Laparoscopic Urorectal Fistula Repair: Value of the Salvage Prostatectomy and Review of Current Approaches

Abstract

Background and Purpose:

The surgical approach and repair for urorectal fistula (URF) is a challenging task. A variety of techniques have been described to treat URFs, and the laparoscopic approach has been approved as an efficient tool for even some complex fistulas. We aimed to report our laparoscopic experience for complex URF repair with special emphasis on salvage prostatectomy.

Patients and Methods:

The study included four men (59–75 years), with laparoscopic repair for complex URFs. URF developed after transurethral resection of the prostate in patients 2 and 3 and after radical prostatectomy in patient 4. Patient 1 had received combined radiotherapy and chemotherapy for the rectal carcinoma; a prostatic abscess developed that resulted at the end in URF. Laparoscopic salvage prostatectomy was performed for patients 1 and 2. A transvesical laparoscopic approach was performed for patient 3, and a transperitoneal transvesical technique was performed for patient 4. A tunica vaginalis flap was used for patient 1, and peritoneal interposition flaps were developed in patients 2 and 4 mL, and no patients needed intraoperative blood transfusion. Postoperative hospital stay was 12 to 34 days. The urethral catheter was removed on postoperative day 11 to 32, and cystography showed no leakage of contrast except in patient 1.

Conclusions:

Laparoscopic URF repair is safe and efficacious in experienced hands even in complex cases, and salvage laparoscopic prostatectomy seems like a valuable operative option. The technique requires advanced experience, however, particularly with pelvic surgery and intracorporeal suturing.

Introduction

U rorectal fistulas (URF) are rare complications of prostatic surgery. Literature on this subject is rare, and the surgical approach and repair is a challenging task.^1
–3 Most of the cases occur during transurethral resection of the prostate for benign or during radical prostatectomy for malignant diseases. Prostatic abscess perforating spontaneously into the rectum is an uncommon reason for URF.⁴ Prostate brachytherapy and penetrating trauma may also cause URF later in the course.⁵

A patient with URF usually presents with urine leaking from the rectum. The first treatment option is conservative and includes urinary and/or fecal diversion. This approach is rarely successful, however.^6,7 A variety of techniques have been described to treat URFs, including transanal, transanorectal, transsphincteric, transabdominal, perineal, and combined approaches that are frequently used.^{2,3,5,8
–10}

The laparoscopic approach has been approved as an efficient tool for even some complex URF.^11

–14 Recently, the da-Vinci robot system has been applied successfully for the management of an URF as an alternative therapy option.¹⁴

We aimed to describe different laparoscopic approaches including our salvage prostatectomy technique for URF repair on four patients and discuss the outcomes. A review of the literature with particular emphasis on the minimal invasive approaches is also included and discussed.

Patients and Methods

Patients

Patient 1. A 66-year-old man with history of rectal carcinoma underwent surgery for the resection of the tumor. Staged as PT₃, pN₂ (9/31), cM0, PL0, pV0. G2, R0. Adjuvant radiation therapy was given to the patient. As a complication of this, sigmoiditis, proctitis with ulceration, and chronic prostatitis with prostatic abscess developed for which he underwent antibiotic therapy. A CT showed multiple liver metastases. Thereafter, the patient received palliative chemotherapy.

One year after radiotherapy, urinary leakage through the anus developed without abdominal pain. Cystourethrography (CUG) revealed a URF and a right vesicoureteral reflux grade II. Rectal examination showed normal findings. Urinary analysis showed increased white blood cells with nitrite positivity. Conservative treatment with a urethral catheter for 8 weeks was initiated and failed; a decision for surgical treatment was taken.

Patient 2. A 59-year-old man had undergone transurethral resection of the prostate (TURP). One year after TURP, URF developed. As a first therapeutic step, we performed laser coagulation of fistula mount and optimal drainage with cystostomy. This therapy failed, and we decided on a laparoscopic approach. A digital rectal examination revealed normal findings. Urinary analysis showed fecaluria and MRI confirmed the URF.

