Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula

Non-conventional applications for Transanal endoscopic microsurgery. A single centre experience and a systematic review of literature

BACKGROUND

Transanal endoscopic microsurgery (TEM) and Transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases of rectal carcinomas. In the past decade, however, several new indications raised, and others could raise in the future. The aim of this review was to evaluate, both in the literature and in our personal experience, the use of TEM and TEO for nonconventional applications, different from rectal tumors.

METHODS

We conducted a systematic review of published papers and we selected articles reporting patients who underwent endoscopic surgery for other medical reason than polyp cancer resection, with TEM or TEO. PubMed, MEDLINE, EMBASE and bibliographies of the selected studies were searched for articles in English published up to May 2020 to identify all relevant articles. We excluded articles reporting TEM and TEO used for classical indications. We finally report our experience of non-conventional use of TEO in 5 patients with different diseases.

RESULTS

The research revealed 800 papers and among them we selected 52 articles for a total of 697 patients. Of all patients, only 52 had intraoperative or postoperative complications, with only 10 patients requiring major surgery.

CONCLUSIONS

Our study suggest that TEM and TEO may be valid alternatives to traditional surgery in situations other than its classical indication. These findings can positively impact on the care of patients, who could benefit from less invasive surgical procedures associated with lower morbidity.

Management of acquired rectourethral fistulas in adults

Rectourethral fistula is an uncommon but devastating condition resulting from surgery, radiation, trauma, inflammation, or occasionally anorectal anomaly. Because of involving the urinary and the digestive system, surgical repair can be challenging. More than 40 different surgical approaches were described in the literature. However, no standardized management exists due to the rarity and complexity of the problem. Spontaneous closure of fistula is rare and most cases need reconstructive procedures. Appropriate preoperative assessment is crucial for the decision of operation time and method. Gradually accumulating evidence indicates surgeons should take fistula size, tissue health and vascularity associated with radiation or infection, urethral stricture, and bladder neck sclerosis into consideration and make a proper treatment plan according to the features of various approaches. Accurate preoperative evaluation and proper approach selection would increase success rates. Multiple surgical team corporation, including colorectal, urological and plastic surgeons, would optimize the outcomes.

Use of biological mesh in trans-anal treatment for recurrent recto-urethral fistula

PURPOSE

To report the author's experience on a mini-invasive technique using bioprosthetic plug and a rectal wall flap advancement in the treatment of recurrent recto-urethral fistula.

MATERIALS AND METHODS

Between 2013 and 2015, seven patients with recurrent recto-urethral fistula were referred to the Pederzoli Hospital, Peschiera del Garda, Verona, Italy. Intraoperatively all patients were found to have a rectal wall lesion and were treated with urinary and fecal diversion. For the persistence of the fistula, all the patients underwent a mini-invasive treatment consisting on placement of a bioprosthetic plug in the fistula covered by an endorectal advancement flap through a trans-anal and trans-urethral combined technique.

RESULTS

Median operative time was 48 min with a median blood loss of 30 ml. Median hospital stay was 3 days (IQR 1-3). No case of fistula recurrence or plug migration was described. None of the patients experienced fecal or urinary incontinence. All patients obtained complete fistula healing.

CONCLUSIONS

Recurrent recto-urethral fistula is a challenging postsurgical complication for surgeons and urologists, and its best treatment is still unknown. Our method seems to be feasible and effective for the treatment of complex recto-urethral fistula.

Minimally Invasive Transanal Repair of Rectourethral Fistulas

BACKGROUND

Rectourethral fistulas (RUFs) represent an uncommon complication of pelvic surgery, especially radical prostatectomy. To date there is no standardised treatment for managing RUFs. This represents a challenge for surgeons, mainly because of the potential recurrence risk.

OBJECTIVE

To describe our minimally invasive transanal repair (MITAR) of RUFs and to assess its safety and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively evaluated 12 patients who underwent MITAR of RUF at our centre from October 2008 to December 2014. Exclusion criteria were a fistula diameter greater than 1.5cm, sepsis, and/or faecaluria.

