Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy

Abstract

Background: Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. Case Presentation: A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Conclusion: Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.