Patient 3. A 65-year-old man had a 10-year history of insulin-dependent diabetes mellitus and peripheral vascular disease. Fecaluria and urine leakage from the rectum during voiding had started 6 months after TURP for benign prostatic hyperplasia. On rectoscopy, a URF was found 5 cm from the anal verge, and urethrocystoscopy demonstrated a URF in the prostatic fossa.

Patient 4. A 75-year-old man had a history of radical prostatectomy for prostate cancer (pT₄, R1, Gleason 3+3=6) followed by radiation therapy and antiandrogen therapy because of a recurrence with multiple bone metastases. The patient underwent a transurethral bladder neck resection for bladder tumor. The pathology report revealed prostate cancer (Gleason 4+4=8), and high-intensity focused ultrasound was performed. After this therapy, the patient underwent right hemicolectomy and colostomy for sigmoid cancer. A routine urinary analysis showed increased white blood cells and feces in the urine. Cystoscopy and cystography showed a URF. Rectoscopy and primary rectal fistula repair was performed with cystostomy as a first step therapy, and the follow-up cystography showed a fistula recurrence. Mono-J catheters were placed transvesically in both ureters.

We performed retroperitoneal laparoscopic fistula repair for patient 1, transperitoneal laparoscopic repair for patients 2 and 4, and transvesical laparoscopic repair for patient 3.

Surgical technique

All operations were performed by the same surgeon (JR). Patient characteristics and surgical outcomes are summarized in Table 1. Under general anesthesia, patients were placed in a low lithotomy and Trendelenberg position head downward, with compression stockings applied to the legs. An 18F silicone urethral bladder catheter was placed.

Table 1.

Characteristics and Outcomes of Patients with UroRectal Fistulas

Patient	1	2	3	4
Age	66	59	65	75
BMI (kg/m²)	36.8	28.56	25.3	26.7
Previous diseases and surgery	Anterior rectal resection with protective iliostomy, postoperative radiation therapy, prostatic abscess	TURP, laser coagulation of fistula	TURP	Radical prostatectomy, postoperative radiation therapy, right hemicolectomy colostomy for sigmoid cancer, primary rectal fistula repair
Conservative therapy	Urinary and fecal diversion (colostomy)	Urinary diversion	Urinary diversion	Urinary and fecal diversion(colostomy)
Fistula localisation	Urethro (prostate)-rectal	Urethro (prostate)-rectal	Vesico-rectal	Vesico-rectal
Access	retroperitoneal	retroperitoneal	transvesical	transperitoneal
Flap	tunica vaginalis	peritoneum	–	peritoneum
Operative time (min)	210	283	114	238
Estimated blood loss (mL)	450	480	50	600
Hospital stay (days)	13	17	12	34
Urethral catheter time (days)	12 (fistula residue, recatheterization)	16	11	32
Follow-up (mos)	11	8	60	10
Success	+	+	+	+

BMI=body mass index; TURP=transurethral resection of the prostate.

Patient 1. A five ports approach such as in laparoscopic radical prostatectomy with classic extraperitoneal ascending Heilbronn-technique as previously described was performed. Briefly, after freeing the apex, the anterior and posterior wall of the urethra was divided. The gland was retracted cranially with the catheter, and the attachments between Denonvilliers fascia and rectum were prepared.^15,16 This approach allowed us to identify and prepare the fistula tract easily (Fig. 1). The fistula tract was thereafter prepared on the rectum and sutured primarily with 3/0 PDS II. A tissue interposition was not possible because of the lack of good vascular tissue deriving from previous irradiation. We developed a 4×4 cm tunica vaginalis flap for the interposition, placed on the fistula and sutured with 3/0 polyglactin stitches (Fig. 2). The urethrovesical watertight anastomosis was performed using the van Velthoven technique.

FIG. 1.

