Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.

PURPOSE: The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation.
METHODS: Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up.
RESULTS: Mean age was 60 years (50-73) with median follow-up of 28.7 months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p = 0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2 months (3.5-24.9). In irradiated patients, 18/20 (90 %) developed BOD compared with 1/7 (14 %) who were not radiated (p = 0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p = 0.0458).
CONCLUSIONS: Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.