Robotic Transanal Minimally Invasive Surgery: Rectourethral Fistula Closure

Abstract

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.