Robotic Simultaneous Repair of Rectovesical Fistula with Bladder Neck Contracture after Radical Prostatectomy: Step-by-Step Technique and Outcomes

doi:10.21203/rs.3.rs-1819564/v1

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Robotic Simultaneous Repair of Rectovesical Fistula with Bladder Neck Contracture after Radical Prostatectomy: Step-by-Step Technique and Outcomes

https://doi.org/10.21203/rs.3.rs-1819564/v1

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The purpose of this study is to report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with bladder neck contracture (BNC) after radical prostatectomy (RP). Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent BNC after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complication Panel Assessment and Recommendations. Four cases with a median age of 68.5 (63.3–72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3–453) minutes, 255 (175–262.5) mL, and 2.5 (2–3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6–10), 38 (32–43), and 30 (27–41) days, respectively. No postoperative complications were reported. The median follow-up time was 13 (6–16) months, and no fistula recurrence was shown. Robotic-assisted repair could represent a feasible and effective approach for the simultaneous repair of RVF with concomitant BNC. Larger studies and treatment standardization are needed to assess the role of minimally invasive surgery in the simultaneous management of RVF with BNC after radical prostatectomy.

Rectovesical fistula

Bladder neck contracture

Reconstructive

Robotics

Minimally invasive surgery.

Rectovesical fistula (RVF) is an abnormal communication between the rectum and the bladder (1). Bladder neck contracture (BNC) is defined as a narrowing of the lumen of the bladder neck that can be seen at the level of the vesicourethral anastomosis (VUA) (2). Their incidence hovers around 1% and 0.3–17.5%, respectively (2–5). These entities have been recognized as medical conditions for centuries, yet individual management remains challenging due to their rarity and complexity (1, 2).

The clinical presentation of RVF includes urinary tract infections (UTI), fecaluria, pneumaturia, and urine leakage per rectum, whereas BNC includes urinary retention, UTI, urinary incontinence, and overflow incontinence. Both conditions severely impact the quality of life (2, 3, 6).

A myriad of surgical approaches has been proposed to treat RVF (transperineal, trans-sphincteric transrectal, transanal, trans-sacral, and transabdominal) (3). In contrast, traditional treatments for BNC include dilation or resection of the bladder neck contracture; however, the failure rate can be as high as 42% (7). Repeat dilations or bladder neck incisions can lead to an advanced and densely scared VUA and urethral lumen obliteration (2). Yet no agreement on standardized management for these conditions has been established (2, 3).

Moreover, both conditions can arise as a complication of previous urological procedures, and when they are present simultaneously, it is defined as a complex fistula. Complex fistulae are associated with a higher recurrence rate, often requiring more aggressive treatments (8). Therefore, surgical management of this condition represents a great technical challenge, mainly due to the alteration of the anatomical structures and the characteristics of the surrounding tissue affected by previous interventions. Although different robotic surgical techniques have been reported for the individual repair of RVF or BNC after radical prostatectomy (RP), simultaneous repair remains a formidable task.

Hence, this study aims to report our experience and outcomes on four consecutive patients using a novel robotic technique for the simultaneous repair of RVF with BNC after radical prostatectomy.

After obtaining Institutional Review Board approval (HS-17-00208), the medical records of four consecutive patients with RVF and concomitant BNC treated by a single surgeon (RS) at a single institution University of Southern California (Los Angeles, California, United States) between 2019 and 2021 were retrospectively reviewed.

Baseline demographic characteristics included age, gender, etiology, American Society of Anesthesiologists (ASA) score, previous high energy treatment, and previous fistula surgical repair. We evaluated perioperative variables such as operative time (OT), estimated blood loss (EBL), tissue interposition, and length of hospital stay (LOS) together with postoperative follow-up data, including early complications (< 30 days), late complications (31–90 days), Jackson-Pratt (JP) drain removal time, bilateral double J-stent removal time, Foley catheter removal time, follow-up time, fistula recurrence, readmission rate, and success rate. Readmission was defined as any subsequent inpatient admission occurring within 90 days from discharge after the index hospitalization. Success was defined as confirmation of fistula closure by cystoscopy and/or cystogram with complete resolution of fistula- and contracture-related symptoms at least 6-month follow-up. Continuous variables were presented as median and quartiles, whereas categorical variables were presented in frequencies and percentages.

Intraoperative complications were reported following the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) (9). In contrast, postoperative complications were classified using the modified Clavien-Dindo Classification System (10) and reported following the European Association of Urology Complication Panel Assessment and Recommendations (11).

At the 12-month follow-up, either a Cystoscopy and/or Computed Tomography (CT) Cystogram were performed to assess fistula resolution or recurrence if it was suspected based on the patient’s interview and physical examination.

Surgical Technique

Patient preparation

Patients received a mechanical bowel preparation and a single dose of prophylactic antibiotic (2nd generation Cephalosporin) preoperatively based on the Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis (12).

