Robotic Management of Rectourethral Fistulas After Focal Treatment for Prostate Cancer.

OBJECTIVE: To describe our management strategy for rectourethral fistula (RUF) after focal treatment for prostate cancer (PCa) using 2 cases as an example. Almost 50% of RUFs are associated with energy treatment modalities for PCa. The adjacent damage to healthy tissue along with limited pliability of it makes the success of the repair troublesome. There is no standardized approach for these scenarios.

MATERIALS AND METHODS: For case 1, an 83-year-old man underwent cryotherapy for PCa. On postoperative day 14, he presented with urine per rectum. Cystoscopy confirmed the presence of an RUF. Urinary and fecal diversions were unsuccessful. Three months later, robotic surgical repair was performed. For case 2, an 85-year-old man underwent salvage therapy for PCa with high-intensity focused ultrasound after previous treatment with external beam radiation therapy. Two months postoperatively, he presented with urine per rectum. A computed tomography scan confirmed the presence of an RUF. Robotic surgical repair was subsequently performed.

RESULTS: Both patients underwent robotic-assisted RUF repair, including salvage prostatectomy , rectal defect closure, and omental flap placement. In the first case, healthy urethra was present after the salvage prostatectomy, and the next step was completion of a vesicourethral anastomosis. In the second case, the next step was closure of the bladder neck and suprapubic tube placement due to the extensive tissue destruction the residual urethra. Success was confirmed with imaging studies and no reported symptoms at 9 and 4 months, respectively.

CONCLUSION: The robotic system is useful for the treatment of a complicated RUF. The optimal reconstruction strategy depends on the ability to reach the distal urethra, the patients' characteristics, and preferences.