V1-02: Novel Technique for the Reconstruction of Refractory Prostatic Urethral Stenosis Associated with Medial Thigh Fistula following Brachytherapy.
Urethral stenosis and fistulae in the radiated patient are difficult reconstructive challenges. While posterior urethroplasty via the perineal approach can be performed for isolated urethral stenosis, prostatic fistulae can be difficult to access perineally. We present a novel technique for a robot assisted reconstruction in a patient with prostatic urethral stenosis and fistula between prostate and the thigh.
The patient is a 69 year old man with a history of prostate cancer treated with brachytherapy 15 years prior to presentation which caused prostatic urethral stenosis and prostato-membranous urethral stricture. After failed repeated endoscopic management, he developed a fistula between the prostatic urethra and medial thigh managed with suprapubic cystotomy and intravenous antibiotics. To salvage the native bladder in this active and otherwise healthy man with a normal bladder capacity, we undertook a salvage prostatectomy with excision of urethral stricture via a combined robotic and perineal approach. _x000D_ We utilized fluorescence visualization and an end-to-end anastomosis sizer in the rectum to achieve a safe robotic dissection. A prostatectomy was performed to resect the fistula to the thigh. To create a tension free anastomosis, a perineal approach was used to mobilize the urethra and the diseased urethra was excised. The urethra was passed into the pelvis after the paired corporal bodies were split. The vesicourethral anastomosis was completed in a running fashion._x000D_ For coverage of prostate to thigh fistula, a left rectus abdominus flap with plastic surgery. The flap was split vertically. One portion was passed posterior to the bladder and through the perineal incision to buttress the ventral surface of the urethra in preparation for future transcorporal artificial urinary sphincter (AUS) placement. The second portion was placed anterior to the urethra to protect the anastomosis. _x000D_
The foley catheter was removed one month post-surgery. At two month follow-up, the patient had no complications. Cystoscopy indicates a patent vesicourethral anastomosis. AUS placement is scheduled for 4 months after surgery for incontinence.
Improved visualization and technical control with a robotic approach, coupled with urethral mobilization and dissection from a perineal approach and muscular flap coverage, allow for definitive reconstruction for patients with complex posterior urethral disease following radiation.