A fistula is an abnormal communication between two parts of the body: it can be, for example, between an organ or a vessel and another structure. More precisely, a fistula is a hole between two internal organs, or between an organ and the surface of the body, that allows leakage. They can appear in any part of the body and are generally the result of complications of endoscopic procedures.

Regarding urology, we refer to rectourinary fistulas (RUF)

Rectourinary fistulas

Rectourinary fistulas (RUF) are rare. Among the different types are recto-urethral, recto-vesical, and entero-urinary.

Signs and symptoms depend on the type of fistula and may include urinary tract infections, fecaluria and leakage of urine into the rectum. Proper evaluation of RUFs includes a thorough physical examination, going through previous records of radiation therapy, gastrointestinal disease, cystoscopy, colonoscopy, barium enema, retrograde urethrography and/or performing a contrast-enhanced tomography (contrast CT).

Recto-urethral fistula

The most common cause of recto-urethral fistulas are the various treatments for prostatic pathologies among which are:

1. Transurethral Resection of the Prostate (TURP).
2. External radiotherapy.
3. High Intensity Focused Ultrasound (HIFU).
4. Cryotherapy.
5. Brachytherapy.

Other causes to consider are anorectal surgeries and radiotherapy in patients with rectal cancer. It is important to note that, although these types of fistulas are semantically understood as a consequence of radical prostatectomies, they should be considered recto-vesical fistulas because they are generated near the anastomosis, with the bladder as the point of origin.

Laparoscopic and robotic management of rectourethral fistulas has been described by Sotelo et al. For fistulas involving the prostatic capsule, the technique includes capsulotomy and resection of the prostate, preserving the seminal vesicles and closing the defect in the rectum in two layers. The bladder is then mobilized distally, after which the urethrovesical anastomosis is performed with the standard technique. In some cases, an omentum or peritoneal flap can be interposed.

Rectovesical fistulas

Rectovesical fistulas are less common. They can occur in several locations, including the bottom of the bladder, where diverticular disease and colon cancer are the most frequent causes (66% and 22% respectively). Another location is the bladder neck, where they follow ablative procedures or removal of the prostate for both malignant and benign causes.

A review of complications after radical prostatectomies in the Medicare population revealed a 1% incidence of rectourinary fistulas. For robotic-assisted radical prostatectomies, the reported incidence for rectal lesions is 0.17%, most of which are detected at the time of surgery. Importantly, there is also an increase in the incidence of fistulas as a result of the growth in the number of salvage prostatectomies.

Dr. René Sotelo et al was the first to report the use of the laparoscopic approach for the treatment of rectovesical fistulas. He reported a transvesical approach, in which the fistula tract is reached by performing a vertical cystotomy, dividing the trigone into two. Once the communication between the bladder and the rectum is identified, meticulous dissection is performed to separate the rectum from the bladder.

The rectum is then closed. A flap of omentum can be prepared to pull it down to serve as an interposition tissue to strengthen the repair. Bladder closure is then performed. Parma et al (9) report a similar case with the same success. The use of the robotic approach was first described by Dr. René Sotelo et al with less surgical and hospitalization time, without recurrence of the fistula.

At USC, we have been pioneers in the management and minimally invasive repair (laparoscopic or robotic) of urinary fistulas. Our experience includes the treatment of more than 60 cases of said types of fistulas. We possess a multidisciplinary team, which includes colorectal surgeons and urologists specialized in reconstruction of the urinary tract, in order to offer the best joint treatment of this complex and demanding condition.