Is minimally invasive transanal surgery an alternative for rectal-urinary fistula correction?

Is minimally invasive transanal surgery an alternative for rectal-urinary fistula correction? ଝ ¿Es la cirugía transanal mínimamente invasiva una alternativa para la corrección de fístulas recto-urinarias? Dear Editor, Rectal injury is a serious and rare complication in the radical treatment of prostate cancer. The incidence reported in radical prostatectomy 1 (RP) is 0-9% in the open surgery 2 and 1-2.7% in the laparoscopic pathway. 3 Between 0.6 and 9% of the lesions after RP will end as fistulas diagnosed late, originating from an inadvertent rec-tal injury or a defective closure of the rectal wall. Their incidence is 0.2-2% in patients undergoing RP, 0.4-8.8% in brachytherapy, 0-6% postradiotherapy, and 0.4% in cryother-apy. The patient with recto-urinary fistula may present pneu-maturia, fecaluria, urine leakage from the rectum, fever, urinary tract infection, sepsis, pelvic abscess, and/or peritonitis. For the diagnosis, techniques such as cys-tourethrography, cystourethroscopy, colonoscopy, or barium enema are employed. Spontaneous closure of the fistula is rare and one must resort to surgical closure if with conservative treatment it has not closed after 3-6 months. One of the most important aspects for the management of recto-urinary fistulas is choosing an appropriate approach in the first attempt to close, since the initial failure complicates subsequent repair attempts. The fistula location, size, and previous treatment of the patient are important aspects to define a new surgery. Rivera 4 suggested a classification of 5 stages for the correct choice of the procedure. There are different techniques for the correction of the fistula and different surgical approaches: abdominal, perineal, and posterior sagittal, 5,6 but there is no consensus about the ideal surgical technique. The transperineal approach, ideal in urethrorectal fis-tulas, allows for the interposition of connective tissue. Kilpatrick and Mason used the posterior transsphincteric approach (dividing the sphincters) to have more direct access to the fistulous tract. The York Mason technique is one of the most appropriate for the treatment of recto-urinary fistulas with a high probability of success 7 and low morbidity. In the transanal approach, described by Parks, a rec-tal flap proximal to the fistula is used after resection of the fistulous tract. The anterior sagittal transsphincteric access described by Gecelter in 1973 was used by Castillo 8 in the management of 5 vesicorectal fistulas with positive results. We report the case of a 65-year-old patient with recurrent recto-vesical fistula operated by transanal minimally invasive surgery (TAMIS) using the Gel Point Path ® device. …