Demonstration of the fistula tract, rectum, neurovascular bundles (NVB), and urinary bladder.

FIG. 2.

Interposing tunica vaginalis flap for the interposition is placed and fixed on the fistula suture line and sutured with 3/0 polyglactin stitches. NVB=neurovascular bundles.

Patient 2. A classic transperitoneal ascending Heilbronn-technique such as in patient 1 was performed. The URF was prepared and closed using 3/0 V-Loc 180^™ sutures (Covidien, Tyco Healthcare Group, Norwalk, CT) in a running fashion. After the prostatectomy, a peritoneal interposition flap was developed and fixed on the suture line with separate 3-0 polyglactin sutures.

Patient 3. A transvesical approach was performed using the suprapubic catheter tract as an optic trocar site and 3-mm working trocars as described before.¹¹ The fistula was identified, and the edge was excised. A running suture (3-0 PDS, RB needle) was used to close the fistula.

Patient 4. A five ports approach such as in our classic transperitoneal ascending Heilbronn technique was performed. The bladder was bivalved, the fistula tract was identified, and the rectum and bladder were prepared separately. The rectal wall was closed using a 3/0 running V-Loc 180 suture. A peritoneal interposition flap was developed and placed on the suture line and sutured with separate 3-0 polyglactin sutures. The bladder incision was closed with a 3/0 V-Loc 180 suture in a running watertight fashion.

Results

Patient characteristics, history, surgical and postoperative outcomes are summarized in Table 1. The range of operative time was 114 to 283 minutes. The range of intraoperative blood loss was 50 to 600 mL. No patients needed intraoperative blood transfusion. Postoperative hospital stay was 12 to 34 days. The urethral catheter was removed on postoperative day 11 to 32.

All patients were discharged from the hospital in good condition. Follow-up CUGs showed no leakage of contrast in all patients.

Postoperative interventions and follow-up

Patients 1 and 2. Oral intake was tolerated by patient 1 on the second day while patient 2 started oral intake on postoperative day 3. Sepsis developed in patient 2; he was admitted to the intensive care unit for 5 days with antibiotics and circulatory support and transferred to the ward on day 7 postoperatively.

The urethral catheter were removed on postoperative day 12 for patient 1 and day 16 for patient 2 because of his postoperative sepsis and the CUG performed that showed no leakage of contrast. Nonetheless, a recurrent fistula developed in patient 1 at 9 months after the surgery, and he still has a urethral catheter.

Patient 3. The patient was kept fasting for 2 weeks, receiving intravenous hyperalimentation. On postoperative day 11, retrograde cystography revealed no contrast leakage through the rectum. The urethral catheter was removed on the same day, and the suprapubic catheter was left in place. Follow-up 3 months postoperatively showed no recurrence of the fistula, and the patient was able to void. The cystostomy was left in place, however, because of residual urine volume of 200 mL.

Patient 4. The patient was received during the first week of intravenous hyperalimentation therapy. On postoperative day 14, cystography revealed a minimal contrast leakage. The urethral catheter was left and mono-J catheters were removed on the same day. The urethral catheter was kept for another month in place and removed after CUG without leakage. The colostomy was closed in the postoperative fourth month. The patient received antiandrogen and bone stabilization therapy with bisphosphonates. The bone metastases showed no progression during the last follow-up.

Discussion

URFs are a rare but devastating complication that can usually develop after TURP or radical prostatectomy.^1
–3 The URFs were differentiated to two groups by Munoz and associates.¹⁷ One is benign and it is infectious and traumatic; the other is a malignancy-related complex fistula, such as neoplastic, surgical, and radiogenic. For these kinds of fistulas, the situation is even more complicated and accordingly the success rate is low. All of the cases in our series were complicated fistulas, occurring after chemotherapy or radiotherapy or combination therapy for different malignancies.

