patient had infection at 2 days. In group 2 the devices were removed due to erosion in 53.4%, and malfunction in 44.3%; after a mean of 5.1 years (60 days 21.4 years), and 9.6 years (0.7 23.5 years) respectively. There was 1 AUS removed for infection after 23 days. 51 patients went on to have a second AUS implanted with 28 (55%) being removed after a mean of 4.9 years, with 14 patients in each group. Erosion occurred in 39.2%, infection in 3.7%, and malfunction in 57.1%. The mean time to explant following erosion was similar in groups 1 and 2 (4.04 vs. 4.05 years). In group 1 there was one patient with infection at 91 days. There were no early infections in group 2. CONCLUSIONS: Patients with augmentation cystoplasty and an AUS developed erosion and infection at equal rates and mean time whether they performed CISC or not.

INTRODUCTION AND OBJECTIVES: Augmentation cystoplasty has been used for over 50 years as a surgical treatment for patients with dysfunctional bladder disorders. Some of these patients may require an artificial urinary sphincter (AUS) to maintain continence; and to perform clean intermittent self-catheterisation (CISC) to ensure bladder emptying. This study reviews outcomes of patients with neuropathic bladder disorders who have had both cystoplasty and AUS implantation. We compare the outcomes of those that regularly CISC with those that do not. METHODS: In this retrospective cohort study, 123 patients (77 male, 46 female) underwent augmentation cystoplasty, by a single surgeon, with implantation of an AUS. The cohort was divided into 2 groups. Group 1 (n1⁄467) performed CISC and group 2 (n1⁄456) did not. Mean age at time of initial surgery was 22 years (4.3-73 years). Mean follow up was 25 years (12-32 years). RESULTS: Of 123 patients, 85 (group 1 n1⁄442 vs. group 2 n1⁄443) had the AUS removed after a mean of 6.3 years (2 days 23.4 years). The mean time to explant was equal in groups 1 and 2 (6.4 years vs 6.2 years). In group 1, erosion occurred in 48.8%, infection in 2.4%, and malfunction 48.8%. The mean time to explant was 4.95 years (42 days 18 years) for erosion and 8.2 years (85 days 23.5 years) for malfunction. 1 patient had infection at 2 days. In group 2 the devices were removed due to erosion in 53.4%, and malfunction in 44.3%; after a mean of 5.1 years (60 days 21.4 years), and 9.6 years (0.7 23.5 years) respectively. There was 1 AUS removed for infection after 23 days. 51 patients went on to have a second AUS implanted with 28 (55%) being removed after a mean of 4.9 years, with 14 patients in each group. Erosion occurred in 39.2%, infection in 3.7%, and malfunction in 57.1%. The mean time to explant following erosion was similar in groups 1 and 2 (4.04 vs. 4.05 years). In group 1 there was one patient with infection at 91 days. There were no early infections in group 2. CONCLUSIONS: Patients with augmentation cystoplasty and an AUS developed erosion and infection at equal rates and mean time whether they performed CISC or not.

INTRODUCTION AND OBJECTIVES: While the perineal urethrostomy (PU) has proven to be a highly successful option for patients with complex urethral stricture disease, it is often utilized as a last resort. The perceived disadvantages of this procedure include the loss of normal anatomy, need to sit to urinate, and concerns about potency and sexual function. We aim to describe our contemporary series of patients treated with perineal urethrostomy. METHODS: We conducted an IRB approved, retrospective review of all patients who underwent PU from 1996 to 2012. Inclusion criteria were age > 18 and male gender. Patients with a temporary PU as part of a staged repair were excluded. Data extracted included patient demographics, stricture etiology, comorbidities, previous therapies, and need for subsequent interventions. All patients who received perineal urethrostomy as definitive management were included in the analysis. PU was considered successful if there was no need for subsequent interventions including dilations, self-calibration or surgical revision. RESULTS: A total of 718 patients underwent urethral reconstruction in the studied time period. Of these, 56 received a PU (7.8%). Etiology was lichen sclerosus in 20 (36%), hypospadias in 10 (18%), and trauma or idiopathic in 26 (46%). Mean follow-up was 21 months. All of these cases consisted of creation of a posteriorly based flap perineal urethrostomy as described by Barbagli. Eight out of 56 patients received a PU after electing not to proceed with a planned second stage urethroplasty. Twenty-eight of the 48 (58%) patients who intended to have definitive PU had failed at least one previous urethroplasty compared with 2 of 8 (25%) patients intending to have staged repair (p1⁄40.1). Of the 56 patients, two patients (3.6%) developed stenosis of the PU. One patient underwent a successful revision of the perineal urethrostomy and the other was placed on self-dilations. Prior radiation, stricture etiology, BMI, diabetes, prior urethroplasty, and stricture length were not predictive of failure. CONCLUSIONS: Perineal urethrostomy is a highly successful technique for severe urethral stricture disease that arrests the need for further interventions in the vast majority of cases with a very low complication or revision rate.

