V01-02: Robotic Repair of Iatrogenic Prostatosymphyseal Fistula Following Photoselective Vaporization of the Prostate
Prostatosymphyseal fistula (PSF) is a rare but serious complication following bladder outlet procedures such as transurethral resection of the prostate (TURP) or photoselective vaporization of the prostate (PVP). To date, 9 cases of iatrogenic PSF have been reported, all treated either conservatively with prolonged urinary diversion or with aggressive surgical management (radical prostatectomy or open fistula repair). Here we demonstrate feasibility of a minimally-invasive robotic-assisted fistula repair with perivesical fat flap coverage.
A 73 year old man presented with pelvic and musculoskeletal pain two months after undergoing PVP for obstructive voiding symptoms, and imaging and cystoscopy revealed a large PSF. The patient was counseled on the management options and elected to proceed with robotic surgical repair. The patient was positioned in low lithotomy and transperitoneal access was obtained with a Veress needle. Port placement was performed in the standard w configuration used in robotic prostatectomy. The bladder was dissected free from the anterior abdominal wall, with progressively more inflamed and fibrotic tissue encountered as the dissection was carried towards the pubic symphysis. The endopelvic fascia was incised bilaterally, and the fistula tract was carefully dissected off the pubis and necrotic areas cauterized. The urethra was then mobilized around the fistula tract to identify healthy tissue for anastomotic repair. A relaxing v incision was made in the anterior prostatic capsule to allow for a wide anastomosis to the distal urethral defect. Two running 3-0 V lock sutures were used to complete the anastomosis over a new Foley catheter. A perivesical tissue flap was then mobilized to provide interposition for the repair and secured over the anastomosis with a V-lock suture. A JP drain was placed.
Operative time was 115 minutes. Estimated blood loss was 50 mls. Total hospital stay was 2 days. A cystogram at 4 weeks post-op demonstrated no leak and the foley catheter was removed. At 7 weeks follow up he was doing well with complete resolution of his pelvic and musculoskeletal pain. He was able to void with minimal complaint, good stream, and a post-void residual of 25cc.
PSF following PVP can be successfully repaired using a robotic-assisted prostate-sparing approach. This offers an attractive alternative to more radical surgical options and may potentially spare the patient from urinary and potency complications associated with radical prostatectomy.