Conservative approaches, consisting of urinary diversion, wide spectrum antibiotics, and parenteral hyperalimentation, may allow cure in certain iatrogenic fistulas. Success rates as high as 25% to 53% have been reported in the literature.^8,18 Most of them (ie, complex fistulas), however, necessitated surgical interventions, especially if the fistula remained in for 3 to 6 months.^19,20 Another conservative approach option is bowel rest via fecal diversion and described by some authors as mandatory. Others, however, advocated that it is necessary only when there are previous failed repairs, complex fistulae, and a history of radiotherapy or pelvic sepsis or in the absence of bowel preparation.²¹ All of our patients had urinary diversion. In addition, our two complex cases (patients 1 and 4) had fecal diversion (colostomies) (Table 1). Conservative therapy failed in all our cases, however, and we decided on minimally invasive surgical therapy.

Successful treatment of an URF is often challenging. Several procedures have been described, which include different approaches and different flap types and techniques.^{9,10,19,22,23} There has been no consensus, however, on the best method of repair.¹⁹

Basic surgical principles include excision and debridement of the fistula tract to healthy vascular tissue, and separation of the rectal and bladder suture lines with tissue interposition.²⁴ Especially for fistulas in irradiated fields with ischemic fibrosis and radiation changes around the fistula, the procedure is technically difficult and the probability of successful closure is low.¹³ Munoz and colleagues¹⁷ reported on 23 patients with complex fistulas using different surgical approaches, and their success rate was only 25% (6 patients) at the first operation.

Laparoscopy in urology has become popular in recent years. It is increasingly performed in many institutions worldwide, and the number of experienced surgeons with improved laparoscopic skills particularly dealing with complex urologic procedures has increased (Table 2). Laparoscopy provides the opportunity of magnification, thus better exposure, of the tissue layers, where many anatomic structures are located close to each other in a limited pelvic space, as in pelvic surgeries. This facilitates better exposure of the rectum and better preparation of the anterior rectal wall and more delicate dissection and removal of the fistula tract.

Table 2.

Summary and Comparison of Previously Published Literature Regarding Minimally Invasive Fistula Repair

Reference	Year	N	Mean pt age (year)	Fistula etiology	Preop cons Tx	Previous fistula repair	Mean op time (min)	Mean blood loss (mL)	Mean hospital stay (days)	Colostomy	Catheter removal time (days)	FU (mos)	Fistula recur
Sotelo¹³	2005	1	62	Open RP	+	+	240	200	3	+	4^a	3	-
Sotelo^{14 b}	2008	1	57	Open RP	+	+	180	-	1	+	4^a	5	-
Quazza¹²	2009	2	NR	RP	NR	NR	255	NR	NR	+	NR	NR	-
Gözen¹¹	2006	1	65	TURP	+	+	114	50	6	+	12	3	-
Present series	2011	4	59–75^c	KP, PA, AR (1) TURP (2) RP + RT (1)	4	2	114–283^c	50–600^c	12–34^c	2	11–32^c	8–60^c	1^d

Two months postoperatively, the suprapubic tube was removed.

Robotic repair.

The range of the value.

Fistula recurrence in patient 1 detected on follow-up.

Pt=patent; Preop=preoperative; cons=conservative; Tx=treatment; op: operative; FU=follow up; recur=recurrence; RP=radical prostatectomy; NR=not reported; TURP=transurethral resection of the prostate; KP=chronic prostatitis; PA=prostatic abscess; AR=apical resection; RT=radiation therapy.

Currently, the published literature regarding laparoscopic URF repair is still rare and consists mostly of case reports.^11

–14 Our results in terms of mean operative time, blood loss, hospital stay, and catheter removal time were similar when compared with other cases (Table 2). In our opinion, the complexity of the fistula plays an important role in the success of the procedure as much as the preferred operative technique. We reached a success rate of 75% (three of four cases), which may be considered successful in our complex fistula group with additional comorbidities.