SURGICAL PROCEDURE

After fistula identification through cystoscopy and 5F-catheter positioning within the fistula, MITAR is performed using laparoscopic instruments introduced through Parks' anal retractor. The fibrotic margins of the fistula are carefully dissected by a lozenge incision of the rectal wall, parallel to the rectal axis. Under the healthy flap of the rectal wall the urothelium is located and the fistulous tract is sutured with interrupted stitches. After a leakage test of the bladder, the rectal wall is sutured with interrupted stitches. Electrocoagulation is never used during this procedure.

MEASUREMENTS

Fistula closure, postoperative complications, and recurrence.

RESULTS AND LIMITATIONS

Median follow-up was 21 (range, 12-74) mo. Median operative time was 58 (range, 50-70) min. Median hospital stay was 1.5 (range, 1-4) d. Early surgical complications occurred in one patient (8.3%). Recurrence did not occur in any of the cases. Limitations included retrospective analysis, small case load, and lack of experience with radiation-induced fustulas.

CONCLUSIONS

MITAR is a safe, effective, and reproducible procedure. Its advantages are low morbidity and quick recovery, and no need for a colostomy.

PATIENT SUMMARY

We studied the treatment of rectourethral fistulas. Our technique, transanally performed using laparoscopic instruments, was found to be safe, feasible, and effective, with limited risk of complications.

Transanal endoscopic surgery for complications of prior rectal surgery

BACKGROUND

Long-term complications of previous rectal surgery (e.g., enterovisceral fistula, anastomotic stricture, rectal stenosis) can be challenging problems for which transabdominal or transperineal surgery with or without definitive fecal diversion is often required. Transanal endoscopic surgery (TES) might allow for local treatment of these complications, thereby saving patients from otherwise major surgery.

PATIENTS AND METHODS

All patients undergoing TES in the IJsselland Hospital (NL) since 1996 were recorded in a prospective database, of which twenty patients were treated for complications after previous rectal surgery. Data on prior treatment, surgical techniques, outcomes, and need for additional surgery were collected.

RESULTS

Twenty patients were identified from the database (rectourinary fistula n = 3, rectovaginal fistula n = 5, anastomotic stricture n = 8, and rectal stenosis n = 4). One of the three (33 %) rectourinary fistulas and two of five (40 %) rectovaginal fistulas were successfully treated with TES. Anastomotic strictures were successfully treated in 5/8 (63 %) patients. Strictures after local excision of rectal tumors were successfully treated in 3/4 (75 %) patients. No minor complication and one major complication occurred (rectovaginal fistula after stenoplasty eventually requiring Hartmann's procedure).

CONCLUSIONS

Transanal treatment of anastomotic strictures, rectal stenosis, and fistula after prior rectal surgery is safe and effective in a large proportion of patients. TES should be considered as a first step in all patients presenting with these late complications after rectal surgery.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

Acquired recto-uretral fistulas: etiopathogenesis, diagnosis and therapeutic options

Rectouretral fistulas are a rare disease, but represent an important problem for the patient that suffers them and a challenge for the urologist and colorectal surgeon who has to manage them. A wide review has been performed focusing on etiopathogenic factors, diagnostic and therapeutic options including the analysis of different surgical techniques. PubMed, MEDLINE y EMBASE medical database were searched up to September 2014.

Transanal endoscopic microsurgery-assisted rectal advancement flap is a viable option for iatrogenic rectourethral fistula repair: a case report

Rectourethral fistula (RUF) is a relatively rare complication of radical prostatectomy, but is extremely difficult to treat. Multiple surgical approaches have been described for definitive treatment, but to date none of them have been determined to be the gold standard, either due to a high recurrence rate of the condition or due to the morbidity associated with the procedure. In this case report, we describe a successful repair of iatrogenic RUF through a multidisciplinary approach consisting of cystoscopy, urethral stent placement, colonoscopy, and TEM-assisted rectal advancement flap.

