V01-05: Robot Repair of Rectourethral Fistula and Vesicourethral Anastomotic Disruption with Gracilis Flap Interposition
Rectourethral Fistula (RUF) is a devastating complication after treatment for diseases of the prostate and rectum. While traditional approaches such as York-Mason or transperineal can be performed for smaller fistula, the treatment of large fistulas may be facilitated by robotic assistance, especially with transabdominal mobilization of the bladder and rectum. We illustrate the technique of a robot assisted combined abdominal and perineal RUF repair with gracilis flap for interposition.
58 year old patient who underwent robotic prostatectomy, complicated by rectal injury and vesicourethral anastomotic disruption. The patient had a 3cm x 4cm RUF managed with colostomy and suprapubic catheter. Surgical procedure starts with cystoscopy, fistula identification, and ureteral stent placement. After placement of trocars and docking of the robot, the bladder is mobilized from the rectum. We combined cystoscopic guidance and near infrared frequency technology (FireflyTM) to localize the RUF. The RUF is incised and the rectum is separated from the urogenital diaphragm. The RUF is oversewn and concurrent perineal dissection is performed with division of the central tendon and creation of a window for gracilis flap passage. The gracilis flap is placed between the rectum and urethra. An anterior approach is used to perform the vesicourethral anastomosis. The patient was assessed for clinical success by absence of symptoms and recurrence on cystoscopic evaluation.
Table 1 details the demographic and preoperative information for our patient. Table 2 details the operative details of our patient. The overall catheter duration was 19 days. A cystoscopy was performed approximately at 40 days after repair with no evidence of recurrence.
Robot assisted combined abdominal and perineal RUF repair is a feasible, and effective technique for managing a complex reconstructive problem.