Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series.

A.A.J. Grüter wrote the paper. S.E. Van Oostendorp, L.J.H. Smits, M. Kusters, M. Özer, J.A. Nieuwenhuijzen and J.B. Tuynman gave their feedback on the paper. J.B. Tuynman, M. Özer and J.A. Nieuwenhuijzen performed the surgical procedure.

A.A.J. Grüter: Investigation, Methodology, Writing - original draft, Resources, Visualization. S.E. Van Oostendorp: Supervision, Writing - review & editing. L.J.H. Smits: Writing - review & editing. M. Kusters: Writing - review & editing. M. Özer: Writing - review & editing. J.A. Nieuwenhuijzen: Writing - review & editing. J.B. Tuynman: Conceptualization, Writing - review & editing.

Waived by ethical committee of Amsterdam UMC, location VUmc.

Patient signed informed consent for the use of clinical data, images of CT scan and video of surgical procedure.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

J.B. Tuynman.

A new minimally invasive perineal approach using a SILS port is proposed in pelvic redo surgery for recto-urogenital fistulae in the most distal part of the pelvis. Usage of the described technique provides potential benefits in visualization and exposure. The three-layer repair using well vascularized tissue like an omentum slip or a pudendal thigh fasciocutaneous flap may lead to lower recurrence rates.

Recto-urogenital fistulae are refractory complications following pelvic surgery. Redo surgery, especially for the most distal fistulae, is challenging because of complex pelvic adhesions. Besides, it brings a large burden to patients as a result of low success rate and associated morbidity. Therefore, it is of major importance to cure fistulae during the first attempt. The transperineal technique is a very old approach utilized by the very first surgeons, but this technique was hampered by poor vision, small operation field and poor control of blood loss. With the utilization of the modern insufflation, the SILS technique and a HD camera, the exposure is maximized with minimal invasiveness. In the cases described above, the minimally invasive perineal approach with the use of a SILS port was applied. Upon diagnosis, fecal and urinary diversion must be started immediately by a nephrostomy, ileostomy or colostomy in order to control the ongoing pelvic sepsis [15] . This type of initial therapy is recommended for a period of three to six months [16] , [17] . After the “cooling-off” period, persisting fistulae should proceed to operative repair. In our experience the minimally invasive perineal approach provides an excellent view and exposure of the described distal recto-urogenital fistulae after previous pelvic surgery. In addition, it avoids major abdominal surgery. On the other hand, laparoscopic abdominal approach is recommended for high rectovaginal and sigmoidvaginal fistulae. Van der Hagen et al. showed a high healing percentage of 95% after laparoscopic abdominal repair [18] . However, abdominal access to urogenital fistulae deep in the pelvis is often a major challenge, since inflammation and fibrosis turns this area into a “no-man’s land”, with obliteration of surgical planes which may sequel to high peri-operative morbidity [19] . Various interposition flaps have been used in the last decades and these interpositions could be the key to surgical success to repair the fistulae. The endorectal advancement flap procedure uses a partial-thickness flap of rectal wall to cover the defect in the rectovaginal septum and was recommended as the treatment of choice for patients with distal rectovaginal fistulae in the early 1980s. The initial results were very promising with healing rates ranging between 78 and 95% [20] . However, later on, patients who had been treated with an endorectal advancement flap showed relatively high recurrence rates of 57% [21] . The puborectal sling interposition for treatment of rectovaginal fistulae has been described with a success rate of 62% [22] . For the rectovesical fistulae, an array of interposition flaps have been investigated in the past as well, including flaps of the gluteus maximus, omentum, gracilis, dartos and levator ani muscle [15] . Ghoniem et al. reported 25 patients with a rectovesical fistula that developed after treatment for prostate cancer (radical prostatectomy, radiotherapy, cryotherapy or combination therapy) treated with transperineal approach and a gracilis muscle interposition. None of the 25 participants had a recurrence with a mean follow-up of 28 months [23] . In the future, additional studies are necessary to assess the efficacy and safety of this minimally invasive perineal approach using a SILS port. In patients with distal recto-urogenital fistulae after previous pelvic surgery, the outcomes of this new technique need to be compared with the conventional abdominal approach. Since recto-urogenital fistulae are a complex problem and tailored approach on an individual patient level is required, a randomized controlled trial is unlikely to be feasible and case-matched studies will conceivably be suited to provide further insight in optimizing treatment strategies. Nevertheless, extensive prospective research may provide long-term outcomes of the described procedure and may identify patients who could benefit most.

Not commissioned, externally peer-reviewed.

The authors report no declarations of interest.