Rectourinary fistula after radical prostatectomy: review of the literature for incidence, etiology, and management

Although rectourinary fistula (RUF) after radical prostatectomy (RP) is rare, it is an important issue impairing the quality of life of patients. If the RUF does not spontaneously close after colostomy, surgical closure should be considered. However, there is no standard approach and no consensus in the literature. A National Center for Biotechnology Information (NVBI) PubMed search for relevant articles published between 1995 and December 2010 was performed using the medical subject headings “radical prostatectomy” and “fistula.” Articles relevant to the treatment of RUF were retained. RUF developed in 0.6% to 9% of patients after RP. Most cases required colostomy, but more than 50% of them needed surgical fistula closure thereafter. The York-Mason technique is the most common approach, and closure using a broad-based flap of rectal mucosa is recommended after excision of the RUF. New techniques using a sealant or glue are developing, but further successful reports are needed.

Treatment of post-prostatectomy rectourethral fistula with fibrin sealant (Quixil™) injection: a novel application

Rectourethral fistulas in adults is a rare but potentially devastating postoperative condition requiring complex and demanding surgery. Fibrin glue treatment has been used with some success in anal and rectovaginal fistulas, and in the case we present here this indication has been extended to a postoperative rectourethral fistula following radical prostatectomy. For the first time, to our knowledge, a fibrin sealant (Quixil) was injected into the fistula tract, and a rectal mucosal flap was used to close the internal opening. The fistula healed in few weeks, and the patient is symptom free after 1 year of follow-up.

TEMS: an alternative method for the repair of benign recto-vaginal fistulae

INDICATIONS

The repair of high recto-vaginal fistula can be challenging since access may be limited via the endo-anal approach yet the alternative trans-abdominal route carries significant morbidity. We report the use of TEMS to repair a recto-vaginal fistula following anterior resection and pelvic radiotherapy.

METHOD

The patient was placed prone and a 25 cm rectoscope was inserted. A proximally based mucosal advancement flap was raised to repair the fistula. The patient was discharged 2 days later and a contrast study confirmed closure of the fistula. COMPARISON WITH OTHER TECHNIQUES: TEMS allows excellent visualisation of a rectovaginal fistula compared to standard endo-anal or trans-vaginal techniques. The morbidity is lower than the trans-abdominal route.

COMMENTS

TEMS is a useful technique for the repair of benign recto-vaginal fistula and has distinct advantages over conventional techniques.

Combined treatment of iatrogenic rectourethral fistula with endoscopic fibrin glue application and clipping

Rectourethral fistula (RUF) formation is a rare complication of prostatic surgery and other pelvic surgical procedures. The results of operations to correct RUF are not always satisfying, with a particular risk of recurrent breakdown or stricture formation at the site of the urethral closure. We present a case of a small RUF treated videoendoscopically with fibrin-glue application combined with endoscopic clipping.

Staging rectourinary fistulas to guide surgical treatment

PURPOSE

Surgical management for rectourinary fistulas remains a reconstructive challenge. There are few guidelines to direct the surgeon to the most successful and least morbid technique. We developed a rectourinary fistula staging system that allows selection of the most appropriate technique for the patient. We present the details of the staging system and surgical outcomes.

MATERIALS AND METHODS

From July 1999 to July 2005 we treated 14 male patients with rectourinary fistula. Mean patient age was 68 years (range 62 to 73). Etiology was rectal injury during open radical prostatectomy in 5 patients, laparoscopic prostatectomy in 1, radiation induced fistula for prostate cancer treatment (brachytherapy and external beam radiation therapy) in 2, neoadjuvant external beam radiation therapy in 2, ischial decubitus ulcer in 3 with spinal cord injury, and cryotherapy and external beam radiation therapy in 1. Cases were staged as stage I--low (less than 4 cm from anal verge and nonirradiated), stage II--high (more than 4 cm from anal verge and nonirradiated), stage III--small (less than 2 cm irradiated fistula), stage IV--large (more than 2 cm irradiated fistula) and stage V--large (ischial decubitus fistula). Diverting colostomy was performed for stages III to V 6 weeks before definitive therapy.

RESULTS

Patients were discharged home after 48 hours. A 22Fr urethral catheter maintained bladder drainage for 3 weeks until cystogram confirmed rectourinary fistula closure. Complications were superficial wound infection and postoperative reexploration of the gracilis flap due to bleeding in 1 case each. All patients were cured after a single operation.

CONCLUSIONS

The surgical challenges of a variety of rectourinary fistula repairs can be managed with minimal morbidity and a high success rate using proper staging to guide urinary tract reconstruction.