VIDEO VIGNETTE
Transanal Minimally Invasive Surgery for Repair of Rectourethral Fistula Sam B. Atallah, M.D. • Teresa C. deBeche-Adams, M.D. • Sergio Larach, M.D. Department of Colon & Rectal Surgery, Florida Hospital, Orlando, Florida
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ransanal minimally invasive surgery (TAMIS) has emerged as a practical method for performing advanced transanal surgery.1 Most experience using TAMIS is for local excision of rectal neoplasia2 and, more recently, transanal total mesorectal excision.3 However, other applications are feasible. The application of TAMIS for the repair of a rectourethral fistula (RUF) is presented. A symptomatic RUF developed in a 59-year-old man 9 months after completion of cryoablative therapy for prostate cancer. In preparation for TAMIS repair, he underwent a diversion of the fecal stream with a laparoscopic loop ileostomy. The patient consented to TAMIS repair of RUF with institutional approval. This video demonstrates how TAMIS can be used to repair the fistula (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A138). The approach involves coring out the fistulous tract, then performing a layered closure with absorbable suture. This fistula was successfully closed, and the loop ileostomy was subsequently reversed 3 months postoperatively. At 23-month follow-up, the patient is doing well without recurrence or difficulty with urination. To our knowledge, this is the first application of TAMIS for the repair of a RUF. This approach is an excellent alternative to more invasive procedures to fistula closure, particularly the transabdominal approach. Successful closure of RUF has also been reported with the use of transanal endoscopic microsurgery; however,
data are sparse, with only 3 published reports to date.4–6 Rectourethral fistula closure remains a difficult problem, and, for fistulas that are radiation induced, closure in this fashion—without interposition of healthy, nonirradiated tissue—is not likely to result in closure. Therefore, a TAMIS layered repair, as demonstrated in this case, is not recommended for radiated RUFs. REFERENCES 1. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24:2200–2205. 2. Albert MR, Atallah SB, deBeche-Adams TC, Izfar S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum. 2013;56:301–307. 3. Heald RJ. A new solution to some old problems: transanal TME. Tech Coloproctol. 2013;17:257–258. 4. Quinlan M, Cahill R, Keane F, Grainger R, Butler M. Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula. Surgeon. 2005;3:416–417. 5. Wilbert DM, Buess G, Bichler KH. Combined endoscopic closure of rectourethral fistula. J Urol. 1996;155:256–258. 6. Hata F, Yasoshima T, Kitagawa S, et al. Transanal repair of rectourethral fistula after a radical retropubic prostatectomy: report of a case. Surg Today. 2002;32:170–173.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com) Financial Disclosure: None reported. Presented at the meeting of the American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: Sam B. Atallah, M.D., 242 Loch Lomond, Winter Park, FL 32792. E-mail: [email protected] Dis Colon Rectum 2014; 57: 899 DOI: 10.1097/DCR.0000000000000136 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 7 (2014)
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Transanal Minimally Invasive Surgery for Repair of Rectourethral Fistula Sam B. Atallah, M.D. • Teresa C. deBeche-Adams, M.D. • Sergio Larach, M.D. Department of Colon & Rectal Surgery, Florida Hospital, Orlando, Florida
T
ransanal minimally invasive surgery (TAMIS) has emerged as a practical method for performing advanced transanal surgery.1 Most experience using TAMIS is for local excision of rectal neoplasia2 and, more recently, transanal total mesorectal excision.3 However, other applications are feasible. The application of TAMIS for the repair of a rectourethral fistula (RUF) is presented. A symptomatic RUF developed in a 59-year-old man 9 months after completion of cryoablative therapy for prostate cancer. In preparation for TAMIS repair, he underwent a diversion of the fecal stream with a laparoscopic loop ileostomy. The patient consented to TAMIS repair of RUF with institutional approval. This video demonstrates how TAMIS can be used to repair the fistula (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A138). The approach involves coring out the fistulous tract, then performing a layered closure with absorbable suture. This fistula was successfully closed, and the loop ileostomy was subsequently reversed 3 months postoperatively. At 23-month follow-up, the patient is doing well without recurrence or difficulty with urination. To our knowledge, this is the first application of TAMIS for the repair of a RUF. This approach is an excellent alternative to more invasive procedures to fistula closure, particularly the transabdominal approach. Successful closure of RUF has also been reported with the use of transanal endoscopic microsurgery; however,
data are sparse, with only 3 published reports to date.4–6 Rectourethral fistula closure remains a difficult problem, and, for fistulas that are radiation induced, closure in this fashion—without interposition of healthy, nonirradiated tissue—is not likely to result in closure. Therefore, a TAMIS layered repair, as demonstrated in this case, is not recommended for radiated RUFs. REFERENCES 1. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24:2200–2205. 2. Albert MR, Atallah SB, deBeche-Adams TC, Izfar S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum. 2013;56:301–307. 3. Heald RJ. A new solution to some old problems: transanal TME. Tech Coloproctol. 2013;17:257–258. 4. Quinlan M, Cahill R, Keane F, Grainger R, Butler M. Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula. Surgeon. 2005;3:416–417. 5. Wilbert DM, Buess G, Bichler KH. Combined endoscopic closure of rectourethral fistula. J Urol. 1996;155:256–258. 6. Hata F, Yasoshima T, Kitagawa S, et al. Transanal repair of rectourethral fistula after a radical retropubic prostatectomy: report of a case. Surg Today. 2002;32:170–173.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com) Financial Disclosure: None reported. Presented at the meeting of the American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: Sam B. Atallah, M.D., 242 Loch Lomond, Winter Park, FL 32792. E-mail: [email protected] Dis Colon Rectum 2014; 57: 899 DOI: 10.1097/DCR.0000000000000136 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 7 (2014)
899
