Rectovesical fistula - Forum

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Paranoid

Rectovesical fistula - Ärzteforum

Post#1 »

Today we were called to see a patient- 62 YO male, 6 days after retropubic prostatectomy- since today passes solid feces through suprapubic cystostomy. (Prostatectomy -for urinary retention).

On exam: pulse 120, tachypneic, spiking, abdomen benign, pus around cystostomy tube, feces dripping from his forskin, urine bag full of shit. PR- the lower 4 cm' of the anterior rectum missing. One can palpate the balloon of the urinary catheter, WBC- 13,000, albumin 2.4.

History of transanal surgery for rectal lesion in 2010- and chemotherapy and perhaps radiotherapy but no records available According to chart pre-prostatectomy rectal examination normal.

What did we do?


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Surgeon

Re: Rectovesical fistula - Ärzteforum

Post#2 »

Not much to do initially, other than to divert. Might consider later recontruction...possibly with a muscle flap...if this is possible. In light of his prior radiation, this might be quite difficult or impossible.

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A Doctor

Re: Rectovesical fistula - Ärzteforum

Post#3 »

Why do I suspect Paranoid did something different than what the rest of us would have?

forceps

Re: Rectovesical fistula - Ärzteforum

Post#4 »

I hate it when this happens! Defunction. If there was radiation, you may not be able to reconstitute this guy for a long, long time.

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Billroth

Re: Rectovesical fistula - Ärzteforum

Post#5 »

Does the patient have any changes from pelvic radiation? Eg, skin changes (tatoos from radiation ports or hair loss or thinkened fibrotic skin, etc.), ureteral strictures and vascular occlusion (?palp fem pulses), h/o radiation proctitis, etc.?

I would do a diverting colostomy.

Poland

Re: Rectovesical fistula - Ärzteforum

Post#6 »

Defunctioning colostomy and I'd tell him that was it for life. I'd include an on table prograde lavage with a proctoscope in the rectum and the patient in Lloyd Davies supports. The problem is how to close the urinary system. The hole is presumably in the prostatic urethra - I would think impossible to repair (ever) in this type of patient. If that was the case I would suture closed the bladder neck, avoiding ureteric damage with an infant feeding tube up each ureteric orifice, and put in a suprapubic catheter. If the hole was in the bladder rather it might heal so I would suture it - with the same safeguards and wait a long time before thinking of removing it.

सर्जन

Re: Rectovesical fistula - Ärzteforum

Post#7 »

Most probably during the enuclation of the prostate the ant rectal wall was also avulsed. this may be due to adhesion from previous RT or if the person was suffering from Ca prostate with extracapsular spread. In my opinion the only course of action at present is to do a double barrel sigmoid colostomy and treat the infection. Nature will do the rest. I would ask the histopathologist to look for prostate malignancy. I saw a similar case about a year back (No malignancy, very strong surgeon!). The patient healed in 6 mts time.

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الجراح

Re: Rectovesical fistula - Ärzteforum

Post#8 »

I have a limited experience in urology,but from my general knowledge I understand that open prostatectomy is now very uncommonly done,particularly in USA in a well equipped place,why this patient didn't have cyctoscopic tanneling of his prostate to relieve retention of urine?

I agree with previous replies of a defunctioning colostomy. I agree with Iain of an attempt to repair the bladder and/or posterior urethra this may be difficult but will save the patient a very messy postoperative poriod,and will remarkably improve UTI. The future planes will depend on the histopathology result,if it is malignant lesion of colonic origin i.e. adenocarcinoma,and there is no distal dissemination,then a sphincter saving colonic resection may be done at a later stage,when infection subside.If it is a malignant prostate or benign prostatic lesion,then the rectum should be assessed by sigmidoscopy in a later stage,for either closure of colostomy or a pull through procedure.

Wired

Re: Rectovesical fistula - Ärzteforum

Post#9 »

Wash your hands?

Grandpa Phil

Re: Rectovesical fistula - Ärzteforum

Post#10 »

Is the question what did you do, what could you do, or what should you do? The trouble is that this problem could come to any of us tomorrow. You suggests he has done something different to what we assume - probably right - but I have spent a couple of days and sleepless nights agonising over this one. What would I do?
1. Defunction bowel and clear the distal end.
2. Divert urine, but how? I would like to think he could eventually be fully reconstituted, which rules out cystectomy and diversion. Diversion to an ileal loop urostomy is rather a big op in one who is septic. Bilateral percutaneous nephrostomy is less invasive, but will not totally divert the urine, and will leave a large cavity of bladder, prostatic cavity and rectum for the Mother of all abscessses. I think I will go for the bilateral nephrostomies.
3. Wait. Give it a month to see if there is any attempt at healing. If radiotherapy was given before, there probably won't be much change, in which case resection of the rectum and anastomosis may be unwise. Perhaps this is another situation where an omental swing with omental interposition between the missing posterior prostatic capsule and the missing anterior rectal wall might just work? Or use two ileal "patches" (one for prostate and one for rectum) would be preferable. If these techniques worked, close colostomy and remove nephrostomies. If they failed, ileal loop urinary diversion as a permanent companion to the colostomy.

What do I think he did? - I think he did a one stage procedure - but I cannot think what.

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