*Marek Roslan1, 2, Michał Borowik1, 2, Maciej Przudzik1, 2, Jarosław Ćwikła3, Dariusz Zadrożny2, 3
Iatrogenic vesicorectal fistula: therapeutic challenges. Case reports and literature review
Jatrogenna przetoka pęcherzowo-odbytnicza – trudności terapeutyczne. Opis przypadków i przegląd piśmiennictwa
1Department of Urology, Collegium Medicum, University of Warmia and Mazury, Olsztyn
2Independent Public Healthcare Centre of the Ministry of Internal Affairs and Administration with Warmia and Mazury Oncology Centre in Olsztyn
3Department of Nuclear Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn
4Department of Oncologic Surgery, Collegium Medicum, University of Warmia and Mazury, Olsztyn
Jatrogenna przetoka pęcherzowo-odbytnicza (IVRF) jest poważnym powikłaniem chirurgii stercza i jelita grubego. Naprawa przetoki stanowi duże wyzwanie. Opisano wiele technik operacyjnych leczenia IVRF, nadal jednak nie ma konsensusu, która z metod mogłaby zostać uznana za złoty standard. Celem pracy jest przedstawienie własnych doświadczeń w leczeniu IVRF w odniesieniu do aktualnych danych z piśmiennictwa.
Omówiono sposoby leczenia IVRF na podstawie trzech chorych w wieku 68, 67 i 72 lat, u których przetoka pęcherzowo-odbytnicza wystąpiła po operacjach radykalnej prostatektomii w dwóch przypadkach i resekcji odbytnicy z powodu raka w jednym przypadku. Wszyscy pacjenci przed rozpoczęciem leczenia w ośrodku urologicznym przebyli kilkukrotne nieskuteczne leczenie operacyjne różnymi metodami. Zastosowane techniki i uzyskane wyniki omówiono w kontekście wybranych pozycji dostępnego piśmiennictwa. Dwóch chorych z IVRF po radykalnym wycięciu stercza zostało wyleczonych metodą naprawy przezodbytniczej, pacjent z IVRF po leczeniu raka odbytnicy został zaopatrzony techniką laparoendoskopową przezpęcherzową i pozostaje w trakcie obserwacji. Okres obserwacji wynosi odpowiednio 36, 8 i 1 miesiąc. Leczenie IVRF jest trudnym wyzwaniem wymagającym od zespołu leczącego znajomości różnych technik operacyjnych i często współpracy interdyscyplinarnej. Niepowodzenia zdarzają się niezależnie od zastosowanej metody. Nowoczesne operacje minimalnie inwazyjne zdają się znajdować istotne miejsce w armamentarium terapeutycznym IVRF.
Iatrogenic vesicorectal fistula (IVRF) is a serious complication of prostate and colorectal surgery. Fistula repair is a highly challenging procedure. Multiple surgical techniques for IVRF repair have been proposed, but there is as yet no consensus as to which method should be recognised as the gold standard. The aim of the paper is to present our own experience in the treatment of IVRF with reference to the most up-to-date literature reports.
Different methods of IVRF treatment are discussed based on 3 patients, aged 68, 67 and 72 years, in whom vesicorectal fistula occurred after radical prostatectomy (2 cases) and rectal resection due to cancer (1 case). Before starting treatment in the urology department, all the patients underwent several unsuccessful surgical procedures performed via various operative techniques. The techniques and patient outcomes are discussed in the context of selected literature reports. Two patients with IVRF after radical prostatectomy were successfully treated by transrectal repair, while the patient with IVRF developing after the treatment of rectal cancer underwent transvesical laparoendoscopic surgery and is currently followed up. The patients’ follow-up periods are 36, 8 and 1 month, respectively. IVRF treatment is a major challenge and requires the medical team to be familiar with a variety of operative techniques. Often, multidisciplinary collaboration is essential for optimal patient management. Therapeutic failures occur regardless of the treatment used. Modern minimally invasive surgical treatments seem to occupy an important place in the therapeutic armamentarium for IVRF.
Iatrogenic vesicorectal fistula is a rare but serious complication of prostate and colorectal surgery, which markedly impairs the quality of life of patients. The incidence ranges from 1 to 3.6%, but it may even reach 11% in patients after radical prostatectomy (1). IVRF presents as pollakiuria, dysuria, painful bladder pressure, pneumaturia and/or faecaluria. Most typically, these symptoms are accompanied by the presence of refractory urinary tract infection (2, 3).
Despite a broad array of operative techniques used in IVRF repair, selection of the optimal method still remains controversial and depends to a large extent on the personal preferences of the operating surgeon (3, 4).