Patient positioning

The patient is positioned and secured in the dorsal lithotomy position. Care is taken to pad all pressure points adequately, and the patient is prepped and draped in the standard sterile fashion. Access to the rectum and urethra is maintained.

Cystoscopy and Fistulous tract cannulation

The anterior urethra is examined cystoscopically and confirmed free of strictures or injury. If BNC is unable to accommodate cystoscope, dilation is performed with S-dilators to access the bladder. If the fistula orifice is found at the previous VUA, the fistulous tract is cannulated with a guide wire for future intraoperative identification. After this, cystoscopic surveillance is performed to ensure no other concomitant lesion. In cases where access into the bladder through the urethra is not feasible due to severe contracture, fistula localization and cannulation can be done through a suprapubic access.

Trocar placement and Robot docking

A small incision is made in the left upper quadrant, and pneumoperitoneum to 15 mmHg is created using the open Hasson technique (13). An 8-mm camera port is inserted through the anterior abdominal wall into the peritoneal compartment. The peritoneal cavity is then inspected with the 0-degree camera ensuring no intraabdominal injury related to access had occurred, and subsequent trocars are placed under direct visualization in a six-port transperitoneal configuration (Fig. 1). Docking of the Xi® DaVinci Surgical System (Intuitive Surgical®, Sunnyvale, CA, USA) is done from the side to allow for simultaneous rectoscopy/cystoscopy if needed. In patients with a fecal diversion, the small incision is made in the right upper quadrant, and the configuration in a similar fashion should be appropriately shifted to the opposite side of the colostomy to avoid injury (Fig. 1).

Omentum harvesting

An omental flap is harvested, replicating the open omentoplasty technique (14). For this section of the procedure, the patient is positioned in reverse Trendelenburg with the Xi® DaVinci Surgical System (Intuitive Surgical®, Sunnyvale, CA, USA) cephalad.

Rectovesical space dissection

Once the omental harvesting is done, the Xi® DaVinci Surgical System (Intuitive Surgical®, Sunnyvale, CA, USA) is undocked, flipped 180 degrees, and re-docked towards the pelvis. The patient is placed in the Trendelenburg position. The dissection starts at the Douglas Pouch and is advanced distally using bipolar cautery and sharp dissection, following Denonvilliers’ fascia until the proximal edge of the fistulous tract is encountered (Fig. 2.a).

Anterior bladder release

An anterior dissection through the Retzius space is then made. The peritoneal incisions are continued laterally, and the bladder is released off the abdominal wall. The dissection is advanced through the bladder neck (Fig. 2.b).

Bladder neck excision

The dissection is taken down the midline until the prior VUA is encountered. The urethra is cut sharply; the opened bladder neck revealed a fistulous tract to the rectum identified by the catheter previously cannulated. The posterior bladder neck is meticulously dissected proximally to the fistulous tract until continuity with the previous posterior dissection is encountered (Fig. 2.c).

Lateral mobilization of the rectum

Lateral and distal mobilization of the rectum is necessary to dissect the fistula edges. Then, fistula edges are freshened by cutting approximately 2 mm of nonviable tissue with scissors. At this point, rectal vascularity can be assessed with indocyanine green (ICG) (Akorn, Lake Forest, IL, USA).

Urethral stump dissection

The borders of the resection are marked in a circular fashion in preparation for the resection. Then, the BNC is excised, and a widely patent urethra with healthy margins is observed (Fig. 2.d). Excised specimens are sent to pathology.

Rectal closure

The rectal closure is performed in two layers in a running fashion, starting distal to the rectal defect using a 2 − 0 V-Loc™ suture (Covidien, Dublin, Ireland) (Fig. 2.e, 2.f). Ideally, a transverse rectal closure is preferred over a longitudinal one to maintain adequate rectal lumen diameter. If needed, a rectoscopy can be performed to assess the rectal caliber and proper closure.

Omentum interposition

The previously harvested omentum is tunneled underneath the bladder and above the rectum. 3–0 V-Loc™ (Covidien, Dublin, Ireland) sutures are used to anchor the interposition flap to the surrounding connective tissue distal to the rectal closure (Fig. 2.g).

Neo-Vesicourethral anastomosis

Once the omentum is interposed and secured, a tension-free and water-tight VUA is completed with a running single knot anastomosis using 2 − 0 Monocryl® suture in a UR-6 needle (Ethicon Inc., Somerset, NJ) (15) (Fig. 2.h, 2.i). Watertightness is confirmed after testing with 100cc of saline. A 20Fr Foley catheter with 5cc of water is placed into the bladder and a JP drain is placed in the pelvis (Online resource).

In cases where excessive tension and unhealthy urethral margins are noted during the VUA, several surgical options are available to overcome these challenges.

