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Abstract

Clinical History and Physical Examination:

A 78-year-old male smoker with medical history positive for lung and bladder cancer presented with lower urinary tract symptoms, and rising prostate specific antigen levels. He underwent prostate biopsy and simultaneous Rezūm therapy at an outside hospital. Biopsy reported Gleason 4 + 3. A Foley catheter was placed postoperatively because of acute urinary retention, and after its removal, urine per rectum was noted. After failure of conservative management, the patient was referred to us.

Diagnosis:

Computed tomography abdomen/pelvis and cystogram revealed rectourethral fistula. Cystoscopy showed a fistulous tract at the prostatic urethra near the apex.

Intervention:

The patient underwent a robot-assisted salvage prostatectomy with rectourethral fistula repair. A 5F open-ended catheter was inserted through the urethra for fistula track identification. A standard salvage prostatectomy was completed, and the rectal fistula tract was oversewn. Neurovascular bundles were medialized to cover fistula closure. Vesicourethral anastomosis was performed and tested for water tightness. Air leak test with flexible sigmoidoscope confirmed rectal integrity.

Follow-Up/Outcomes:

Total operative time was 3 hours and 22 minutes. Estimated blood loss was 100 mL. Final pathology report was Gleason 4 + 3 with negative margins and no evidence of extraprostatic extension. The patient was discharged on the second postoperative day. Jackson-Pratt drain was removed on postoperative day 19. At 4 weeks, the Foley catheter was removed after a cystogram was negative for extravasation. Since then, the patient has remained continent, voiding appropriately, and with good bowel movement for a follow-up period of 7 weeks.

No competing financial interests exist.

Runtime of video: 5 mins 1 sec