JOURNAL OF ENDOUROLOGY Volume 19, Number 6, July/August 2005 Mary Ann Liebert, Inc.

Techniques in Endourology Laparoscopic Rectovesical Fistula Repair*

RENE SOTELO, M.D., ALEJANDRO GARCIA, M.D., HENRY YAIME, M.D., EDUARDO RODRGUEZ, M.D., RINCI DUBOIS, M.D., ROBERT DE ANDRADE, M.D., OSWALDO CARMONA, M.D., and ANTONIO FINELLI, M.D.

ABSTRACT Background and Purpose: Rectovesical fistula (RVF) is a rare complication of radical prostatectomy. A 62year-old man with clinically localized prostate cancer underwent open radical prostatectomy that was complicated by rectal injury and subsequent RVF development. Conservative management failed, and the patient was referred for surgical correction. Technique: The operative steps consisted of (1) cystoscopy, (2) RVF catheterization, (3) ureteral catheterization, (4) five-port transperitoneal laparoscopic approach, (5) cystotomy, (6) opening of the fistulous tract, (7) dissection between the bladder and the rectum, (8) closure of the rectum, (9) interposition of omentum, (10) suprapubic cystostomy placement, (11) bladder closure, and (12) colostomy creation. Results: The operative time was 240 minutes. The hospital stay was 3 days. The urethral catheter was kept indwelling for 4 days. At 8 weeks postoperatively, the suprapubic tube was removed and the colostomy reversed. At 1-month follow-up, the patient remains free of fistula recurrence. Conclusion: Laparoscopic rectovesical fistula repair is feasible and represents an attractive alternative to the standard approaches.

INTRODUCTION

ECTOVESICAL FISTULA (RVF) is a rare entity.1 Acquired rectourinary fistulae, an infrequent complication of pelvic conditions, remain a therapeutic problem for which neither a widely accepted classification nor long-term outcome data are available. Acquired rectourinary fistulae have been classified as benign, secondary to Crohns disease, trauma, perirectal sepsis, or iatrogenic injury; and malignancy-related, secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects.2 An RVF can follow extirpative or ablative procedures of the prostate for both benign and malignant processes. The clinical features of RVF include pneumaturia, fecaluria, and urinary drainage from the rectum. The fistula site is usually detected by rectal examination and can be identified at cystourethroscopy or cystourethrography or with a contrast study of the rectum.1 Gas within the bladder, in the absence of recent transurethral instrumentation, is the classic finding of bowel fistula to the bladder.

Successful management of rectourinary fistulae typically requires aggressive reoperative therapy, with permanent diversion more often being required for malignancy-related lesions. Better outcomes can be anticipated for benign fistulae. To facilitate spontaneous closure, management often includes fecal diversion (colostomy) and urinary diversion (suprapubic cystostomy, indwelling urethral catheter, or both). However, this approach is rarely successful, and the duration of diversion required is unclear.1 Herein, we describe our technique of laparoscopic rectovesical fistula repair.

CASE REPORT
A 62-year-old man with a serum prostate specific antigen concentration of 4 ng/mL and a Gleason score 7 (4 3)/10, clinical stage T2a prostate cancer underwent open radical prostatectomy. He received mechanical bowel preparation preopera-

Section of Laparoscopic and Minimally Invasive Surgery, Department of Urology, La Floresta Medical Institute, Caracas, Venezuela. *Videoclip illustrating the technique can be reviewed on the enclosed CD-ROM or online at www.liebertpub.com/end.

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604 tively. A rectal injury occurred during surgery and was repaired primarily. Six days postoperatively, the patient experienced fecaluria and pneumaturia. The clinical findings and office evaluation (rectal examination and cystoscopy) supported the diagnosis of RVF and localized the defect. The initial management included an indwelling urethral catheter without fecal diversion. The fistula failed to close, and the patient was referred to our center for corrective surgery. During the informed consent process, the patient was advised about other surgical alternatives and that a conversion to laparotomy might be required. The equipment used is outlined in Table 1, and the surgical steps are described below.

SOTELO ET AL.

TECHNIQUE Patient preparation

The patient receives a full mechanical bowel preparation the day before surgery. Antibiotics are given perioperatively. The patient is induced with a general anesthetic. FIG. 1. Both ureters and RVF were cannulated with different-colored ureteral catheters.

