Laparoscopic transvesical urethrorectal fistula repair: a new technique.

INTRODUCTION: Urethrorectal fistulas are rare, and several open operative approaches and techniques have been used in treatment. We report our preliminary experience with laparoscopic transvesical urethrorectal fistula repair after iatrogenic urethrorectal fistula. A 65-year-old man with insulin-dependent diabetes mellitus and peripheral vascular disease was hospitalized 6 months after transurethral resection of the prostate for benign prostatic hyperplasia with a recurrent urinary tract infection, fecaluria, and urine leakage from the rectum during voiding. Urethrocystoscopy revealed a urethrorectal fistula in the prostatic fossa. Primary conservative treatment failed.

TECHNICAL CONSIDERATIONS: The patient was placed in the lithotomy position, and the suprapubic tract was dilated to allow a 10-mm telescope. Carbon dioxide gas was used to distend the bladder (15 mm Hg, flow rate 3 L/min). Next, two 3-mm pediatric trocars were inserted under direct vision. The fistula was identified and the edge of the fistula excised. A running suture (3-0 PDS, RB needle) was used to close the fistula. Finally, a 16F Foley urethral catheter was passed under direct vision, followed by a suprapubic catheter. On postoperative day 12, retrograde cystography revealed no contrast leakage from the rectum. Follow-up after 3 months showed no recurrence of the fistula.

CONCLUSIONS: A transvesical laparoscopic technique might be useful for selective cases of urethrorectal fistula. Other methods of laparoscopic urethrorectal fistula repair have included bivalving of the bladder and omental interposition. The laparoscopic transvesical approach provides many advantages, including easy access and identification of the fistula tract, good surgical exposure, and minimal tissue manipulation.