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). 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; ▶Video1). 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. OTSC closure is an effective treatment for acute (iatrogenic) perforations of the gastrointestinal tract [1–4]. In one patient with an early vesicorectal fistula, OTSC application was successful in closing the fistula 5 days after surgery [5]. However, attempts to close chronic vesicorectal fistulas have so far been unsuccessful [4, 5]. 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.