1.       Introduction

 Vesicorectal fistula is an abnormal communication between the bladder urothelium and the rectal mucosa. The most common etiologies are Diverticulitis, Chron’s disease and Cancer. Is an extremely rare event following radical prostatectomy [1]. The clinical presentation often occurs with pneumaturia, fecaluria, urinary tract infection and tenesmus. Non-surgical management depends of the clinical features of the patient. Few symptomatic with non-toxemic status and non-malignant etiology could be treated with antibiotic therapy, total parenteral nutrition and bowel rest. In poorly responsive or symptomatic patients, proximal colostomy and bladder catheterization might be an alternative treatment. In the absence of infection or obstruction, definitive management aim to separate both organs and to close the defect. Partial omentum retail may be required between the suture lines or rectal mucosa retail over the bladder suture could be used. Open definitive treatment presents high morbidity and high recurrence rate. Minimally invasive repair techniques such as laparoscopic transperitoneal approach can reduce the treatment morbidity and was recently described with good results. This article aims to reported some improvements and standardization in comparison with our initial technique report 

2.       Methods and Patient 

A 57 years-old-male was admitted asymptomatic with serum PSA level of 5,63 ng/mL and normal Digital Rectal Exam. Six core prostate biopsy revealed 3/12 fragments with adenocarcinoma presenting with Gleason score of 6 (3 + 3). Laparoscopic Radical Prostatectomy (LRP) was performed without perioperative complications and patient was discharged at postoperative day 2. Thirteen days after surgery, presented faecaluria and urinary drainage from anus. Patient had an excellent general status and normal vital signs. DRE revelad a 0.5 cm palpable round channel in the anterior rectal wall, 4 cm above the anal orifice. The fistula was confirmed with urethrocystography and cystoscopy 14 days after LRP. Uretherocystography revealed leaking of contrast to rectum. Initially we recommended conservative treatment with bladder catheterization and colostomy. This treatment was carried out for 2 months without success. 

Before the definitive treatment, cystoscopy was performed to identify the fistula characteristics and to plan the definitive surgical repair. Cystoscopy revealed a 0.5 cm oval channel 2mm above anastomotic area. Rectoscopy confirmed the fistula orifice 4 cm above anal border. TAMIS approach was indicated due to reduced morbidity and our good personal experience with this technique [1]. The patient is placed in lithotomy position. Cystoscopy was performed to identify the fistula and place the guide wire through the vesicorectal fistula and both ureteral orifices were catheterized for protection. Operation was performed under general anesthesia. The patient was placed in to jack-knife position with the buttocks apart in order to access the rectum though the anal orifice. We used Alexis^® (Applied Medical System) device idevice for 2.5-6 cm size incisions to configure the TAMIS platform. In this case we used an ANAL GELPOINT to place one 5 mm portal for 0-degree optic and two 3 mm minilaparoscopic trocars. The fistula was identified and circumferentially dissected with hook and monopolar energy (Figure 1).

After complete isolation of the fistula tract a continues suture with 3-0 poliglactin was performed to restore bladder wall. After, we applied fibrin glue (bioglue) (Ethicon inc) in the defect covering (Figures 2,3) and sealing the bladder suture.

Finally, an anterior rectal U-shaped flap was dissected (Figure 4), advanced and sutured (Figure 5) with 3-0 poliglactin to assure the replacement of good tissue at repaired area. This flap was previously described by Gil-Vernet for bladder advancement to repair vesico vaginal fistula [2].  

3.       Results 

Operative time was 150 minutes and blood loss were minimal. No perioperative complications occurred. Hospital stay was 22h. Bladder catheter was removed 21 days after the surgery. Patient returned to regular activities in 2 weeks. After 8 weeks, urethral catheter demonstrated complete bladder epithelization without urinary leak. Three months after surgery, bowel restoration was performed. No signs of recurrence after 6 months of follow-up. 

4.       Discussion

Transanal Minimally Invasive Surgery (TAMIS) emerges as an alternative approach to Transluminal Endoscopic Microsurgery (TEM) since 2009 [3]. The advantages are fast recovery with preliminary good results [4]. A 4-year review of available clinical data on TAMIS, it is shown that early results are encouraging and that this new approach to transanal surgery is undergoing worldwide growth [1]. TAMIS was initially described for treatment of benign lesions. After that, treatment of malignant lesions was also described. Albert and cols. performed a retrospective analysis of 50 patients with benign and malignant rectal lesions treated with TAMIS. All procedures were made without conversion to other approaches and 68% of patients were discharged on the day of surgery. Only 6% were found to have microscopically positive margins. No long-term complications were observed [5]. Beyond local excision, TAMIS have other applications. Atallah and cols. performed TAMIS to treat a man with rectourethral fistula after cryoablation treatment for prostate cancer [3]. Martins-Perez and cols. suggest that the greatest advantage to TAMIS for rectal cancer is the easier distal rectal mobilization allowing the operating surgeon to achieve an improved surgical field exposure and visualization in comparison with others transluminal approaches [5]. These reports have encouraged us to propose this approach to treat vesicorectal fistula and evaluate its outcomes in 2014 [6]. 

Due the lack of specifically materials developed for this approach and limited experience with this access make reconstruction time prolonged when compared to conventional procedures. We opted to use minilap instruments because of the small working space and limited capacity of the rectal lumen to distend under CO₂ gas insufflation.

Luminal dilatation, instrumental manipulation and intraoperative suture were the greatest challenges during the procedure. However, no complication was observed, and procedure was completed without conversion. One of the most feared troubles in the repair of vesicorectal fistulas is the loss of functionality due to rectal morbidity of most techniques traditionally used, such as anal stenosis and fecal incontinence. None of these postoperative complications were observed in our report. TAMIS is less invasive but limited visualization and small working space can difficult a good repair. Appropriate experience and skill are mandatory for surgeons to become qualified with this new technique. Minimally invasive surgery done by an expert professional is less aggressive, reduces the risk of complications and may reproduce the results of traditional techniques. Although with a short follow-up, the preliminary result is encouraging. 

5.       Conclusion 

Transanal Minimally Invasive Surgery (TAMIS) to treat vesicorectal fistula is feasible and seems to have lower morbidity when compared with more traditional techniques. It is effective and can be offered as an option by experienced laparoscopic surgeons. The greatest difficulties were maintaining luminal dilation, instrumental manipulation and intraoperative suture.

Figure 1: Fistula identification with guidewire and circumferential dissection with monopolar hook.

Figure 2: Dissected fistula.

Figure 3: Fibrine glue application.