1. Posterior bladder neck reconstruction and a robotic transabdominal urethral mobilization can be performed to decrease the distance between the bladder neck and the urethra.

2. Open transperineal urethral mobilization can be performed to mobilize the urethra towards the bladder neck.

Other strategies can be attempted in a stepwise manner in order to achieve healthy margins and tension-free VUA. If tension-free VUA is technically unfeasible, definitive closure of the bladder neck, with subsequent opening of the anterior bladder wall for a new VU anastomosis, should be the first alternative. In cases where these approaches are unachievable, the placement of a permanent SPT is the best next step. Cystectomy with urinary diversion stands as the last resort.

Robot undocking and Skin closure

The Xi® DaVinci Surgical System (Intuitive Surgical®, Sunnyvale, CA, USA) is undocked, and all trocars are removed. The left-sided 12mm AirSeal™ (Conmed, Utica, NY, USA) incision port is closed using a Carter-Thomason® II Port Closure System (CooperSurgical, Inc., Trumbull, CT) under direct visualization with 0 Vicryl® suture (Ethicon Inc., Somerset, NJ). Lastly, fascial and skin incision closure is performed.

Postoperative management

The JP drain is removed according to the drainage and not before the postoperative day (POD) 6. In contrast, the Foley catheter is removed post-operatively after a CT Cystogram confirms no anastomotic leak. Pericatheter removal antibiotics are given.

Four patients with a median age of 68.5 (63.3–72.3) years were treated. All cases were ASA III score and occurred after RP. None of the cases received previous high-energy treatments. Three out of four (75%) patients had at least one previous surgical repair attempt (two were through a transabdominal approach, and the remaining was a transanal endoscopic microsurgical fistula repair with a myorectal flap). (Table 1)

Fecal diversion was present in three patients before the simultaneous repair, which was reverted at 4 (4–5) months after the surgical repair. A previous urinary diversion was present in one patient due to the severity of BNC. All cases were managed robotically. Interposition omentum flaps were used in all our cases (Table 1). One patient had an open transperineal urethral mobilization performed to reach healthy urethral margins and tension-free VUA (Fig. 3).

All surgeries were uneventful. No transfusions or conversions to open where needed and no intraoperative complications were recorded. The median OT, EBL, and LOS were 370 (291.3–453) minutes, 255 (175–262.5) mL, and 2.5 (2–3) days, respectively. No postoperative complications were reported during the early (< 30 days) and late period (31–90 days). Median JP drain removal time, bilateral double J-stent removal time, and Foley catheter removal time were 6 (6–10), 38 (32–43), and 30 (27–41) days, respectively.

The median follow-up time was 13 (6–16) months. No patients were lost to follow-up. No fistula recurrence was reported during the follow-up period. No deaths were recorded during the follow-up period. All patients met the criteria for successful simultaneous repair of RVF with BNC (Fig. 4) (Table 2).

Throughout centuries, authors have reported the individual repair of these staggering conditions (1–3, 16, 17). However, no simultaneous repair has been reported yet.

Both conditions can arise as a complication after RP. According to our experience, RVF has been mislabeled as rectourethral fistula when they occur after RP. Typically, the fistula originates in the bladder neck near the anastomosis and not within the true prostatic urethra (3).

On the other hand, BNC's exact pathophysiology remains poorly understood. The development of BNC has been associated with technical and patient-related factors. Technical factors assumed to increase the risk of BNC include prior energy treatments, absence of mucosal eversion, poor vesicourethral mucosal apposition, increased blood loss, urine extravasation, ischemia of the bladder neck, and excessive intraoperative narrowing of the anastomosis, leading to subsequent scarring, and BNC (16, 17).

BNC resection requires distal dissection until viable urethra is encountered to perform a VUA, which increases the risk of disturbing the integrity of the membranous urethra, affecting the patient’s continence, explaining the need for an artificial urinary sphincter in some patients. Despite high success rates of BNC repair reported in the literature with open approaches, the incontinence rates remain high (18). The increased use of robotic technology for prostatectomy has decreased historical rates of BNC from 32% to less than 3%. Moreover, Kirshenbaum et al. reported the robotic repair of twelve patients with BNC with a success rate of 75% and 82% rate of continence at 13.5 months (19). Similarly, Musch et al. reported a success rate of 83% (20).

However, the presence of BNC changes the way the surgeon approaches fistula repair as this condition needs to be corrected before the fistula itself is excised. The timing of RVF repair remains controversial. We recommend waiting at least six weeks from the noxious event to allow tissue inflammation to decrease. It might be tempting to offer an early repair to improve the patient’s symptoms and quality of life, but this can compromise tissue healing, thus compromising the chances for successful fistula repair.

