Robot-assisted transperitoneal repair of a recto-vesical fistula, a case report

Abstract

Objective: Recto-urethral fistulae (RUF) and recto-vesical fistulae (RVF) are usually related to prostate cancer (PCa) treatment, mainly radical prostatectomy (RP), and a 0.53–9% fistulization rate was observed. Although conservative management is attempted, spontaneous healing is anecdotal and surgical management is often required. Most authors suggested an open approach as less common alternative, due to higher morbidity [1]. Nowadays robotic-assisted surgery represents a viable option. Patients and surgical procedure: we report the case of 71 years-old men who developed an RVF after robot-assisted RP for a Prognostic-Grade-Group 3, pT3bN0 PCa. A conservative attempt, including a transurethral catheter and a colostomy was unsuccessful. A transanal closure according to the Latzko technique was subsequently attempted without results. Then, a robot-assisted transperitoneal repair was planned. Results: before surgery, ureteral stents were positioned. The patient was placed in a low lithotomy position and trocars were arranged as per conventional robot-assisted pelvic surgery. A wide cystotomy was performed at the dome so that the fistula could be visualized and a Pollack catheter was inserted through it. Then, the recto-vesical space was developed, mainly with blunt dissection and cold scissors. The fistulous tract was excised both from the rectal and bladder sides. A double-layer interrupted suture was performed to close both the anterior aspect of the rectum and the bladder. The water tightness of the bladder was assessed with saline solution. An omental flap was then placed between the rectum and the bladder to separate the two suture lines. Conclusions: although over 40 techniques have been described which all share the basic principles for urinary fistula surgical repair, there is no consensus on the optimal treatment. In the last decades, most cases were managed through a transperineal or transanal open approach. With the introduction of robotic surgical systems, the transabdominal approach could be considered a viable option.

Keywords

• Rectovesical fistula
• Omental flap
• Minimally invasive
• Transabdominal
• Robotic surgery