Transanal minimally invasive surgery (TAMIS): case report of a novel approach for rectourethral fistula repair

Introduction

Rectourethral fistula (RUF) is an abnormal communication between the digestive and urinary tracts. In most cases, it is secondary to a surgical procedure rather than congenital (1). The incidence of RUF ranges from 0.53% to 8% depending on the series and approach used (2,3). It is a relatively rare complication of prostatic interventions that is extremely difficult to treat. Several surgical approaches have been described for definitive treatment. However, none of these have been established as the gold standard due to either a high recurrence rate or the morbidity associated with the procedure. This case report describes the successful repair of an iatrogenic RUF using a multidisciplinary, two-stage approach. The first stage involved de-functionalization of the digestive and urinary tracts, followed by definitive closure in a second operation using a transanal minimally invasive surgery (TAMIS) technique.

TAMIS represents a novel approach to rectal pathology, using a natural orifice and traditional laparoscopic instruments, providing a minimally invasive alternative for the treatment of RUF. We present this case in accordance with the CARE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-7/rc).

Case presentation

This report presents a case of a 59-year-old male patient with a history of arterial hypertension, dyslipidaemia, and benign prostatic hyperplasia. The patient underwent a laparoscopic Millin-type prostatic adenomectomy without intraoperative complications. However, during the immediate postoperative period, he experienced faecaluria, leukocytosis, and fever. A contrasted computed tomography (CT) (Figure 1) and urethrocystoscopy confirmed the presence of a RUF at the level of the prostatic urethra.

Figure 1 Contrasted CT. The green square shows the fistulous tract with extravasation of contrast into the rectum and perirectal space, associated with a liquid collection with a hydro-aerial level. CT, computed tomography.

Due to the patient’s clinical condition, conservative treatment was initially chosen. This involved a transverse colostomy and bladder catheterization via cystostomy, diverging both the urinary and digestive tracts. The patient was discharged without complications and monitored as an outpatient. Three months after the initial surgery, the fistula remained and the case was presented to the multidisciplinary committee of our institution, which agreed that a combined approach was required. During the second operation, the urology team placed a Foley catheter guided by cystoscopy, and our team performed a TAMIS with primary closure of the fistulous tract.

The technique used involved cystoscopy (Figure 2) and placement of a bladder catheter and cystostomy replacement by the urology team. The patient was then placed in a prone jackknife position, and a rectal examination revealed a 1 cm fistulous orifice at the level of the lower rectum. A transanal GelPOINT Path device was inserted (Figure 3), and pneumorectum was performed. The fistulous orifice was identified once again (Figure 4), and the edges were resected circumferentially. A rectal mucosal flap was raised. Longitudinal stitches were made with a resorbable suture to close the fistulous tract. The rectal mucosal flap was then advanced over the fistulous tract and secured with separate stitches of a resorbable suture.

Figure 2 Cystoscopy. The blue arrow shows the fistulous tract.

Figure 3 Transanal GelPOINT Path device.

Figure 4 Laparoscopic view of the fistulous tract.

The patient was discharged from the hospital on the first postoperative day with a cystostomy and Foley catheter, which were removed 14 and 30 days postoperatively, respectively.

Currently, at the third postoperative month, the patient is progressing satisfactorily with no recurrence confirmed clinically or by cystourethrography. In the short term, we are considering the reconstruction of the intestinal tract.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

Rectal-urethral fistula (RUF) is a rare condition where there is an abnormal connection between the rectum and the lower urinary tract, and was first described by Rufus of Ephesus in 200 A.D. (3).

It can be congenital, but is usually acquired due to underlying diseases such as Crohn’s disease, diverticulitis, or colorectal neoplasia, pelvic trauma, or iatrogenic causes, being the latter accountable for most of the cases. More precisely, usually due to surgery or multimodal treatment (external radiotherapy, brachytherapy, and/or cryotherapy) for prostate cancer, occurring in approximately 0.1–3% in patients who received these therapies (1,3).

The occurrence of RUF after prostate surgery may be due to an inadvertent rectal injury or an unsuccessful primary repair of a rectal injury noticed during surgery. The incidence of RUF following this type of surgery varies according to the series, ranging from 0.53% to as high as 8% in laparoscopic approaches (2,3).

The diagnosis of this condition is established based on clinical signs such as faecaluria (43–65%), haematuria (67–85%), or urine excretion from the rectum during urination (45%). Additionally, it may present as a urinary tract infection (73%), pelvic abscess, or non-specific symptoms such as abdominal pain and dysuria (1). Complementary studies, such as cystourethrography, barium enema, or contrasted CT, can aid in the diagnosis. Rectoscopy or cystoscopy is used to characterize the RUF, identifying its location, size, and distance from the anal margin, in order to plan surgical treatment (3).

Treating RUFs is a challenge for both the surgical team and the patient, as it drastically alters the patient’s quality of life. Several surgical strategies have been proposed, ranging from highly invasive and with a high morbidity rate, such as transperineal and transabdominal, to conservative approaches such as TAMIS. According to the literature, the transperineal approach is the most commonly used (65.9%), followed by transsphincteric (15.7%), transabdominal (12.5%), and finally transanal (5.9%) (4).

TAMIS is a hybrid approach that combines transanal endoscopic microsurgery (TEM), which was first described by Buess in 1985 (5), with single-port laparoscopy using a natural orifice. This approach offers a cost-effective alternative by utilizing the laparoscopic instruments that are already available in most hospitals. Although its use has mainly been described for the treatment of neoplastic pathology, it can also be adapted to treat benign lesions, such as rectal fistulas (6).

The decision to pursue conservative or aggressive treatment for RUF is a complex one, particularly due to the lack of clear guidelines and literature on the optimal approach.

Contamination with urine and faecal material makes spontaneous closure of the RUF unlikely. Therefore, treatment often involves de-functionalization of the urinary and digestive tracts (7). However, this strategy may not be sufficient as definitive treatment, as demonstrated in our case.

Another important point to consider is the fact that complex fistulae, compounded by a previously operated on and sometimes irradiated field, resulting in alteration of the natural dissection planes and severe fibrosis, in most cases require aggressive approaches and mini-invasive treatment is not indicated (3).

TAMIS is a novel technique, and further research is needed to determine its efficacy beyond neoplastic pathology. The platform represents a minimally invasive and versatile tool that offers colorectal surgeons a new perspective on rectal pathology (8).

Conclusions

TAMIS is a minimally invasive technique with low morbidity that has indications beyond oncological pathology. In this case, we demonstrate that it is a valid option in a multidisciplinary approach for the treatment of RUF. Nevertheless, further research is required to refine treatment protocols and improve outcomes in cases of RUF.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-7/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-7/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-7/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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