Patient positioning
The patient is placed in a low lithotomy position in stirrups. Sequential compression stockings are applied to the lower extremities.

Cystotomy and dissection of fistulous tract and area between bladder and rectum
The posterior wall of the bladder is incised vertically with the ultrasonic shears in proximity to the fistula. The catheter that runs along the fistulous tract is identified, and the incision is carried vertically downward. This is continued in the direction of the catheter that defines the fistula until the posterior aspect of the catheter is exposed. Nonviable or necrotic tissue is excised sharply with scissors (Fig. 2). Once the communication between the bladder and the rectum becomes evident, a meticulous dissection is performed to separate the rectum from the bladder using a combination of ultrasonic shears and laparoscopic scissors (Fig. 3).

Cystoscopy
Initially, cystoscopy is performed, and both ureters are catheterized. This facilitates ureteral identification and protection during excision and closure of the fistula. A ureteral catheter of a different color from those used for the ureters is then pulled through the fistula into the rectum and retrieved through the anus to facilitate identification during the excision (Fig. 1).

Closure of the rectum Port placement

A five-port transperitoneal approach, similar to that for laparoscopic radical prostatectomy, is used. The rectal closure is then initiated. A 20 poliglecaprone suture (Monocryl; Ethicon, Somerset, NJ) on a UR-6 needle, starting with the initial knot on the outer surface of the rectum, is used to close the rectum in one layer (Fig. 4). Five interrupted sutures are placed.

TABLE 1. EQUIPMENT USED

IN

LAPAROSCOPIC RVF REPAIR

Tissue interposition
If it is long enough, intact omentum can be brought down to serve as a tissue interposition to bolster the repair. Otherwise, the ultrasonic shears can be used to make incisions to create a pedicle flap of omentum, with careful planning to preserve the vascular supply. The initial suture of the closure of the rectum is used to anchor the tissue interposition (Fig. 5).

Basic laparoscopic set 10-mm 0 camera lens Suction irrigator 12-mm trocar 10-mm trocar 5-mm trocars (3) Hook electrocautery Harmonic Scalpel Endoshears Curved dissector 5-mm needle holders Carter-Thomason device Ureteral catheters (3) 20F Foley catheters (2) Cystoscope 10F Blake drain 5-mm atraumatic grasping forceps (2)

Closure of the bladder

The bladder closure is subsequently performed in one layer using a 20 Monocryl suture in a running fashion (Fig. 6). This suture is run in a superior direction, but the closure is not completed until after the suprapubic tube has been placed.

Cystostomy and colostomy creation

An extraperitoneal suprapubic cystostomy tube is placed under laparoscopic guidance, and then closure of the bladder is

RECTOVESICAL FISTULA REPAIR completed. The bladder is filled with saline to assess how watertight a closure has been achieved. In addition, a urethral catheter and a Blake drain are placed. A laparoscopy-assisted colostomy is performed by identifying the most mobile portion of the sigmoid colon, bringing it up to the anterior abdominal wall, and making a standard colostomy-site incision in the skin and fascia. A loop colostomy is then created using standard techniques. The fascia of the laparoscopic ports should be closed and other exit maneuvers (assessing hemostasis, confirming drain location) performed immediately prior to making the colostomy incision, as the pneumoperitoneum will be lost.

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Postoperative care
We believe that a very important aspect of the postoperative course is to maintain the patency of the urethral catheter by preventing clot obstruction and retention. These tubes are irrigated only if there is suspicion of obstruction. Ambulation is encouraged, and appropriate prophylactic antibiotics are given. The urethral catheter and Blake drain are removed on the third postoperative day.

FIG. 3. Dissection of bladder from rectum and exposure of fistulous tract.

