eP548 - Robotic Management of Rectourethral Fistula

Purpose/Background: Rectourethral fistula (RUF) is an uncommon condition that can result from surgery, trauma, malignancy, and radio- or cryotherapy. Management is challenging and depends on the location, size, presence of pelvic sepsis, and history of radiation and/or previous failed repair(s); various surgical approaches including transabdominal, transanal, transperineal, or transsphincteric have been employed. Herein we present our experience and outcomes with robotic management of RUF.Methods/Interventions: A prospectively maintained registry was retrospectively reviewed for robotic RUF procedures performed between December 2017 – May 2023 at our institution. Patients who had non-robotic surgeries were excluded. The cohort was classified into 4 groups; Group 1 (DP): dual organ preservation (bladder & rectum), group 2 (RE): rectal exenteration, group 3 (BE): bladder exenteration, and group 4 (DE): dual organ exenteration.Results/Outcomes: A total of 20 patients underwent robotic RUF operations. Of these, 10 patients underwent DP, 3 RE, 3 BE, and 4 DE.For DP, RE, BE, and DE groups, the mean age was 69.6, 72.3, 63.0, and 68.5 years, respectively. The mean BMI was 25.9, 22.7, 29.3, and 32.8, respectively. The mean ASA classification was 2.7 for DP, RE, and BE, and 2.5 for DE. All patients had a history of genitourinary malignancy, prostate cancer accounting for the majority (19 patients). In terms of risk factors, 2 (DP), 3 (RE), 3 (BE), and 3 (DE) patients had prior radiotherapy; 1 (DP), 0 (RE), 0 (BE), and 1 (DE) patient had prior cryotherapy, and 2 (DP), 0 (RE), 1 (BE), and 2 (DE) patients had prior pelvic sepsis. Prior to their index surgery, 6 (DP), 0 (RE), 2 (BE), and 3 (DE) patients underwent fecal diversion; and 2 (DP), 0 (BE), 1 (RE), and 3 (DE) patients underwent urinary diversion.The mean operative duration was 8.2, 11.0, 13.1, and 16.8 hours for DP, RE, BE, and DE groups; and the mean estimated blood loss was 202, 283, 275, and 450 mL, respectively. The mean length of stay was 4.5 (DP), 5.7 (RE), 10.3 (BE), and 10.8 (DE) days.The mean follow-up was 16.5 months (DP), 29.0 (RE), 27.9 (BE), and 21.1 (DE); mean follow-up for all patients was 21.0 months. A total of 9 patients had a Clavin-Dindo grade complication of III or greater; 3 (DP), 2 (RE), 2 (BE), and 2 (DE). No intra-operative complications occurred. RUF recurrence occurred in 2 patients (10%), 1 patient in each of the DP and BE groups.Conclusion/

Discussion: Robotic-assisted approaches for the treatment RUF appear safe and feasible with acceptable outcomes. Long term follow up and additional studies are needed to compare complication and recurrence rates based on surgical modality and extent of organ resection.Table 1: Demographics, operative details, and outcomesASA: American Society of Anesthesiology Score
BMI: Body Mass Index
CD: Clavian-Dindo
DE: Dual Organ Exenteration
DP: Dual Organ Preservation
EBL: Estimated Blood Loss
hrs: Hours
LOS: Length of Stay
mL: Milliliters
RE: Rectal Exenteration
BE: Bladder Exenteration