The open salvage prostatectomy was reported before in the literature, especially for postirradiation URFs. Mundy, Andrich and coworkers²⁵ have advocated that good exposure of the rectal defect after a salvage radical prostatectomy for closure and interposition of an omental flap before the vesicourethral anastomosis was advantageous. They found, however, that the salvage radical prostatectomy was not easy to perform in this group of patients with complex fistulas.

We have performed a salvage laparoscopic prostatectomy for URF in patients 1 and 2. Laparoscopic radical prostatectomy has become an accepted alternative to open surgery worldwide with distinct advantages such as the reduction of postoperative pain, complication rate, hospital stay, and convalescence related to the less invasive approach.^26,27 The laparoscopic approach to URF requires advanced laparoscopic experience, particularly with pelvic surgery and intracorporeal suturing. The type of surgery that will be performed depends mostly on the training and experience of the surgeon. For these reasons, this operation is not proposed for surgeons in the early learning curve. To date, we have treated more than 2500 patients successfully using the Heilbronn techniqu²⁸ with both laparoscopic and robot-assisted approaches in our institution.

The role and value of salvage prostatectomy in these complex and difficult cases is still to be determined. It seems beneficial, however, if an established laparoscopic technique is combined with experience. Another important point to underline is the advantage of the Heilbronn technique, because the posterior dissection is performed on the rectum at an early step of the operation; this allows good exposure of the rectum and better dissection of the anterior rectal wall and the fistula tract. Furthermore, we think that the robotic approach would also facilitate the salvage prostatectomy procedure with the well-known advantages—especially the high quality, three-dimensional vision and six degrees of freedom in the deep pelvis might increase the surgical outcomes. Therefore, we intend to perform the next URF procedures in our institution with robot assistance.

Nonetheless, a recurrent fisula developed in one of the patients (patient 1) at 9 months after the surgery. He had received combined radiotherapy and chemotherapy for the rectal carcinoma; thereafter, a prostatic abscess developed that resulted in URF. An interposition flap is obligatory in similar complex cases. We have preferred a large tunica vaginalis flap in this case (Fig. 2) because of the low tissue quality of omentum and peritoneum. Jordan and colleaues²⁹ have reported better results using muscular flaps, such as gracilis or rectus abdominis, in similar complex cases. Besides all the advantages of the minimally invasive technique, developing these bulky flaps seems still technically challenging for minimally invasive approaches.

As observed in previous studies, laparoscopic radical prostatectomy is technically more challenging in obese patients and may contribute to increased operative times, blood loss, and positive surgical margins.^30
–32 This might be another negative factor in our patient 1 with a high body mass index (36.8 kg/m²).

The transvesical approach and intravesical laparoscopic suturing have already been described by Gill and associates.³³ Recently, many investigators have presented their experience with laparoscopic transvesical operations for fistulas using the intracorporeal suturing technique.^34
–36 We have reported our experience and technique for transvesical laparoscopic urethrorectal fistula repair¹¹ The laparoscopic extraperitoneal and/or transvesical approach offers several advantages, including excellent exposure; avoidance of bowel manipulation, such as occurs in the transabdominal approach, or cutting through the muscles, such as in the perineal approach; decreased operative time and postoperative morbidity, and, finally, earlier convalescence. This approach, however, is suited only for the fistulas close to the bladder neck. We preferred in our patient 4 a similar transperitoneal approach that has allowed us additionally to develop a peritoneal interposition flap.

Conclusions

Laparoscopic URF repair seems to be a safe, feasible, efficacious alternative to the open abdominal approach, and salvage laparoscopic prostatectomy seems like a valuable operative option with the well-known advantages of laparoscopy. Although it is not possible to draw a strict conclusion with the limited number of patients in our series, we recommend this minimally invasive surgery in the management of URF, particularly by experienced laparoscopic surgeons in high volume centers. We think that the robotic approach would facilitate the salvage prostatectomy procedure with the well-known advantages. Further randomized studies are warranted to compare the outcomes of laparoscopy vs open URF repair.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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