Successful Endoscopic Closure of Rectovesical Fistula with OVESCO Clip

Abstract

SymbolIntroduction: Rectovesical fistula is usually a complication of inflammatory bowel disease, radiation, colorectal malignancy or trauma during surgery particularly after prostatectomy. The preferred management for fistulae is primary resection with anastomosis. However, with approval of over-the-scope larger endoscopic clips, endoscopic closure of these type of fistulae is gaining in practice. We present a case of rectovesical fistula that was successfully closed endoscopically by OVESCO clip.SymbolCase Report: A 57-year-old male with prostate cancer started passing urine from rectum 2 weeks after robotic-assisted laparoscopic radical prostatectomy. Fluorocystogram showed extensive extravasation of contrast confirming the presence of a large rectovesical fistula. Initially, conservative management was attempted, but he did not tolerate an indwelling foley. GI was consulted for colonoscopy prior to planned surgery. A 1 cm mature fistulous opening was noted in the rectum. The size of the fistula was deemed compatible to closure with OVESCO clip. After completion of colonoscopy, adult gastroscope was introduced through the rectum and Ovesco clip device was mounted on the gastroscope. Using OTSC™(over-the- scope clip) twin grasper, the edges of fistula was drawn into the OVESCO clip device, along with suction and then clip was deployed. Good closure of the fistulous opening was confirmed with 200 cc of methylene blue dye injected through the suprapubic catheter with no leak into the rectum suggesting adequate closure of the fistula. Post procedure, fluorocystogram showed no leakage of contrast into the rectum. Patient was seen in 2 weeks and had continued relief of his symptoms. Discussion: Latrogenic Rectovesical fistulae pose a major management challenge. Creating a temporary or permanent diverting ostomy is burdened by high morbidity and mortality. With advancement in endoscopic techniques, these fistulae can be successfully closed by OVESCO technique, thereby avoiding invasive surgery and its complications. This would also be extremely helpful both from treatment and palliative aspect in patients with metastatic cancer who have fistulae due to local spread of cancer. We conclude that Endoscopy with OVESCO clip placement can be used as an alternative to surgical management for rectovesical fistula in selected patients.