The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula.

OBJECTIVE: To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF). RUF may appear after radical prostatectomy. Their treatment represents a challenge; many therapies have been proposed, from conservative to aggressive surgical approaches. Transanal endoscopic surgery (TEO or TEM) is a minimally invasive technique to access the site of the RUF to perform repair. MATERIALS AND METHODS: This is an observational study with prospective data collection, conducted between September 2006 and December 2015. All patients were diagnosed with RUF following management of prostate cancer. Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion. If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition. If this failed, gracilis muscle was applied as salvage therapy. RESULTS: Ten patients were diagnosed with RUF. In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion. Eight patients underwent repair by TEO or TEM, 4 with biological mesh interposition; all 4 presented recurrence. In the other 4 patients treated via TEO or TEM, 2 had early recurrence, whereas the others had healed at follow-up visits after 4-6 months (2 of 8)-a success rate of 25%. The 6 patients who recurred were treated with gracilis muscle interposition via a transperineal approach. CONCLUSION: The low rate of positive results obtained by TEO or TEM argues against its use as technique of choice in RUF, and against the use of biological meshes.

[Urological outcome of patients with sacral agenesis: 20 years follow-up]. / Evolución urológica de pacientes con agenesia de sacro: 20 años de seguimiento.

OBJECTIVES: Complete or partial sacral agenesis is a rare malformation consisting in the absence of one or more sacral vertebrae. It is part of a caudal regression syndrome and it may be associated with other congenital anomalies (Currarino Syndrome). It does not have an established etiology but is associated with insulin-dependent diabetes mellitus in the mother (1%). The objective of this is study was to retrospectively analyze the urological outcome of patients with sacral agenesis in our case series. METHODS: Retrospective analysis of 14 patients between 1975 and 2005. We evaluated reason for consultation, urological status, continence outcome, urological complications, hospital admissions and number of office visits. RESULTS: No patient had history of diabetic mother The number of male/female patients were similar. Mean age at first visit was 13.2 years and main reason for consultation was urinary incontinence. 60% of the patients presented associated myelomeningocele. 70% had a normal upper urinary tract at the beginning of follow-up; 10 patients presented some degree of incontinence (70%). Mean follow-up was 19.7 years (7-30): 50% of the patients keep a normal upper urinary tract. All of them have presented symptomatic urinary tract infection. The main urological reason for hospital admission was programmed surgery (7). The mean number of visits per year was 1.9. CONCLUSIONS: Sacral agenesis is a rare congenital malformation requiring an early diagnosis to avoid mid-term urological complications. These patients need life-long urological follow-up. The mean reason for consultation is urinary incontinence secondary to neurogenic bladder which may be satisfactorily treated in most cases.

Evolución urológica de pacientes con agenesia de sacro: 20 años de seguimiento / Urological outcome of patients with sacral agenesis: 20 years follow-up

OBJETIVO: La agenesia sacra total ó parcial es una malformación infrecuente que consiste en la ausencia de una ó más vértebras sacras. Forma parte del síndrome de regresión caudal y se puede asociar a otras anomalías congénitas (síndrome de Currarino). No tiene una etiología establecida pero se asocia a madres diabéticas insulinodependientes (1%). El objetivo de este estudio ha sido analizar retrospectivamente la evolución urológica de los pacientes con agenesia sacra de nuestra serie. MÉTODOS: Análisis retrospectivo de 14 pacientes entre 1975 y 2005. Se valoró el motivo de consulta, situación urológica y neurológica de entrada, tiempo de seguimiento, evolución de la continencia, complicaciones urológicas, ingresos hospitalarios y número de visitas ambulatorias. RESULTADOS: Ningún paciente tenía antecedentes de madre diabética. La distribución por sexos fue similar. Todos los casos fueron de agenesia total. La edad media en la primera visita fue de 13,2 años y el principal motivo de consulta fue la incontinencia urinaria. El 60% de pacientes presentaban mielomeningocele asociado. El 70% tenían el tracto urinario superior normal al inicio del seguimiento; 10 pacientes presentaban algún grado de incontinencia (70%). El tiempo medio de seguimiento ha sido de 19,7 años (7-30): el 50% de los pacientes mantienen el tracto urinario superior normal. El 65% de los pacientes se mantienen continentes. Todos han presentado infección urinaria sintomática. El motivo urológico principal de ingreso hospitalario ha sido la cirugía programada (7). El número medio de visitas anuales por paciente ha sido de 1,9. CONCLUSIONES: La agenesia de sacro es una malformación congénita infrecuente que requiere un diagnóstico precoz para evitar complicaciones urológicas a medio plazo. Estos pacientes son subsidiarios de un control urológico de por vida. El principal motivo de consulta es la incontinencia urinaria por vejiga neurógena que puede ser tratada satisfactoriamente en la mayoría de los casos

OBJECTIVES: Complete or partial sacral agenesis is a rare malformation consisting in the absence of one or more sacral vertebrae. It is part of a caudal regression syndrome and it may be associated with other congenital anomalies (Currarino Syndrome). It does not have an established etiology but is associated with insulin-dependent diabetes mellitus in the mother (1%). The objective of this is study was to retrospectively analyze the urological outcome of patients with sacral agenesis in our case series. METHODS: Retrospective analysis of 14 patients between 1975 and 2005. We evaluated reason for consultation, urological status, continence outcome, urological complications, hospital admissions and number of office visits. RESULTS: No patient had history of diabetic mother. The number of male/female patients were similar. Mean age at first visit was 13.2 years and main reason for consultation was urinary incontinence. 60% of the patients presented associated myelomeningocele. 70% had a normal upper urinary tract at the beginning of follow-up; 10 patients presented some degree of incontinence (70%). Mean follow-up was 19.7 years (7-30): 50% of the patients keep a normal upper urinary tract. All of them have presented symptomatic urinary tract infection. The main urological reason for hospital admission was programmed surgery (7). The mean number of visits per year was 1.9. CONCLUSIONS: Sacral agenesis is a rare congenital malformation requiring an early diagnosis to avoid mid-term urological complications. These patients need life-long urological follow-up. The mean reason for consultation is urinary incontinence secondary to neurogenic bladder which may be satisfactorily treated in most cases