INTRODUCTION AND OBJECTIVES: Previous publications have reported on the role of ureteral reconstructive techniques for repair of ureteral defects from extirpative surgery for urologic malignancies or external trauma. Our institution has managed a large volume of ureteral obstruction and injuries from other sources such as iatrogenic injury during pelvic surgery and retroperitoneal fibrosis. We sought to review this experience, report on outcomes, and develop an algorithm for treatment. METHODS: We reviewed the charts of 139 patients that underwent ureteral reconstruction or endoscopic treatment of ureteral injury in an eleven-year period at a single institution by three surgeons (TTH, PJM, BJF). Data including mechanism of injury, type of repair, location of injury, length of stricture, comorbid factors, length of follow up, success rate, complications, and need for secondary procedures was obtained. Success rate was defined based on ureteral patency and stabilization or improvement of renal function. RESULTS: 115 patients met inclusion criteria, of which 18 were bilateral systems, for a total of 133 renal units. 24 patients were excluded due to primary repair for UPJ obstruction, active malignancy, or external traumatic injuries. Mechanism of injury included iatrogenic injury during pelvic surgery (50%), radiation-induced or idiopathic retroperitoneal fibrosis (26%), endoscopic stone surgery (4%), and other (20%). Location of the injury was proximal (22%), mid (36%), and distal ureter (42%). The average length of stricture was 5 cm. The type of repair included ureterolysis +/omentoplasty (n 1⁄4 17), ureteroureterostomy (n 1⁄4 5), ureteral reimplant +/psoas hitch (n 1⁄4 58), Boari Flap (n 1⁄4 2), TUU (n 1⁄4 3), ileal ureter (n 1⁄4 39). Our primary success rate was 93%, with 7% of patients undergoing a subsequent procedure. Of the 9 failures, 3 underwent successful secondary procedure for a total success rate of 95%. There were 11 major complications defined as a Clavien grade 3 or greater including bowel obstruction, enterocutaneous fistula, anastomotic dehiscence, boari flap necrosis, and one death within 90 days. Median length of follow up was 121 days. CONCLUSIONS: Ureteral reconstruction for benign stricture disease is highly successful. Most strictures can be resolved utilizing simple techniques such as ureteral reimplantation +/psoas hitch. Longer strictures, particularly those involving the proximal or mid ureter, often require complex techniques such as ileal-ureteral substitution.

The surgical and non-surgical treatment of localised prostate cancer may be complicated by bladder neck contractures, prostatic urethral stenoses and bulbomembranous urethral strictures. In general, such complications following radical prostatectomy are less extensive, easier to treat and associated with a better outcome and more rapid recovery than the same complications following radiotherapy, high-intensity focussed ultrasound and cryotherapy. Treatment options range from minimally invasive endoscopic procedures to more complex and specialised open surgical reconstruction.In this chapter the surgical management of bladder neck contractures following the treatment of prostate cancer is described together with the management of prostatic urethral stenoses and bulbomembranous urethral strictures, given the difficulty in distinguishing them from one another clinically.

