V52 - Recto-Vesical Fistula After Colonic Pullthrough: Attempted Endoscopic Management With Over-The-Scope Clip

CME Eligible

Purpose/Background: Fistulas involving the gastrointestinal and urogenital tracts are rare, challenging complications often arising after either radiation or pelvic surgery, requiring major abdominoperineal reconstructive procedures. Minimally invasive endoscopic approaches, such as the use of an Over-The-Scope Clip (OTSC), have shown some success in managing these defects. Our group previously reported successful management of acquired rectourethral fistulas using a combined technique of electrocautery and OTSC closure after radiation for prostate cancer. We present a case of a rare recto/neocolo-seminal vesicle fistula following colonic pullthrough for an imperforate anus, where a minimally invasive endoscopic OTSC closure was attempted and ultimately unsuccessful, while taking into account patient factors.

Methods/Interventions: A patient 53-year old male with significant cardiac comorbidities was diagnosed with a highly symptomatic fistula between the left seminal vesicle and neo-rectum following a colonic pullthrough procedure for congenital imperforate anus 51 years prior. Imaging confirmed a fistulous communication between the mid to upper rectum and the seminal vesicles. Initial plans for a definitive surgical repair were modified after intraoperative cystoscopy revealed a 1 cm fistula opening between the urethra and the seminal vesicles, with a continued connection to the rectum. Given the proximity of the fistula to the bladder trigone and urethra as well as patient factors and preferences, a less invasive approach with OTSC and electrocautery was undertaken. Surgical management included diversion of both stool and urine with a diverting loop colostomy and a suprapubic catheter alongside a Foley catheter left in situ to optimize conditions for healing. This was undertaken with the understanding that the approach had a low probability of success but was aligned with the patient's wishes.

Results/Outcomes: After electrocautery, the OTSC was successfully deployed at the fistula site. Initial follow-up showed the patient was temporarily asymptomatic, consistent with the immediate technical success of the closure. However, the fistula ultimately recurred, and the patient became symptomatic again after three months of follow-up. This outcome highlights the high degree of difficulty in achieving durable closure of complex fistulas in this anatomical location, especially given the post-surgical nature of the fistula.

Conclusion/Discussion: This rare and unique case illustrates a multidisciplinary effort to manage a complex recto-seminal vesicle fistula with a minimally invasive approach. The short-term recurrence of the fistula suggests a limitation of the endoscopic approach for this delayed surgical complication from a remote coloanal anastomosis for an imperforate congenital anus. Ultimately, the failure of the endoscopic repair confirmed the need for definitive management with a formal surgical procedure without burning any bridges, should the patient elect to proceed.

Over-The-Scope Clip Closure of Recto-Seminal Vesicle Fistula
CT with rectal contrast showing a Recto-Seminal Vesicle Fistula