ectourethral fistula (RUF) is a devastating condition that is difficult to manage. The majority of RUFs are associated with multimodal treatment for prostate cancer. 1 The remaining RUFs result from radiation, trauma, inflammation, or congenital anorectal anomalies. 2 The most common location of the fistula is at the vesicourethral junction. 3 Conservative management often starts with a fecal and urinary diversion to allow for spontaneous closure, which is frequently unsuccessful. 4 Small and nonradiated RUFs without complications are treated with transanal or transperineal approaches. A treatment algorithm has been proposed, yet a total of 40 different techniques have been described. 2,5 Robotic transanal minimally invasive surgery allows for better visualization because of quality optics, 360° field of view, and precision from wristed instruments which enable precise closure of all layers while using smaller flaps. [6][7][8] In this video at http://links.lww.com/DCR/C118, we present a 79-year-old man who underwent primary cryoablation for prostate cancer. A month later, he experienced recturia. He denied any urinary incontinence or urinary tract infections. MRI pelvis, colonoscopy, and cystoscopy identified a fistula tract just proximal to the external urethral sphincter and distal to the verumontanum in the posterior urethra. A transperineal prostate biopsy did not demonstrate cancer recurrence. We elected for a transanal approach using the robotic transanal minimally invasive surgery platform. An 8-mm fistula was identified above the anorectal junction and widely excised. The rectoprostatic plane was entered and flaps were created. The prostatic capsule was closed primarily and a piece of AlloDerm was placed as a buffer between the rectum and the prostate. 9 Platelet-rich plasma and fibrin glue were injected over suture lines. The rectum was closed primarily, and fecal diversion was performed. Following healing, he kept the urinary catheter for 4 weeks after CT cystogram, and his ileostomy was closed after 3 months. His bowel and urinary function have returned to baseline.
Background Renal transplant patients presenting with diverticulitis remain a clinical challenge for health care professionals. Secondary to immunosuppression, renal transplant recipients are often considered for early operative intervention due to concerns for an unreliable physical exam and feared morbidity and mortality associated with non-operative management. Methods This study aimed to evaluate trends in management of renal transplant patients with diverticulitis at a quaternary referral center. Results One hundred ninety-one renal transplant patients admitted to the hospital with diverticulitis were identified. Of this cohort, 71 (37%) underwent surgical resection, of which 20 (28%) were performed emergently. The overall 30-day operative mortality was 8% (6/71), of which there was a significant difference between emergent (25%, 5/20) and elective (2%, 1/51) groups ( P = .006). Patients who underwent elective surgery were more likely to receive a minimally invasive approach (51%) and were significantly more likely to undergo stoma reversal ( P = .006). Discussion Our study shows that not all renal transplants with diverticulitis will require operative intervention and many can be safely treated non-operatively. Elective resection and surgical management should be considered on an individual basis. Patients treated with elective resection were more likely to undergo a minimally invasive approach and restoration of intestinal continuity.
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