Urology Video Journal (Sep 2020)
A Minimally Invasive Approach To The Management Of Urethrovasocutaneous Fistula
Abstract
Purpose: To describe a unique, minimally invasive approach to the management of a complex urethrovasocutaneous fistula utilizing the Da Vinci Xi robot.Introduction: Urethrovasocutaneous fistula are exceedingly rare [1]. Its etiology is varied and it is often presented as case reports [2-3]. At this time there is no standard managementMaterials and Methods: A 66 year old male was seen in clinic with difficulty voiding and years of persistent drainage from his scrotum. He endorsed a history of multiple prior direct visual internal urethrotomy (DVIU) for urethral stricture disease. An MRI of the prostate was performed due to an elevated PSA of 18 in the context of multiple negative biopsies and noted a 237 cubic centimeter (cc) prostate. A retrograde urethrogram and a voiding cystourethrogram confirmed a urethrovasocutaneous fistula. After discussion the patient was not interested in a urethroplasty at this time.A Cystoscopy was performed with a DVIU to allow placement of a 18 french 3-way foley catheter. Utilizing the Da Vinci Xi platform, we placed ports in the standard fashion for a robot assisted radical prostatectomy. An 8 millimeter (mm) camera port was placed 15 centimeters cranial to the pubic symphysis just above the level of the umbilicus. At this level, a single 8mm port was placed 8cm lateral to the camera port on the left. The remaining two 8mm ports were placed at 8cm and 16cm to the right of the camera. A 12mm assistant port was placed roughly two fingerbreadths from the left anterior superior iliac spine. A 5 millimeter assistant port was placed cranial to, and between the camera port and the robotic arm fourth arm trocar. The patient was placed in a steep trendelenburg and the da Vinci Xi was docked. A ligation of the vas deferens was performed bilaterally. A simple robotic prostatectomy was then performed; a robotic tenaculum was utilized for dynamic retraction.Results: The patient was seen for follow-up at two weeks post-operatively. After removal of the foley the patient voided well with a post-void residual of 30cc. Resolution of scrotal drainage was documented. The patient was seen at two months after his operation and once again no leakage from the scrotum was noted. He continued to void with a residual less than 50cc and his International Prostate Symptom Score was 4, with a quality life score of 0.Conclusion: We documented a successful, minimally invasive approach to the management of a complex urethrovasocutaneous fistula. We anticipate future urethroplasty when the patient is amenable
