Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy

Andrew Watts; Neil J Kocher; Eric Pauli; Jay D Raman

doi:10.1089/cren.2019.0132

Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy

J Endourol Case Rep. 2020 Sep 17;6(3):139-142. doi: 10.1089/cren.2019.0132. eCollection 2020.

Authors

Andrew Watts¹, Neil J Kocher², Eric Pauli³, Jay D Raman⁴

Affiliations

¹ College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.
² Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
³ Division of Minimally Invasive Surgery, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.
⁴ Division of Urology, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.

Abstract

Background: Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. Case Presentation: A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Conclusion: Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.

Keywords: endoscopic repair; over-the-scope clip system; postoperative complication; prostate cancer; prostatectomy; rectovesical fistula.