The York Mason approach to repair of iatrogenic rectourinary fistulae

doi:10.1016/S0002-9610(96)00015-3

The American Journal of Surgery

Volume 173, Issue 3, March 1997, Pages 213-217

https://doi.org/10.1016/S0002-9610(96)00015-3 Get rights and content

Background

We report our experience of 8 patients who underwent repair of iatrogenic rectourinary fistulae via the transsphincteric (York Mason) approach.

Patients and Methods

Eight patients developed rectourinary fistulae in the course of treatment of prostate cancer. Three fistulae developed after radiation therapy alone, three after prostatectomy, and two after both surgery and radiation therapy. Five patients underwent fecal diversion in conjunction with repair.

Results

All fistulae remained closed after repair. All patients were continent of stool after primary surgery or after colostomy closure if they had been diverted. Two patients had complications associated with urethral catheters that resolved with changing the catheters.

Conclusion

The transsphincteric (York Mason) approach in the repair of rectourinary fistulae results in successful closure of the fistulae without impairment of continence to stool. This procedure is much simpler than complicated transabdominal or transperineal approaches to these fistulae.

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Cited by (63)

Incidence of Rectal Injury After Radical Prostatectomy: A Systematic Review and Meta-analysis
2023, European Urology Open Science
Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.
To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.
A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.
Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46–0.73) in contemporary series with significant across-study heterogeneity (I² = 100%, p < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66–2.38) and laparoscopic RP (1.25%; 95% CI 0.75–2.08) followed by perineal RP (0.19%; 95% CI 0–276.95) and robotic RP (0.08%; 95% CI 0.02–0.31). Age ≥60 yr (0.56%; 95% CI 0.37–06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99–9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92–18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.
RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.
Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.
Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series
2020, International Journal of Surgery Case Reports
Citation Excerpt :
In a minority of patients recto-urethral/vesical or rectovaginal fistula can occur, which are most frequently caused by surgery, trauma, diverticulitis, Crohn’s disease and cancer [5,6]. In particular the iatrogenic rectovaginal or rectovesical fistulae after pelvic surgery rarely heal without surgical reintervention [7,8]. Definitive surgical treatment of the fistula is associated with postoperative morbidity, such as surgical site infections (22%), urethral incontinence (16.7%), intra-abdominal abscesses (16.7%), as well as a high failure rate i.e. recurrence of the fistula (44%) [9,10].
Iatrogenic recto-urogenital fistulae are refractory complications that rarely heal without surgical intervention. The ongoing local infection causes pain, discomfort and substantially impacts quality of life. Surgical repair requires adequate exposure and space to fill with healthy tissue, which is a major challenge in pelvic redo surgery. An abdominal approach to repair the fistula is associated with major morbidity and often fails to expose the deep pelvis. In our experience a novel transperineal minimally invasive approach a utilizing single incision laparoscopic surgery (SILS) technique could offer improved results.
In the present study, three cases of patients with recto-urogenital fistulae after pelvic surgery are described. Two patients were diagnosed with a rectovesical fistula and one patient with a rectovaginal fistula. In all three cases, a minimally invasive perineal approach, using a SILS port, was used to perform surgical repair. The closure of the fistulae involved: a separate repair of the urethra/bladder or vaginal defect and the rectal defect, followed by interposition of vascularized tissue by either a pudendal thigh fasciocutaneous flap or omentoplasty.
This study is the first to report on a minimally invasive perineal approach, utilizing a SILS technique for recto-urogenital fistulae repair after previous pelvic surgery. The current approach improves exposure, creates surgical space, optimizes view and allows the interposition of vascularized tissue, without causing substantial blood loss and avoiding major abdominal surgery.
Modified Transanosphincteric (York Mason) Repair of Nonradiated Rectourinary Fistulae: Patient-reported Fecal Continence Outcomes
2018, Urology
To review our experience with the modified York Mason (MYM) procedure in the treatment of rectourinary fistulas (RUFs) and to assess fecal continence using patient-reported measures.
A retrospective review was performed of patients who underwent MYM repair of nonradiated RUF with gluteal free fat graft from 2008 to 2016 at a single institution. Success was defined as resolution of the fistula without need for further surgery. The Cleveland Clinic-Florida Wexner Fecal Incontinence Score (CCFFIS) and the Patient Global Impression of Improvement (PGI-I) surveys were administered by phone.
