The genitourinary tract is frequently affected by iatrogenic injuries during pelvic and abdominal surgeries, which can cause intraperitoneal leakage and urinary bladder fistula [1]. The perineal fistula is rare, and few surgeons have experience treating it. Some factors are related to a higher incidence of bladder injuries and higher fistula recurrence, such as previous radiotherapy, history of previous pelvic surgery, local infection, and congenital urinary tract abnormalities. The transperineal approach is an excellent option to avoid the intra-abdominal adhesions from previous surgeries. However, it is limited by poor visualization and limited access to control eventual bleeding [2]. Laparoscopy helps the deep pelvis visualization, but it requires training to operate in a reduced space [3]. Although robotic surgery brings better movement performance and improves reconstruction, it is not yet available for most people worldwide, and the laparoscopic approach may be the best alternative. We present the laparoscopic approach to a perineal bladder fistula in a stepwise video of a case report.

A 57-year-old male patient had neoadjuvant chemotherapy and radiotherapy for rectal adenocarcinoma. Then, during the open abdominoperineal amputation, he had a 2cm lesion in the posterior wall of the bladder. It was between the ureteral meatus in the midline and was closed with two layers of absorbable sutures. The patient had a high drain output, and the tomography showed a 0.5 cm hole in the posterior bladder wall. With cystoscopy, we visualized the lesion with sutures and decided on ureteral derivation bilaterally, externalizing through the urethra, for three weeks. The drain flow decreased, and the patient was discharged. However, two weeks after the removal of the ureteral stents, he returned to the hospital complaining of urine coming out of the perineal wound. A new cystotomography showed a contrast leakage in the midline of the posterior bladder wall.

Considering the location of the fistula and the difficulty of visualization during the previous surgery, we chose the laparoscopic approach. The patient was in a Trendelenburg position with legs in a semi-lithotomy position to allow a cystoscopic combined approach. The surgery started with endoscopic visualization of the fistula and bilateral ureteral stenting. The trocars were placed at pelvic surgery fashion. However, considering the midline incision from the previous surgery, we opted for open access at the right para-rectal trocar spot. Then, we introduced the camera and placed the five-millimeter trocar at the right iliac fossa under visualization. Therefore, we could visualize small bowel adhesions at the midline and carefully release them. Once gut adhesions are frequent and challenging, the surgeon must approach carefully, applying gentle traction with atraumatic instruments, and cut the adherences with scissors without energy. The pelvic anatomy was altered by previous surgery, radiotherapy, and fibrosis. We identified the bladder, dissected and opened its posterior and distal region until the fistula. Then we performed two layers of polyglactin 3.0 continuous sutures starting before the fistula and running throughout the posterior wall. The bladder was filled with saline and confirmed no leakage.

The patient had low debt in the abdominal drain, and  was discharged five days after surgery. Three weeks later, a retrograde urethrocystography showed good bladder capacity and no leakage, and we removed the Foley catheter. After six months of follow-up, there are no signs of fistula neither oncologic recurrence.

This video demonstrates the laparoscopic approach to the perineal bladder fistula. Despite insufficient space, adherences, and anatomical abnormalities, laparoscopy shows an advantage in pelvic visualization. Besides, it is a feasible option, and this video encourages pelvic surgeons to choose it and increase evidence about it.

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