Management of urethrocutaneous fistulae complicating sacral and perineal pressure ulcer in neurourological patients: A national multicenter study from the French‐speaking Neuro‐urology Study Group and the Neuro‐urology committee of the French Association of Urology

Abstract

Purpose To describe the epidemiologic characteristics of urethrocutaneous fistulae (UCF) in sacro‐perineal pressure ulcer (SPPU) in neurourological patients and to assess outcomes after surgical urinary diversion. Materials and Methods Through the French‐speaking Neurourology Study Group and Association of Urology network, a retrospective multicenter study in nine major urology and physical medicine and rehabilitation (PMR) units was conducted. All patients with SPPU associated with UCF between 2000 and 2016 were included. Data concerning: sociodemography, clinical, medical and biological comorbidities, neurological and urological history, pressure ulcer characteristics, and finally urinary diversion surgery were collected. Complications and SPPU healing/relapse were assessed. Results In all, 74 patients were included. The median age on diagnosis: 45.9 years (interquartile range [IQR], 38.7‐53.4) and median follow‐up: 15.1 months (IQR, 5.7‐48.8). A psychiatric disorder was the most frequent comorbidity (44.6%). Only 59.5% and 50% had regular PMR and urologic follow‐up, respectively. Seventy‐one patients (95.9%) underwent urinary diversion surgery. Among those, relapse occurred in 15 (21.1%) at the end of the follow‐up. The diversion was noncontinent in 85.9%. The major complications rate was 26.8%. A total of 30 late complications in 21 patients were reported. The most frequent was obstructive pyelonephritis (n = 9). All of the patients who underwent surgical diversion without cystectomy (n = 5) developed a pyocyst. Finally, the pressure ulcer healing rate when patients underwent both urinary diversion and pressure ulcer surgery was 74.4%. Conclusions Our retrospective data suggest that UCF complicating SPPU is a rare and severe pathology. The combination of radical urinary diversion with cystectomy and pressure ulcer surgery should be performed as often as possible.

A Systematic Review of Pressure Injuries Associated with Urethrocutaneous Fistula

“…The management of a urinary fistula in the specific case of PI is identical to any other urinary fistula: The traditional adage “keep your fistulas dry” still applies. Therefore, the first step is urinary diversion 3 . Keep in mind that fecal diversion also plays a crucial role in the treatment of fecal- and urinary-contaminated PIs.…”

“…Urinary diversion is essential to keep the PI free of excessive moisture and improve the local wound environment. 3,12 The most popular and easiest-to-perform urinary diversion technique is suprapubic cystostomy. Intra-abdominal bladder neck closure can be performed with failed or incomplete drainage with suprapubic cystostomy, often due to bladder neck dysfunction or to neurologic bladders.…”

“…Although the use of bilateral ischiectomies resulted in 46% of urethral diverticula in 48 patients 19 within 5 months to 11 years, only 21 cases associated with urethrocutaneous fistulas were reported in the literature. [3][4][5]11,20 Nevertheless, this does put urethral diverticula and urethrocutaneous fistulas on the same continuum of postischiectomy complications. 21 In the present review, only 16.7% of patients (5/30) had bilateral ischiectomies, and 56.7% (17/30) reported no ischiectomy and still presented with urethrocutaneous fistulas.…”

“…One of the most dreaded complications of perineal PIs is urethrocutaneous fistulas, 3 which can lead to soft tissue infections, sepsis, and death. Urine leakage impedes wound healing, rendering wound closure impossible without urinary diversion.…”

Widespread Postponement of Functional Urology Cases During the COVID-19 Pandemic: Rationale, Potential Pitfalls, and Future Consequences

“…However, some situations warrant a discussion about balancing the risks and benefits, especially in the case of threatening infectious lesions (eg, ongoing complicated perineal infections, urethrocutaneous fistulae complicating a sacroperineal pressure ulcer, symphysitis, recurrent severe UTIs). These conditions, although rare, require surgical management without delay in a frail population to avoid severe complications or death [8]. The essential step in treatment is to dry the perineum by performing a noncontinent urinary diversion.…”