Of 17 patients who underwent MYM repair with a mean age of 61.8 years old, the most common fistula etiologies were prostatectomy in 11 patients (65%), cryoablation in 2 patients (12%), and transanal tumor excision (12%). Three patients (18%) failed prior perineal repairs. The mean fistula size was 10.1 mm (range 2-25), the median operative time was 231 minutes (range 151-365), and the median length of stay was 2.0 days (range 1-13). At the median follow-up of 39.4 months, 16 of the 17 patients (94%) had successful primary closures. The condition of the 10 patients who responded to the phone survey was “much better” (median PGI-I score 2), with 89.5% mean improvement. The mean CCFFIS was 1.4 (range 0-5) on a scale of 0 (total continence) to 20 (complete incontinence). Two patients (20%) reported rare (<1 per month) fecal incontinence, and 2/10 (20%) reported frequent flatal incontinence, but none reported significant lifestyle change or sought further treatment for bowel symptoms.
The MYM technique has a high success rate in the treatment of nonradiated RUF with negligible impact on fecal continence.
Gracilis muscle transposition for complex perineal fistulas and sinuses: A systematic literature review of surgical outcomes
2014, Journal of the American College of Surgeons
Recto-uretral fistulas management with the York Mason procedure: Surgical techniques and outcomes
2014, Progres en Urologie
Rapporter notre expérience de réparation des fistules uréthro-rectales (FUR) par la technique de York Mason.
Nous avons analysé rétrospectivement, les dossiers des patients traités chirurgicalement pour FUR par la technique de York Mason, entre 2000 et 2012.
Dix-sept patients ont été inclus dans l’étude. Tous les patients avaient une dérivation digestive avant l’intervention. Nous avons observé quatre récidives de FUR (23,5 %). Les récidives sont intervenues sur un terrain radique pour deux patients et sur une récidive carcinologique pour un patient. La quatrième récidive a été traitée par une deuxième intervention de York Mason avec succès.
Dans notre étude, l’utilisation de la technique de York Mason a été fiable et reproductible pour le traitement des FUR. Le facteur principal d’échec était un antécédent de radiothérapie pelvienne.
5.
To report our experience for the management of urethro-rectal fistula by the York Mason technique.
We retrospectively analyzed the data of patients treated surgically for FUR by the technique of York Mason, between 2000 and 2012.
Seventeen patients were included in the study. All patients had a bowel diversion before surgery. We observed four recurrences of FUR (23.5%). Recurrences occurred in a radiation field for two patients and in a oncologic recurrence for 1 patient. The fourth recurrence was treated by a second procedure of York Mason successfully.
In our study, the York Mason technique was safe and reproducible for the treatment of FUR. The main factor of failure was a history of pelvic radiotherapy.
Twenty-year experience with surgical management of recto-urinary fistulas by posterior sagittal transrectal approach (York-Mason)
2011, Surgery
Citation Excerpt :
Since 2010, patients have undergone only colostomy. Patients were treated with the York-Mason technique as described previously.2,5 In this procedure, the patient is placed in a jack-knife position and adhesive tape is used to spread the buttocks.
We describe our 20-year experience with a posterior transrectal approach (York-Mason procedure) to treat recto-urinary fistula (RUF). Most RUFs are secondary to lower urinary or intestinal tract surgery. Spontaneous closure is infrequent, and operative treatment is often mandatory. Several surgical approaches have been proposed.
We reviewed retrospectively the medical records of 14 patients presenting with RUF in our Department between 1988 and 2010. In 10 patients, RUFs developed after radical retropubic prostatectomy (RRP); in the other 4 patients, RUFs resulted after other surgical interventions. All patients were treated with the York-Mason approach. A temporary colostomy and suprapubic cystostomy were performed in all patients except one.
All patients were treated successfully. After fistulectomy, colostomies were closed after 4 mo, and patients reported fecal continence and no postoperative anal strictures. The colostomy was left in place permanently in 1 patient due to the simultaneous presence of Crohn’s disease, in another with ulcerative rectocolitis, and in a third scheduled for adjuvant radiotherapy for relapse after RRP. In 1 patient, daily medications were essential because of wound infection. In the patient with Crohn’s disease, the fistula recurred 11 years after first repair. Two patients died of metastatic prostate cancer 1 year after repair of the RUF.
The posterior sagittal transrectal approach allows easy access and good surgical exposure, facilitating identification of the fistulous tract. In our opinion, the York-Mason approach guarantees the greatest success rate with the least morbidity.

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^**: The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.

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The York Mason approach to repair of iatrogenic rectourinary fistulae**

Background

Patients and Methods

Results

Conclusion

Urology

J Urol

J Urol

J Urol

J Urol