V405: Robotic Transvesical Rectourethral Fistula Repair Following a Robotic Radical Prostatectomy

Video

Introduction and Objectives
Rectourethral fistulas in men are most commonly seen following therapeutic interventions for prostate cancer, whether via prostatectomy, radiation therapy or cryotherapy. We present a video of a robotic assisted technique for surgical repair of recto-urethral fistula.

Methods
A 61-year old male developed a rectourethral fistula near the bladder neck following a robotic assisted radical prostatectomy, likely secondary to an unrecognized rectal injury. After failure of conservative measures, including an indwelling Foley catheter and a suprapubic tube, he was referred to our center for surgical repair. Utilizing a 6-port transperitoneal setup, similar to that described for a robotic prostatectomy, we performed a robotic assisted transvesical rectourethral fistula repair. We initially proceeded with cystoscopy to identify the fistula and its location with respect to the ureteral orifices. Following port placement and lysis of adhesions, the bladder dome was identified through retrograde filling through the patient’s catheter. Then, a horizontal cystotomy was made and the camera and working arms were advanced transvesically to the fistulous opening. A ureteral catheter was placed to aid in protection of the ureteral orifice during dissection. The fistula was then circumferentially mobilized to the base of the tract. The rectal wall and the bladder were closed individually using a 3-0 Maxon suture. Following this, the patient’s suprapubic tube was exchanged and the cystotomy at the bladder dome was closed in two layers. The cystotomy closure was verified to be water-tight with bladder irrigation. Our colleagues in Colon and Rectal Surgery then performed a temporary loop-ileostomy.

Results
The operative time was 200 minutes, including cystoscopy and temporary loop ileostomy formation. The patient had an uncomplicated postoperative course and was discharged on hospital day two. The indwelling Foley catheter and suprapubic tubes were removed at three weeks post-operatively following a cystogram showing no residual extravasation.

Conclusions
Given this result, a transvesical robotic assisted repair of a rectourethral fistula repair appears technically feasible in appropriately selected candidates. Longer follow up and larger case series will be needed to validate this finding.

Funding: None