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DOI: 10.1055/a-0641-4865
Successful closure of a chronic vesicorectal fistula after radical prostatectomy with an over-the-scope clip
Publication History
Publication Date:
03 July 2018 (online)
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A vesicorectal fistula after prostatectomy is a nightmare for the urologist. Treatment is challenging, invasive, and often unsuccessful. Endoscopic treatment using an over-the-scope clip (OTSC) may be an elegant alternative for the closure of such fistulas, even if they persist for several months after initial surgery.
We report the case of a 62-year-old man with a vesicorectal fistula originating from the urethrovesical anastomosis after laparoscopic radical prostatectomy. A micturating cystourethrogram 7 weeks after surgery showed the presence of the fistula ([Fig. 1]), which was treated conservatively at first because of minimal complaints. However, the fistula persisted and was confirmed by endoscopy ([Fig. 2]).
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Fistula closure was performed 5 months after surgery using an OTSC (Ovesco). First, the fistula tract was visualized and debridement of the re-epithelialized fistula tract took place. An OTSC was then placed over the rectal orifice of the fistula, while regular checks were made – by moving the urethral catheter – for patency of the urethra ([Fig. 3]; [Video 1]). Immediately after the procedure, the symptoms of pneumaturia and rectal urine loss disappeared and the patient has remained symptom-free until now, 18 months after the treatment. Endoscopy at 12 months demonstrated that the OTSC had disappeared and a scar was present as a result of the treatment, but there was no sign of a residual fistula.
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Video 1 Endoscopic closure of a chronic post-surgical vesicorectal fistula by application of an over-the-scope clip (OTSC).
Quality:
OTSC closure is an effective treatment for acute (iatrogenic) perforations of the gastrointestinal tract [1] [2] [3] [4]. In one patient with an early vesicorectal fistula, OTSC application was successful in closing the fistula 5 days after surgery [5]. However, attempts to close chronic vesicorectal fistulas have so far been unsuccessful [4] [5]. To our knowledge, this is the first report that describes the successful closure using an OTSC of a chronic vesicorectal fistula. The debridement of the re-epithelialized fistula tract is probably essential for long-term fistula closure in these patients.
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References
- 1 Shoar S, Poliakin L, Khorgami Z. et al. Efficacy and safety of the over-the-scope clip (OTSC) system in the management of leak and fistula after laparoscopic sleeve gastrectomy: a systematic review. Obes Surg 2017; 27: 2410-2418
- 2 Saxena P, Khasab MA. Endoscopic management of esophageal perforations: who, when, and how?. Curr Treat Options Gastroenterol 2017; 15: 35-45
- 3 Weiland T, Fehlker M, Gottwald T. et al. Performance of the OTSC system in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review. Surg Endosc 2013; 27: 2258-2274
- 4 Mercky P, Gonzalez JM, Aimore Bonin E. et al. Usefulness of over-the-scope clipping system for closing digestive fistulas. Dig Endosc 2015; 27: 18-24
- 5 Brodak M, Kosine J, Tachecí I. et al. Endoscopic treatment of a rectovesical fistula following radical prostatectomy by over-the-scope clip (OTSC). Wideochir Inne Tech Maloinwazyjne 2015; 10: 486-490