The York-Mason technique typically produces very good outcomes, but in view of the fact that it is quite invasive, a number of minimally invasive procedures have been introduced as alternatives (5, 6).
Some of the novel surgical modalities include transvesical procedures using both multiple- and single-port laparoscopic instruments (3, 7).
Nevertheless, transrectal surgery to repair fistulas in convenient locations can be a valuable alternative (6).
In this paper, we present the cases of three patients with vesicorectal fistulas treated by different methods, with a focus on therapeutic challenges, based on our own experiences and a literature review.
Case report 1
A 68-year-old patient was referred to our department because of persistent IVRF symptoms. In January 2014, the patient underwent radical laparoscopic prostatectomy complicated by haemorrhage and rectal perforation. Following conversion to the open method, rectal injury was managed in the standard fashion. On the 6th postoperative day, the patient developed symptoms of vesicorectal fistula. The Foley catheter was maintained, and on the 28th postoperative day another attempt was made to close the fistula. Laparotomy was performed, the fistula was closed, and colostomy was done. After another 5 days, the patient was discharged home with a permanent catheter. The symptoms of the fistula persisted, and in March 2016 the patient was hospitalised with signs of sepsis. In May 2016, the man was admitted to our department, where an extended diagnostic work-up was performed, and a vesicorectal fistula was diagnosed at the site of the vesicourethral anastomosis, 10 mm in diameter. The PSA level was not determinable. The patient was considered eligible for repair surgery from the perineal approach, and was discharged home on postoperative day 4 with a permanent catheter. On the 10th postoperative day, the fistula recurred. Another repair surgery was performed from the suprapubic approach in October 2016. Because of adhesions from previous surgeries and a hard scar infiltrate involving the bladder and the rectum, the procedure was difficult, and it took a total of 180 minutes to complete. This surgery was unsuccessful, too. A follow-up examination showed a persistent IVRF with a diameter of 3 mm. In February 2017, a repair surgery was performed laparoscopically from the transrectal approach (with the patient in prone position with elevated pelvis and bent knees). The surgical procedure took 120 minutes. The patient recovered, and in September 2017 the continuity of the digestive tract was restored. The man shows a significant degree of urinary incontinence.
Case report 2
A 67-year-old patient, an active smoker, was admitted to the Urology Department in October 2018 with symptoms of vesicorectal fistula which occurred on the 5th day after laparoscopic radical prostatectomy (LRP) in May 2018. The patient had a Foley catheter in the bladder, and all attempts at healing the fistula on the catheter were unsuccessful. During periods without a catheter, he demonstrated symptoms of stress urinary incontinence. Prior to the LRP procedure, the patient had coronary artery bypass surgery and right femoral artery bypass graft. Following diagnostic endoscopy (cystoscopy) and diagnostic imaging (cystography), a vesicorectal fistula (10 mm in diameter) was identified at the level of the vesicourethral anastomosis. The patient did not have colostomy surgery. In addition, the level of PSA was found to have increased from 0.2 ng/ml in June 2018 to 0.7 ng/ml in September 2018, indicating biochemical progression.
Because of the presence of IVRF, the patient was found ineligible for adjuvant radiotherapy. In October 2018, the man underwent a fistula repair surgery using the technique of transvesical laparoendoscopic single site surgery (T-LESS). Three months after the operation, the patient had practically no fistula symptoms. However, follow-up cystoscopy revealed a VRF tract, 1 mm in diameter. Based on that finding, the patient was considered eligible for transurethral fulguration, which was performed in February 2019. The procedure turned out to be unsuccessful, and in May 2019 the fistula was closed from the transrectal approach (with the patient in the lithotomy position), achieving patient recovery. The surgical procedure took 110 minutes. On account of the elevated PSA level (0.9 ng/ml) and contraindications to MRI, PSMA T4 scintigraphy was performed, showing a focus of pathological tracer uptake with a diameter of 1 cm, consistent with a metastasis into the presacral lymph node (fig. 1). In December 2019, the patient completed radiation therapy targeted to the metastatic focus. In February 2020, the PSA level was 0.008 ng/ml. The man shows a significant degree of urinary incontinence.
Fig. 1. In Patient 2, a PSMA T4 scintigraphy scan showed a pelvic metastatic lymph node, 1 cm in diameter, subsequently subjected to radiation therapy
Case report 3
A 72-year-old man was referred to the Urology Department in December 2019 with symptoms of vesicorectal fistula (rectal leakage of urine, recurrent urinary tract infections) persisting since 2017. The patient had a permanent Foley catheter.
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