V903: MINI-INVASIVE TRANSRECTAL REPAIR OF RECTO-URINARY FISTULA AFTER RADICAL PROSTATECTOMY
VideoIntroduction and Objectives
Recto-urinary fistulas after radical prostatectomy are a rare but significant complication difficult to solve. Over time incidence has been reduced from 11% as reported in older literature (Urology 1995, 45:266) to 0.12% recently (Urology 2010, 76:1088).
A 63 year old man with prostate cancer (pT2,Gleason 3+3) had a rectal injury during radical retropubic prostatectomy (RRP). It was repaired intra-operatively with a 2 layer suture, without interposition of tissue between the bladder and the rectum. Three weeks after the RRP a cystography showed apparently normal results, and the catheter was removed. Two days later urine leakage from the rectum was observed. A bladder catheter was reinserted and a CT scan revealed a fistula between the rectum and the urethra.
Two months after the RRP the patient was prepared for the fistula surgical repair. We introduce through the fistula, by means of a urethrocystoscopy, a ureteral J catheter that is retracted from the anus. A bladder catheter is introduced and the patient is placed in a prone position. An anal-rectal retractor is positioned. We used laparoscopic tools to work in the narrow surgical field. With a scalpel, a lozenge of the rectal wall around the fistula is incised. All rectal scar tissue is removed. Laparoscopic scissors are used to carve the edges of the rectal wall, until we reach soft, healthy tissue. The rectal wall is separated from the scar tissue of the fistula, which is isolated. Using a laparoscopic needle-holder we suture the urotelial wall, that is deeper than the rectal wall. We do not remove the tissue of the fistula and to close the fistula, we pass 3-0 Vycril stitches over and under the catheter. Then we remove the J catheter and we pass an additional stitch to make the suture watertight. We check our stitches for water tightness by filling the bladder with saline solution. Then we trim the incised rectal edges in a direction transversal to the urotelial sutures lying below, until we find soft tissue, which, when sewn, will slide easily to cover the sutures in the urotelial wall. We make 6 deepbite stitches through healthy tissue using 3-0 Vycril thread and we knot it.
The patient was sent home the day after the operation. He kept the catheter for 14 days. He underwent a cystography to check progress before the catheter was removed.
We have successfully performed this operation in 4 pts, with no tissue interposition between the bladder and the rectum, and have never recoursed to a colostomy. The advantages of the rectal approach are obvious: no need of colostomy and little surgical trauma.