Management of post-traumatic rectovesical/rectourethral fistulas: Case series of complicated injuries in wounded warriors and review of the literature

Abstract

Introduction: Penetrating injuries to the pelvis and perineum can result in fistulas between the rectum and lower urinary tract. These injuries are often complicated, which creates challenges for successful repair. Operative strategies may include initial fecal and/or urinary diversion combined with an eventual trans-perineal, trans-anal, or posterior/transrectal approach, but the selected approach should be guided by precise anatomic localization of the injury. We aim to discuss different possible repair strategies as well as the relevant data surrounding gastrointestinal-genitourinary (GI-GU) fistula management. Materials and Methods: We present this series of three post-traumatic rectovesical and rectourethral fistulas to illustrate the surgical options for treatment of these conditions. In this series, we have retrospectively reviewed our experience at Walter Reed National Military Medical Center in caring for three Wounded Warriors who had suffered these types of injuries. The study was exempt from institutional review board approval because of the size of the series. Results: Our three patients all were managed with initial urinary and fecal diversion before an eventual trans-perineal, trans-anal, or posterior/transrectal approach. All three patients ultimately underwent reversal of diverting ostomies with good functional results and successful resolution of their GI-GU fistulas. Conclusions: This series demonstrates the complexity of traumatic GI-GU fistulas. Successful management depended on early diversion of both urine and feces, localization of the fistula, and an interdisciplinary surgical approach specifically tailored to each patient. All three patients had favorable overall functional outcomes despite their devastating injuries. This review should help to illustrate some of the possible repair strategies for these difficult surgical problems.