Endoscopic Repair of a Recto-Vesicular Fistula

Abstract

Colo-vesicular fistulae are infrequent complications of malignancy, inflammatory processes, and postoperative complications. As spontaneous closure rates are less than 2%, some form of therapy is typically required. With new advances in endoscopy, less invasive treatment options are now available for fistula closure, decreasing morbidity, and peri-operative mortality. Here we describe a unique case of endoscopic repair of a recto-vesicular fistula. 65 year-old-male with a history of hypertension, hyperlipidemia and prostate cancer status post laparoscopic radical prostatectomy, presented with fevers, and passing urine per rectum 10 days post-prostatectomy. A CT cystogram revealed a posterior bladder perforation, retro-vesicular abscess and a fistula to the rectum. The patient was initially treated conservatively with antibiotics and Foley catheter placement for 7 weeks. Although the abscess had resolved, repeat imaging continued to show a recto-vesicular fistula arising from the anterior wall of the distal rectum. Surgical approaches for repair of the fistula were discussed with the patient. Options presented included the perineal approach, which would require either gracilis interposition along with fecal diversion, or robotic-assisted abdominal repair, with omental interposition and fecal diversion. As both options would require the creation of an ostomy, the patient opted to explore less invasive options. The decision was to proceed with possible endoscopic closure. The patient underwent sigmoidoscopy 6 months postoperatively. Endoscopically, the fistula, measuring approximately 5mm in size was found along the anterior wall of the rectum, approximately 5 cm from the dentate line. The fistulous tract was denuded with a cytology brush and argon plasma coagulation. A 10 mm 12/6 over the scope clip was then applied using an anchor and cap suction technique over the rectal fistula with successful closure. Nonsurgical closure of GI defects may be desired in various situations, such as dehiscence of surgical anastomoses, perforations, or in the case above, repair of inflammatory or neoplastic fistulae. Emerging technology, such as the over-the-scope clip has been developed not only for repair of bleeding ulcers, but repair of small mural defects. In animal models, full-thickness closure of defects of as large as 27 mm have been achieved. The procedure described above represents a minimally invasive option for closure of colo-vesicular fistulae.