Fistula From Prostate Cancer Surgery
If you developed a rectourinary fistula as a result of prostate cancer surgery, have you been the victim of medical negligence?
Rectum injured during prostate surgery
The operation of radical prostatectomy either performed openly, or more recently laparoscopically (keyhole surgery), for the treatment of confined carcinoma of the prostate is associated with a small risk of injury to the rectum. The figures quoted in the literature indicate an incidence rate of 3%.
Therefore damage to the rectum is an accepted albeit rare complication or radical prostatectomy. It may be more likely in patients who have had extensive transrectal biopsies of the prostate, as this can cause the rectum to become adherent to the prostate, increasing the risk of injury.
Diagnosing a rectourinary fistula during surgery
An injured rectum can result in a rectourinary fistula, where a hole connect the rectum and the bladder or urethra. It can also be described as a rectourethral fistula.
If the fistula is recognised during the operation, it can be repaired there and then. However, usually this will require a proximal de-functioning colostomy and insertion of a urinary catheter for a prolonged period of time to allow the injury to heal.
It is best that the injury is identified and repaired at the time of the procedure, because on the balance of probabilities it will heal completely.
Diagnosing a rectourinary fistula after surgery
But sometimes a fistula is not identified until after the operation. If it is not immediately detected and repaired, it will cause faeces to appear in the urine. The urine will be dark in colour and may also contain air.
If a patient has recently undergone a radical prostatectomy and faeces is present in their urine, a rectourinary fistula must be immediately suspected. The presence of faecal material in the urine is diagnostic of a communication between the bowel and bladder, and the most likely cause is a fistula caused at the time of the original surgery.
A diagnosis can be confirmed with a cystoscopy. If the bladder does contain faecal material it should be washed out.
Delay in diagnosing a rectourinary fistula
There should not be very much of a delay in diagnosing the fistula, even if it is missed during the original operation. The patient will start to pass faeces in their urine shortly after the procedure, and this must be investigated immediately.
Repairing a rectourinary fistula which was missed during surgery
Once diagnosed, the normal course of events would be to drain the bladder by means of a urinary catheter for a period of three months to see whether there the fistula closes spontaneously (i.e. on its own). A colostomy can also be used to divert the faeces, giving the injury space to heal.
Only if these methods fail is an attempt at surgical repair undertaken. As mentioned above, it is common practice to delay fistula surgery for three months after the original injury. If faecal matter continues to pass through the catheter, medical practitioners can be sure that the fistula has not closed and surgery is required.
Surgery performed too soon
Surgery must not be embarked upon too soon after the original operation. Although a fistula left untreated can become enlarged, it is best to wait until the surrounding tissues have recovered from the procedure. It is for this reason that a colostomy is required, because it will allow the tissues to settle. If an attempt is made to close the fistula too soon after the original operation, it is doomed to failure.
Surgical technique for repairing a rectourinary fistula
Furthermore, the correct surgical technique should be used during the repair. Numerous techniques have been adopted for the closure of a rectourinary fistula. Study results suggest that with an appropriate surgical technique, the success rate of an initial procedure is (in most series) 75% to 100%.
A laparotomy (open surgery) might involve cutting open the lower abdomen, separating the bladder neck from the urethra, and identifying the rectal fistula. The rectal hole would then be closed with dissolvable stitches, and an omental patch brought down and sutured over the repair. Afterwards there would be a repair of the bladder neck and re-anastomosis of the bladder neck to the urethra. A loop ileostomy would be fashioned and the abdomen closed.
Usually a colostomy will be fashioned above the sigmoid colon to better allow the area to heal. The ileostomy must not be made too narrow or it will cause an obstruction, which in turn can cause an incisional hernia.
Recurring rectourinary fistula
Unfortunately it is possible for the fistula to return. If so, the same course of action should be taken. Firstly medical practitioners must wait to see if the fistula closes spontaneously. If not, another surgical procedure will be needed.
Rectourinary fistula medical negligence
Therefore a rectourinary fistula is a rare but accepted complication of radical prostate surgery. Its occurrence does not amount to medical negligence, unless of course the surgeon did not act with reasonable skill and expertise.
However, the fistula should be quickly detected after the operation because the patient will begin to pass faecal matter in their urine. This should be acted upon and a prompt diagnosis made.
Once diagnosed, the fistula should be managed appropriately. Namely, the tissues should be allowed to settle with the aid of a colostomy and catheter. If the injury does not heal, a surgical repair should be conducted, with the correct technique employed.
A failure to achieve this standard of care could amount to a successful medical negligence claim. Reasons of why a claim might arise include:
- Medical practitioners failed to investigate faeces in the urine and therefore delayed the diagnosis
- Medical practitioners attempted a repair of the fistula too soon, causing it to fail
- The surgeon selected the wrong surgical procedure for the repair, causing it to fail
Speak to a solicitor
If you suffered a rectourinary fistula during radical prostate surgery and you believe there is a case of medical negligence, please get in touch with us at Glynns Solicitors.
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