INTRODUCTION AND OBJECTIVES: Sacral Neuro Stimulation (SNS) is an FDA approved treatment for urgency/frequency, urge incontinence, urinary retention, and fecal incontinence. Successful outcome is predicated on accurate location of the lead based on anatomy and physiologic response. Adjacent foramina S2, S3, and S4 may have sufficient locational overlap to cause unintended clinical localization of the wrong foramina. Detailed anatomic imaging and analysis may provide relevant information regarding lead placement effecting patient response. METHODS: DICOM images from a de-identified, IRB-approved database of 1mm slice pelvic CT images were rendered into 3D models using Mimics (Materialise) software. Images with bony deformity were excluded. Points of interest, tagged throughout each pelvis, were used to measure angles and distances of interest on the rendered 3D volumetric models. Both male and female pelvic CT images were included. The medial-lateral distance from the medial edge of the S2-S4 foramina to the sacral spinous processes were measured, along with the caudad-cephalad distances from the cephalad edge of S2-S4 foramina to the dorsal aspect of the sacro-iliac (SI) joints. The position of S2, S3, and S4 relative to the sacral spinous processes and inferior SI joints were determined, with sub-populations (clusters) of S2, S3, and S4 foramina identified. Statistical analysis was performed using SPSS 18.0 (IBM, Somers, NY). RESULTS: Of the 150 pelvises enrolled, 133 met criteria for inclusion. The greatest adjacent population overlap occurs bilaterally between the most caudad cluster of S2 and the most cephalad cluster of S3, regarding which up to 9% (12/133) of the left and up to 14% (18/133) of the right S2 foramina may be errantly localized during a clinical attempt to locate S3. Overlap between the most caudad S3 cluster with the two most cephalad S4 clusters represents insignificant clinic impact ( 4%). 20% of the total population had a fifth left sacral foramen, and 22% had a fifth right sacral foramen. CONCLUSIONS: Significant anatomic variation exists in regard to foramen location. Reliance on anatomic landmarks alone or unreliable physiologic responses may hinder accurate lead placement. Further investigation, such as cadaveric or clinical trial, is necessary to obtain more conclusive data regarding the true clinical incidence of errant foramen localization.

INTRODUCTION AND OBJECTIVES: Neo-adjuvant chemoradiation is commonly administered nowadays prior to abdomino-perineal resection (APR) or anterior resection (AR) for locally invasive rectal cancer. This has changed the nature and severity of the urological complications that may arise from the surgery alone. METHODS: 21 patients (54-80, mean 63 years) presented 3 months to 3 years (mean 1 year) after surgery and radiotherapy for rectal cancer. 13 had a urocutaneous fistula or a urorectal fistula (URF) following APR. 4 developed a URF after AR. Four others presented with voiding difficulty and recurrent urinary tract infection (UTI) after APR. All had pelvic pain which was inversely related to the volume of the leakage. Retrograde urethrography and MRI showed a fistulous track, usually arising from the prostatic urethra, between the verumontanum and the bladder neck, with a variable degree of cavitation into the presacral space in all. Four patients with less troublesome symptoms were treated conservatively but 1 subsequently required surgery for an infected cavity that ruptured. He and 15 of the 17 others had the cavitating fistula excised and a repair of the urinary defect, and of the rectum in those with a URF after an AR. The repair was transperineal in 12 and abdomino-perineal in 4. The other 2 had a single diversion of the urinary tract or the bowel with repair of the other system. RESULTS: 8 of 12 transperineal repairs were successful. 4 failed, generally because of failure to obliterate the presacral cavity with gracilis muscle, and were repeated abdomino-perineally. These and 4 other abdomino-perineal repairs (in which the omentum was used to pack the cavity) were all successful. In all, 8 patients required an augmentation cystoplasty to deal with a small bladder or to close the defect in the prostatic urethra or, usually, for both. 2 patients have required an Artificial Sphincter (AUS) subsequently; 5 wear 1-2 pads a day; the other 9 with a urinary reconstruction are dry. The post-operative recovery is commonly protracted. Although the surgery usually gives a clinically satisfactory result, the radiological result often appears anatomically imperfect. CONCLUSIONS: Most patients with fistulae following treatment of rectal cancer can be salvaged and do not need a double diversion. Some, with minor symptoms, do not need surgery at all. Reconstruction is a major undertaking; is usually best done abdomino-perineally; commonly requires a cystoplasty for a small bladder or to close the defect in the prostatic urethra or both; and may need further surgery to implant an AUS.