Pelvic surgery is associated with local complications. These complications occur particularly in patients who underwent previous pelvic radiation. Persisting recto-urogenital fistulae occur in 0–10%, are often resistant to conservative therapy and substantially impact patients’ quality of life [1] , [2] , [3] . A fistula is defined as an abnormal connection between two epithelialized surfaces such as skin, blood vessel, bowel lumen or hollow organ (bladder, gallbladder). Anorectal fistulae represent a large share of problems in the field of coloproctology with an incidence of 0.021% [4] . In a minority of patients recto-urethral/vesical or rectovaginal fistula can occur, which are most frequently caused by surgery, trauma, diverticulitis, Crohn’s disease and cancer [5] , [6] . In particular the iatrogenic rectovaginal or rectovesical fistulae after pelvic surgery rarely heal without surgical reintervention [7] , [8] . Definitive surgical treatment of the fistula is associated with postoperative morbidity, such as surgical site infections (22%), urethral incontinence (16.7%), intra-abdominal abscesses (16.7%), as well as a high failure rate i.e. recurrence of the fistula (44%) [9] , [10] . Currently, there is no consensus about the optimal method of surgical repair. The major challenge in pelvic redo surgery is to achieve adequate exposure. The recto-urethral/vesical and rectovaginal fistulae are located anteriorly, deep and low in the pelvis, where the surgical approach is hampered by distortion of the anatomy due to extensive fibrosis, caused by previous surgery and the preceding septic episode. The standard abdominal approach often requires full mobilisation of the omentum and re-adhesiolysis, which is associated with conversion to open surgery. Transanal Minimally Invasive Surgery (TAMIS) is a less invasive approach, which is slowly being implemented as a perineal approach to pelvic surgery. The spectrum of pathology that can be managed with TAMIS has evolved from excision of small rectal lesions to a transanal total mesorectal excision (TaTME), salvage surgery in anastomotic leakages, treatment of endometriosis and pouch surgery [11] , [12] . It is also applicable in transvaginal right hemicolectomy with natural orifice specimen extraction (NOSE) [13] . A transperineal approach using a single incision laparoscopic surgery (SILS) port might be better suited for surgical treatment of fistulae located distally in the pelvis. This approach could offer improved access with good exposure compared to the conventional transabdominal approach. In this single-centre retrospective study, we report three cases of minimally invasive perineal redo surgery using a SILS port for the surgical treatment of recto-urogenital fistulae. The aim of this study is to provide a detailed description of this surgical approach and to evaluate this procedure. This study was conducted in accordance with the modified PROCESS criteria, which provides a structure for reporting surgical case series [14] .

A 65-year-old woman underwent a completion TaTME after previous local excision of a high-risk pT1 adenocarcinoma of the rectum (well-to-moderately differentiated, Kikuchi level sm3, no lymphatic and vascular invasion with clear resection margins) with an estimated survival rate of 90%. On POD 12, vaginal passage of gas and stool indicated the presence of a rectovaginal fistula. A CT-scan of the abdomen confirmed a rectovaginal fistula ( see Fig. 3 ). Fig. 3 CT scan of the abdomen with rectal contrast shows a rectovaginal fistula. The arrow points to the rectovaginal fistula. Fig. 3 Fig. 4 Perineal incision with the pudendal thigh flap. Fig. 4 CT scan of the abdomen with rectal contrast shows a rectovaginal fistula. The arrow points to the rectovaginal fistula. Perineal incision with the pudendal thigh flap. A diverting loop ileostomy was constructed for fecal diversion and the colon was antegradely flushed to discard feces. Hereafter, but during the same operation, a SILS port was positioned for both transvaginal and transanal minimal invasive surgery. Again, the first step included exploration and dissection of the fistula. Secondly, a transperineal approach was utilized to dissect the space between rectum and vagina both proximal and distal to allow optimal mobilization of rectum and vagina to close the defect without tension. The next step consisted of suturing the vaginal wall. Simultaneously an omentoplasty was performed which facilitated the insertion of the mobilized omentum up to the perineal body and was closed subcutaneously. Finally, the defect in the wall of the rectum was closed by a two-row running suture; hence again resulting in a three-layer closure ( see Box 2 for a detailed step by step description ). The total surgery time of this operation was 285 min. The blood loss during this procedure was less than 30cc and so no blood transfusions were needed. Box 2 Step by step procedure for rectovaginal fistula closure. Step 1: Laparoscopic mobilization of an omentum in order to facilitate an omentoplasty. Step 2: Identification of the fistula tract by a transanal approach. Excision of the fistula tract traced and separation of the rectal and vaginal wall. Step 3: Transperineal access with small incision to create more space distally and proximally of the fistula using a SILS port. Step 4: Sutured closure of the vaginal wall from transvaginal placement of the port. Step 5: Bring down the omentoplasty to the perineum bridging the site of the previous fistula tract. Transanal anchoring sutures of the omentoplasty subcutaneously. Step 6: Transanal full thickness closure of the defect in the rectal wall with the use of a SILS port. Step 7: Reversed leak test by filling the pelvic cavity from the abdominal site with saline. Insufflation and transanal and transvaginal inspection of the closure sites for air leakage. Alt-text: Box 2 Step 1: Laparoscopic mobilization of an omentum in order to facilitate an omentoplasty. Step 2: Identification of the fistula tract by a transanal approach. Excision of the fistula tract traced and separation of the rectal and vaginal wall. Step 3: Transperineal access with small incision to create more space distally and proximally of the fistula using a SILS port. Step 4: Sutured closure of the vaginal wall from transvaginal placement of the port. Step 5: Bring down the omentoplasty to the perineum bridging the site of the previous fistula tract. Transanal anchoring sutures of the omentoplasty subcutaneously. Step 6: Transanal full thickness closure of the defect in the rectal wall with the use of a SILS port. Step 7: Reversed leak test by filling the pelvic cavity from the abdominal site with saline. Insufflation and transanal and transvaginal inspection of the closure sites for air leakage. Alt-text: Box 2 Antibiotic therapy (oral ciproxin and intravenous metronidazole) was continued for 5 days. After the interventions, no recurrence of the fistula was noticed during the follow-up examinations. A CT scan with rectal contrast at 2 months of follow-up was performed to evaluate potential recurrence or inflammation at the site of the earlier fistula tract. After clinical and radiological confirmation that the area was healed, without any signs of recurrence, the ileostomy could be reversed five months after the initial surgical treatment. After the reversal, the patient recovered and has not shown any signs of fistula recurrence up until 6 months after reversal.

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