Successful closure of a chronic vesicorectal fistula after radical prostatectomy with an over-the-scope clip
A vesicorectal fistula after prostatectomy is a nightmare for the urologist. Treatment is challenging, invasive, and often unsuccessful. Endoscopic treatment using an over-the-scope clip (OTSC) may be an elegant alternative for the closure of such fistulas, even if they persist for several months after initial surgery.
We report the case of a 62-year-old man with a vesicorectal fistula originating from the urethrovesical anastomosis after laparoscopic radical prostatectomy. A micturating cystourethrogram 7 weeks after surgery showed the presence of the fistula ( [Fig. 1] ), which was treated conservatively at first because of minimal complaints. However, the fistula persisted and was confirmed by endoscopy ( [Fig. 2] ).
Fig. 1 Cystography after the bladder had been filled with contrast media showing contrast in the rectum because of a vesicorectal fistula.
Fig. 2 Colonoscopic views showing the epithelialized vesicorectal fistula: a before the instillation of indigo carmine into the urinary bladder via a transurethral catheter; b after the instillation of indigo carmine.
Fistula closure was performed 5 months after surgery using an OTSC (Ovesco). First, the fistula tract was visualized and debridement of the re-epithelialized fistula tract took place. An OTSC was then placed over the rectal orifice of the fistula, while regular checks were made – by moving the urethral catheter – for patency of the urethra ( [Fig. 3] ; [Video 1] ). Immediately after the procedure, the symptoms of pneumaturia and rectal urine loss disappeared and the patient has remained symptom-free until now, 18 months after the treatment. Endoscopy at 12 months demonstrated that the OTSC had disappeared and a scar was present as a result of the treatment, but there was no sign of a residual fistula.
Fig. 3 Colonoscopic views showing: a after debridement of the fistula, the rectal fistula orifice being drawn into the cap of the over-the-scope clip (OTSC) system by applying gentle suction; b a retroflexed image of the rectum after OTSC placement.
Video 1 Endoscopic closure of a chronic post-surgical vesicorectal fistula by application of an over-the-scope clip (OTSC).
OTSC closure is an effective treatment for acute (iatrogenic) perforations of the gastrointestinal tract     . In one patient with an early vesicorectal fistula, OTSC application was successful in closing the fistula 5 days after surgery  . However, attempts to close chronic vesicorectal fistulas have so far been unsuccessful   . To our knowledge, this is the first report that describes the successful closure using an OTSC of a chronic vesicorectal fistula. The debridement of the re-epithelialized fistula tract is probably essential for long-term fistula closure in these patients.
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Alexandra M. J. Langers, MD, PhD
Department of Gastroenterology and Hepatology
Leiden University Medical Centre
PO Box 9600
2300 RC Leiden
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