ROLE IN UROLOGIC PRACTICE

The operative time for this initial case was 240 minutes with an estimated blood loss of 200 mL. The length of stay was 3 days. The urethral catheter was removed on postoperative day 4. No complications occurred. Two months postoperatively, the suprapubic tube was removed and the colostomy reversed. At 1-month follow-up, the patient remains free of fistula recurrence. Successful treatment of an RVF is often challenging. Several procedures have been described, and there has been no consensus on the best method of repair.3 The modified York-Mason technique is a simple and effective posterior sagittal transanal approach. Other repairs have been performed through a perineal incision, a dilated but intact anal sphincter, a posterior para-anal/rectal approach, and transabdominal and transvesical approaches.4,5 Dafnis and colleagues reported a transsphincteric repair,6 and Garofalo and associates described their experience with a rectal advancement flap technique.3 Zmora et al reported gracilis muscle transposition7 and concluded that with patients experiencing an iatrogenic rectourethral fistula after radical retropubic prostatectomy or radiation, fecal and urinary diversion with muscle transposition followed by reestablishment of both urinary and intestinal continuity may be the treatment of choice. Our technique offers the traditional laparoscopic advantages of improved visibility with optical magnification, hemostasis, reduced abdominal pain, shorter hospital stay, faster recovery, and earlier return to work. Notably, the transperitoneal laparoscopic technique provides easy access to omentum or appendix epiploica to be used for tissue interposition. We feel that tissue

FIG. 2. Posterior wall of bladder is incised vertically, dividing trigone with Harmonic Scalpel, and dissection is continued to RVF.

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FIG. 6. FIG. 4. Closure of rectum.

Bladder closure.

CONCLUSIONS
interposition is integral to successful RVF repair. Furthermore, a concomitant colostomy is facilitated laparoscopically without having to reposition the patient, as would be the necessary with some of the aforementioned surgical approaches. This technique represents an extension of our approach to laparoscopic vesicovaginal-fistula repair.8 It requires advanced laparoscopic experience, particularly with pelvic surgery and intracorporeal suturing. This is only the initial case, and the exact role of this technique in the management of RVF is yet to be determined. Only with greater experience and long-term follow-up will we be able to define its place in the surgical armamentarium for RVF repair. Laparoscopic rectovesical fistula repair is feasible and represents an attractive alternative to the standard approaches.

REFERENCES
1. Renschler TD, Middleton RG. 30 years of experience with YorkMason repair of rectourinary fistulae. J Urol 2003;170:12221225. 2. Munoz M, Nelson H, Harrington J, Tsiotos G, Devine R, Engen D. Management of acquired rectourinary fistulae: Outcome according to cause. Dis Colon Rectum 1998;41:12301238. 3. Garofalo TE, Delaney CP, Jones SM, Remzi FH, Fazio VW. Rectal advancement flap repair of rectourethral fistula: A 20year experience. Dis Colon Rectum 2003;46:762769. 4. Kilpatrick FR, Mason AY. Post-operative recto-prostatic fistula. Br J Urol 1969;41:649654. 5. Stephenson RA, Middleton RG. Repair of rectourinary fistulae using a posterior sagittal transanal transrectal (modified York-Mason) approach: An update. J Urol 1996;155:19891991. 6. Dafnis G, Wang YH, Borck L. Transsphincteric repair of rectourethral fistulae following laparoscopic radical prostatectomy. Int J Urol 2004;11:10471049. 7. Zmora O, Potenti FM, Wexner SD, Pikarsky AJ, Efron JE, Nogueras JJ, Pricolo VE, Weiss EG. Gracilis muscle transposition for iatrogenic rectourethral fistula. Ann Surg 2003;237:483487. 8. Sotelo R, Mariano MB, Garcia A, et al. Laparoscopic repair of vesicovaginal fistula. J Urol 2005;173:16151618.

Address reprint requests to: Rene Sotelo, M.D. Instituto Medico La Floresta Urbanizacion La Floresta Calle Santa Ana con Av. Principal La Floresta, PB Consultorio 707.Zip 1080 Caracas, Venezuela E-mail: renesotelo@cantv.net agarciasegui@cantv.net

FIG. 5.

Interposition of omentum.

RECTOVESICAL FISTULA REPAIR

607 these patients. One must have not only a Plan A but also a Plan B, Plan C, Plan D, etc.

