"Robotic-assisted surgical management of a post-brachytherapy rectoprostatic fistula: a case report"

Rectourethral fistula represents a rare but devastating complication following prostate cancer treatment, with radiation-induced fistulas presenting particular challenges due to compromised tissue vascularity and healing capacity. While various surgical approaches have been described, management of complex post-brachytherapy rectoprostatic fistulas remains challenging with limited reports of successful robotic-assisted techniques. This case report presents a novel robotic-assisted surgical approach incorporating technical modifications including rectal rotation with mesorectal interposition, which has not been widely documented in the literature for managing radiation-induced rectoprostatic fistulas.

A 54-year-old male with localized prostate cancer (clinical stage T2N0M0, Gleason score 3 + 3) developed fecaluria, pneumaturia, and severe pelvic pain one year after brachytherapy treatment. Diagnostic imaging revealed a 1.6 cm anterior rectal wall defect with a fluid-filled cavity between the rectum and prostate. Following initial palliative sigmoidostomy for symptom relief, definitive repair was performed 13 months later using robotic-assisted radical prostatectomy with segmental rectal resection and coloanal anastomosis. Key technical innovations included bladder stabilization with externalized sutures and 180° rectal rotation, positioning the posterior mesorectum as a natural barrier against fistula recurrence. The procedure duration was 365 min with 200 mL blood loss and no immediate complications. At 24-month follow-up, the patient demonstrated complete fistula resolution with normal bowel function (Wexner continence score: 3) following stoma reversal. Prostate-specific antigen remained undetectable with no evidence of cancer recurrence. The patient reported significant quality-of-life improvement, resuming pre-illness physical activities including walking 7-10 km daily.

This case demonstrates the feasibility and effectiveness of robotic-assisted surgical management for complex radiation-induced rectoprostatic fistulas. The novel technique of rectal rotation with mesorectal interposition may provide additional protection against recurrent fistula formation compared to conventional approaches. This innovative robotic approach could be considered in selected patients with extensive radiation-induced tissue damage where traditional repair techniques may be insufficient, potentially offering improved outcomes in this challenging clinical scenario.