Our technique offers the already well-known advantages of the robotic platform following the surgical principles for successful fistula repair, even in the challenging setting of simultaneous repair of RVF with concomitant BNC (3, 8, 20). This transabdominal approach offers numerous advantages. It allows the surgeon to repair the fistula and the BNC simultaneously while placing an interposed tissue at the repair site. It also provides access to the rectum allowing for easier closure of the rectal defect without tension. Additionally, it enables mobilization of the bladder to facilitate a tension-free VUA and access to create a fecal or urinary diversion at the time of surgery if necessary (21, 22). Robotic surgery constitutes a promising approach in the urology reconstructive field, especially in cases where RVF and BNC require simultaneous repair.

Despite promising results with the robotic platform, we acknowledge the need for further studies with larger cohorts to allow urologists worldwide to have enough data to solidify the management strategy of these patients. However, our experience constitutes a starting point to improving the management of this condition that significantly affects patients’ quality of life. We acknowledge the limitations of our study. First, it constitutes a retrospective study with small sample size and comprises a single surgeon's experience at a single academic center. A multicenter or a randomized study is warranted. Secondly, we acknowledge the risk of performance bias. This procedure should be performed at centers with appropriate training, expertise, and a multidisciplinary team, given the complexity of this pathology. Lastly, although a small sample size, it is, to our knowledge, the first and largest robotic experience of this nature reported to date.

Robotic-assisted repair could represent a feasible and effective approach for the simultaneous repair of RVF with concomitant BNC. Larger studies and treatment standardization are needed to assess the role of minimally invasive surgery in the simultaneous management of RVF with BNC after radical prostatectomy.

Authors contribution:

All authors contributed to the study's conception and design. Material preparation and supplementary materials were performed by Aref S. Sayegh, Anibal La Riva, Laura C. Perez, and Luis G. Medina. The first draft of the manuscript was written by Aref S. Sayegh.Data collection and analysis were performed by David G. Ortega and Maria A. Lizana.Supervision was performed by Rene Sotelo. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Statements and Declarations

Funding: “The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.”

Competing Interest: “The authors have no relevant financial or non-financial interests to disclose.”

Consent: Written informed consent was obtained from the patients for publication of this article and any accompanying images and video.

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*Table 1*	Demographic Data of Patients Undergoing Simultaneous Repair RVF with BNC
DEMOGRAPHIC DATA
Age (yr.), median (range)		68.5 (63.3 – 72.3)
Sex, n (%)
Male		4 (100)
ASA Score, n (%)
III		4 (100)
Etiology, n (%)
Post-Surgery
Radical Prostatectomy		4 (100)
Previous High Energy Treatments, n (%)		0 (0)
Previous Fistula Repair Attempt, n (%)		3 (75)
Previous Fecal Diversion, n (%)		3 (75)
Previous Urinary Diversion, n (%)		1 (25)
*Abbreviations: RVF: Rectovesical Fistula; BNC: Bladder Neck Contracture; ASA:** American Society of Anesthesiologists*

*Table 2*	Perioperative, and Postoperative Data of Patients Undergoing Simultaneous Repair RVF with BNC
PERIOPERATIVE DATA
Operative Time (min), median (range)		370 (291.3 - 453)
Estimated Blood Loss (mL), median (range)		255 (175 – 262.5)
Length of Hospital Stay (days), median (range)		2.5 (2 - 3)
Tissue Interposition, n (%)
Omentum		4 (100)
Surgical Approach, n (%)
Robotic		4 (100)
Intraoperative Transfusions or Conversions, n (%)		0 (0)
Intraoperative Complications, n (%)		0 (0)
POSTOPERATIVE DATA
Postoperative Complications, n (%)		0 (0)
JP Drain Removal time (days), median (range)		6 (6-10)
Foley Catheter Removal time (days), median (range)		30 (27-41)
Bilateral Double J-stent removal (days), median (range)		38 (32-43)
Follow-up time (months), median (range)		4 (3-11)
Readmission Rate, n (%)		0 (0)
Fistula Recurrence, n (%)		0 (0)
Success Rate, n (%)		4 (100)
Abbreviations: RVF: Rectovesical Fistula; BNC: Bladder Neck Contracture. JP: Jackson-Pratt.

No competing interests reported.

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Robotic Simultaneous Repair of Rectovesical Fistula with Bladder Neck Contracture after Radical Prostatectomy: Step-by-Step Technique and Outcomes

Status:

Version 1

Abstract

Figures

Introduction

Materials And Methods

Surgical Technique

Patient preparation

Patient positioning

Cystoscopy and Fistulous tract cannulation

Trocar placement and Robot docking

Omentum harvesting

Rectovesical space dissection

Anterior bladder release

Bladder neck excision

Lateral mobilization of the rectum

Urethral stump dissection

Rectal closure

Omentum interposition

Neo-Vesicourethral anastomosis

Robot undocking and Skin closure

Postoperative management

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

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