Grüter A A J, Van Oostendorp S E, Smits L J H, Kusters M, Özer M, Nieuwenhuijzen J A, Tuynman J B
Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands.
Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Plastic Surgery, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands.
Int J Surg Case Rep. 2020;77:733-738. doi: 10.1016/j.ijscr.2020.11.067. Epub 2020 Nov 19.
Iatrogenic recto-urogenital fistulae are refractory complications that rarely heal without surgical intervention. The ongoing local infection causes pain, discomfort and substantially impacts quality of life. Surgical repair requires adequate exposure and space to fill with healthy tissue, which is a major challenge in pelvic redo surgery. An abdominal approach to repair the fistula is associated with major morbidity and often fails to expose the deep pelvis. In our experience a novel transperineal minimally invasive approach a utilizing single incision laparoscopic surgery (SILS) technique could offer improved results.
In the present study, three cases of patients with recto-urogenital fistulae after pelvic surgery are described. Two patients were diagnosed with a rectovesical fistula and one patient with a rectovaginal fistula. In all three cases, a minimally invasive perineal approach, using a SILS port, was used to perform surgical repair. The closure of the fistulae involved: a separate repair of the urethra/bladder or vaginal defect and the rectal defect, followed by interposition of vascularized tissue by either a pudendal thigh fasciocutaneous flap or omentoplasty.
This study is the first to report on a minimally invasive perineal approach, utilizing a SILS technique for recto-urogenital fistulae repair after previous pelvic surgery. The current approach improves exposure, creates surgical space, optimizes view and allows the interposition of vascularized tissue, without causing substantial blood loss and avoiding major abdominal surgery.
医源性直肠泌尿生殖瘘是难治性并发症，若无手术干预则很少愈合。持续的局部感染会引起疼痛、不适，并严重影响生活质量。手术修复需要充分暴露和有空间填充健康组织，这在盆腔再次手术中是一项重大挑战。经腹途径修复瘘管会带来严重的并发症，且往往无法暴露深部盆腔。根据我们的经验，一种采用单切口腹腔镜手术（SILS）技术的新型经会阴微创方法可能会取得更好的效果。
在本研究中，描述了3例盆腔手术后发生直肠泌尿生殖瘘的患者。2例患者被诊断为直肠膀胱瘘，1例患者为直肠阴道瘘。在所有3例病例中，均采用经会阴微创方法，使用SILS端口进行手术修复。瘘管的闭合包括：分别修复尿道/膀胱或阴道缺损以及直肠缺损，然后通过阴部大腿筋膜皮瓣或网膜成形术置入带血管组织。
本研究首次报道了一种经会阴微创方法，利用SILS技术修复既往盆腔手术后的直肠泌尿生殖瘘。当前方法改善了暴露，创造了手术空间，优化了视野，并允许置入带血管组织，且不会造成大量失血，避免了大型腹部手术。
