[Laparoscopic repair of rectovesical fistula after radical retropubic prostatectomy].
BACKGROUND
We present the video of a laparoscopic repair of a rectovesical fistula after radical retropubic prostatectomy. The rectal lesion had not been detected during the first procedure. The rectal bladder fistula appeared on the 14th post-operative day. After three weeks from the procedure,the patient underwent a laparoscopic repair of the rectovesical fistula. A temporary external colon conduit was performed at the same time.


METHODS
We performed a cystoscopy before the surgery; it showed a fistula behind the bladder neck at 5 o'clock, distally to the left ureteral orifice. Two ureteral stents were inserted into both the ureters to make sure not to determine any injury to these structures during the operation. With the patient in the supine position, we introduced 5 trocars with the Hasson technique trans-peritoneally. The pouch of Douglas was opened and the bladder was divided from the rectum.The bladder posterior wall was widely opened till reaching the rectal bladder fistula.The fistula was located distally to the left ureteral orifice, very close to the bladder neck. Through a blunt dissection, we divided the margins of the rectal fistula from those of the posterior bladder wall.Indeed, we performed a suture of the rectal wall without any tension. The rectal lesion was closed in a double-layer suture with 3-0 Vicryl.We introduced a probe into the rectum to make sure there was no leakage on the suture. A flap of peritoneum of the Douglas was put between bladder and rectum.We closed the longitudinal opening of the trigone and the bladder posterior wall through a continuous suture.An external colic conduit was packaged to guarantee the closure of the fistula. The left colon was put through the abdominal wall widening the 5 mm trocar opening located on the left pararectal space.


RESULTS
The operative time was 240 minutes. There were no post-operative complications. The bladder catheter was removed at 1 month after surgery,only after performing a cystography, which showed no leakage.Two months later, the colostomy was closed. At a 12-month follow-up the patient had no fistula recurrence.


CONCLUSIONS
The treatment of arectovesical fistula after radical prostatectomy remains a complex procedure: different types of corrective surgical approaches have been described. The laparoscopic approach is an alternative to standard procedures. The optical magnification allows a good view of the fistula in a very deep and narrow space. It also allows easy performing of the colostomy.
Divisione di Urologia Ospedale Fatebenefratelli e Oftalmico Milano, Milan, Italy. paolo.parma@virgilio.it
Paolo
P
Parma
Alessandro
A
Samuelli
Bruno
B
Dall'Oglio
Livio
L
Cappellaro
Candido
C
Bondavalli
Francesco
F
De Luca
D003558:Cystoscopy; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D011468:Prostatectomy / Q000009:adverse effects* / Q000379:methods; D011471:Prostatic Neoplasms / Q000601:surgery; D012003:Rectal Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome; D001747:Urinary Bladder Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*