Introduction: We present a case highlighting surgical management of an entero-conduit fistula (ECF), with robot-assisted laparoscopy (RAL). The patient is a 71-year-old male with a history of non-invasive high-grade urothelial carcinoma (UC) of the left distal ureter who underwent a RAL distal ureterectomy and ureteroneocystostomy and subsequent left RAL completion nephroureterectomy and eventual RAL radical cystoprostatectomy (RC) and intracorporeal ileal conduit (IC) diversion due to recurrence despite an induction course of intravesical BCG. Most recently, he developed metastatic disease to his right lung and underwent robot-assisted right lobectomy. Currently, the patient is disease-free. Nearly two years after RC, he presented with food particles and air per his urostomy. He also had a positive poppy seed test. Initially, pouchoscopy identified a pinpoint ECF tract at the proximal end of the IC. A 6-month trial of conservative management was unsuccessful with multiple episodes of pyelonephritis of his solitary right kidney requiring prophylactic antibiotics. Here, we demonstrate our approach to RAL ECF repair.
Methods: We began with pouchoscopy, which revealed a larger ECF, able to be cannulated by a 5 Fr open-ended catheter. Injection of contrast highlighted the ECF. A simultaneous pouchogram revealed reflux to the solitary right kidney. Access was obtained using a 5mm optical trocar without difficulty. We noted no significant intra-abdominal adhesions despite his past surgeries. Four 8mm robotic ports and a 5mm assistant port were used as outlined in the video. The ureteral anastomosis was easily identified, and further dissection revealed the ECF in proximity to the bowel-bowel anastomosis staple line. We upsized the left 8mm robotic port to 12mm to use a 45mm robotic stapler. The ECF tract was stapled and oversewn using 4-0 silk sutures. Omentopexy and interposition flap was performed by mobilizing the omentum and fixating it in between the bowel and IC using 4-0 silk sutures to prevent recurrence.
Results: Operative console time was 98 minutes with 25mL of blood loss. He was discharged on the same day. The red rubber catheter, which was secured to the IC, was removed at his 2-week post-operative visit. He remains symptom-free at the time of his 6 month follow up visit.
Conclusions: First-line treatment of ECF is conservative management, with surgical repair reserved for rare failure. This case shows the feasibility of RAL ECF repair and revisions for urinary diversion-related complications. Additionally, it highlights a potential benefit of RAL given minimal adhesion development despite multiple prior major intra-abdominal surgeries done using the robotic approach.
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