Robotic repair of iatrogenic prostatosymphyseal fistula following photoselective vaporization of the prostate

Abstract

IntroductionProstatosymphyseal fistula is a rare but serious complication following transurethral procedures for benign prostatic hyperplasia such as transurethral resection of the prostate (TURP) or photoselective vaporization of the prostate (PVP). To our knowledge, only nine cases have been reported in the literature, and all have been treated with either radical prostatectomy or open fistula repair using omental or peritoneal interposition flaps. Here we describe a novel prostate-sparing robotic-assisted laparoscopic Y–V fistula repair with perivesical fat interposition flap. MethodsA 73 year old gentleman presented with pelvic and musculoskeletal pain two months after undergoing PVP for obstructive voiding symptoms. Imaging and cystoscopy revealed a large prostatosymphyseal fistula, and after discussion of the risks and benefits, the patient opted to proceed with operative repair. The patient was positioned in low lithotomy, transperitoneal access was obtained with a Veress needle, and port placement was done in the standard "W" configuration used in robotic prostatectomy. The bladder was dissected free from the anterior abdominal wall. At the level of the pubis the planes were obliterated and tissues were indurated. The endopelvic fascia was cleared using electrocautery and the lateral prostate and urethra were exposed and well defined at the apex. The fistula tract was carefully dissected off the pubis and necrotic areas were cauterized. The urethra was then mobilized around the fistula tract to prepare a good edge for anastomosis. A Y–V repair using two running 3-0 V-loc sutures was then performed in the prostatic capsule to allow for a wide anastomosis to the distal urethral defect. A Foley catheter was placed. A perivesical fat flap was then secured over the anastomosis with a V-loc suture and a drain was placed. ResultsOperative time was 115 min. Estimated blood loss was 50 ml and hospital stay was 2 days. The Foley was removed 4 weeks post-operatively after a cystogram demonstrated no leakage. At 3 months follow up he was doing well with complete resolution of his pelvic and musculoskeletal pain. He was voiding with good stream with post-void residual of 25 ml. He remained symptom-free at 2 years. ConclusionsProstatosymphyseal fistula following PVP can be successfully repaired using a robotic-assisted laparoscopic, prostate-sparing approach. In the carefully selected patient without prostate cancer, this offers an efficacious and attractive alternative to more radical surgical approaches and avoids the urinary and potency complications associated with radical prostatectomy.