EDITORIAL COMMENT
Rectovesical fistula can be one of the most challenging problems in reconstructive urology. The description of multiple approaches underlines the fact that no one treatment is yet identified as the most efficacious or most straightforward technically. Usually, authors on this subject are very experienced, and one wonders if some of their success is not related to their advanced operative skills and not specific elements of their particular preferred repair. This report describes the inevitable application of laparoscopy to this difficult problem. It is an excellent description by an obviously experienced group that may open this field to further innovations in laparoscopic treatment of the problem. The principles emphasized include intimate knowledge of the preoperative anatomy; meticulous definition of the ureteral, urethral, and fistula anatomy with stents; and application of standard maneuvers such as multilayer closure and interposing of vascularized tissue (in this case, omentum). When used by sufficiently experienced surgeons, it should be successful. Of note, the basic principles of repair have remained unchanged since the early part of last century.1 While this paper does an excellent job of communicating the details of laparoscopic treatment of uncomplicated fistula, I would like to emphasize some issues that might change the operative approach to this problem.

What is conservative treatment?

Most surgeons attempt a period of conservative therapy for rectourinary fistula, often including diversion using urethral or suprapubic urinary catheterization, colostomy, low-residue diets, or a combination. I do not know how vigorous such attempts should be or when they should be abandoned because of futility. Some authors wait 4 months before definitive therapy is attempted.3 Post-traumatic rectourethral fistula has been shown to heal after urinary and fecal diversion in almost half of patients in 1 to 6 months4 and after prostate surgery in 3 of 8 patients (38%) within 6 months.5 Analysis of multiple published reports indicates a healing rate between 25%6 and 53%.7 Some suggest using chronic suppressive antibiotics during this waiting period,3 although randomized trials proving the utility of this approach do not exist.

When to plan surgery

Theoretically, definitive surgical therapy should be delayed to allow inflammation to subside and potentially increase the potential for healing. Modern authors suggest at least a 6- to 8week period of diversion to allow inflammation to subside if a longer waiting period for spontaneous closure is not used.7 Richard A. Santucci, M.D., FACS Detroit Receiving Hospital and Wayne State University School of Medicine Detroit, Michigan

Radiation
The first complicating factor is prior irradiation of the field. In this case, other authors have emphasized that omentum may not be sufficient to allow healing of the injured tissues and that bulky muscular flaps such as gracilis or rectus abdominis may need to be used.2

REFERENCES
1. Young HH, Stone HB. The operative treatment of urethro-rectal fistula: Presentation of a method of radical cure. J Urol 1917;1:289. 2. Jordan GH, Lynch DF, Warden SS, McCraw JD, Hoffman GC, Schellhammer PF. Major rectal complications following interstitial implantation of 125iodine for carcinoma of the prostate. J Urol 1985;134:1212. 3. Bukowski TP, Chakrabarty A, Powell IJ, Frontera R, Perlmutter AD, Montie JE. Acquired rectourethral fistula: Methods of repair. J Urol 1995;153:730. 4. al-Ali M, Kashmoula D, Saoud IJ. Experience with 30 posttraumatic rectourethral fistulas: Presentation of posterior transsphincteric anterior rectal wall advancement. J Urol 1997;158:421. 5. Goodwin WE, Turner RD, Winter CC. Rectourinary fistula: Principles of management and a technique of surgical closure. J Urol 1958;80:246. 6. Elmajian DA. Surgical approaches to repair of rectourinary fistulas. AUA Update Series 2000;19:42. 7. Visser BC, McAninch JW, Welton ML. Rectourethral fistulae: The perineal approach. J Am Coll Surgeons 2002;195:138.

Abandonment of the lower urinary tract

The second issue involves the advisability of even attempting primary repair of some rectourinary fistulae. Although intimate knowledge of available reconstruction techniques should allow repair in the majority of patients, a minority will have such severe lower urinary-tract dysfunction that suprapubic diversion should be considered. We have seen patients with a complex of profound urinary incontinence, associated distalurethral stricture, rectourinary fistula, and severe bladder dysfunction, in whom a successful repair of the rectourinary fistula would still leave them incontinent and for whom that the potential for normal urinary function is slim. In these patients, we have included suprapubic urinary diversion such as ileal loop or large-bowel loop in our patient counseling. Although we have not used it, we have also considered other types of diversion such as ureteral anastomosis to an existing colostomy (wet colostomy). Creativity is the hallmark of the approach to