Rectourethral fistula with combined bladder-neck and rectal injury after holmium laser enucleation of the prostate: staged multidisciplinary reconstruction

Abstract

Rectourethral fistula after holmium laser enucleation of the prostate (HoLEP) is exceptionally rare. A man in his early 80s presented four days after HoLEP with urine per anus and fecal urethral catheter drainage. CT showed anterior rectal and bladder-base defects with pelvic collections. Emergency laparotomy achieved source control with bladder closure, suprapubic drainage, and colostomy. Persistent communication required staged bilateral nephrostomy diversion before robot-assisted fistula repair, rectal repair, and bladder-neck closure. Imaging confirmed closure and bowel continuity was restored, although suprapubic drainage remained definitive. Fistula, bowel, and urinary outcomes warrant separate reporting.

1. Introduction

Holmium laser enucleation of the prostate (HoLEP) is a guideline-endorsed treatment for benign prostatic obstruction with a well-characterized perioperative safety profile.^1,2 Rectourethral fistula is among its rarest reported complications. To our knowledge, a single dedicated case has been described,³ alongside one report of vesicosigmoid fistula after HoLEP⁴ and one of rectourethral fistula after open suprasymphyseal adenoma enucleation.⁵ Acquired rectourethral fistula is far more often a consequence of prostate cancer treatment, particularly radiotherapy, and no standardized pathway or clearly superior repair technique has been established.^6,7

We describe a man in his early 80s in whom HoLEP was complicated not by an isolated fistulous tract but by combined bladder-neck, prostatic-urethral, and anterior rectal injury, managed by emergency source control, staged urinary and fecal diversion, delayed robot-assisted reconstruction, and subsequent restoration of bowel continuity.

2. Case presentation

2.1. Patient information

A male patient in his early 80s had a history of benign prostatic hyperplasia, hypertension, and dyslipidemia, with no known allergies. There was no history of prostate cancer, pelvic radiotherapy, or previous pelvic surgery. The most recent available prostate-specific antigen was 0.840 ng/mL approximately 10 months before the index procedure, and the most recent available prostate volume was 40 mL on ultrasonography approximately 20 months before the index procedure. The patient underwent HoLEP for benign prostatic hyperplasia at an outside facility. Operative details and histopathologic findings from the index procedure were unavailable.

2.2. Clinical findings

Over the following four days, he developed abdominal distension and suprapubic pain, followed by passage of urine per anus and of fecal material through the urethral catheter. On presentation to the emergency department, the patient was afebrile at 36.9°C, with a heart rate of 81 beats/min, blood pressure of 144/64 mmHg, respiratory rate of 19/min, and oxygen saturation of 97% on room air. Initial examination showed a distended but soft and lax abdomen. Subsequent examination revealed mild suprapubic tenderness without rebound tenderness or peritoneal signs. Laboratory studies showed a white-cell count of 7.81 × 10⁹/L and a serum creatinine level of 135 μmol/L; no admission C-reactive protein result was available. Piperacillin–tazobactam was initiated, with a single dose of vancomycin administered the same day and one dose of caspofungin the following day. The admission urine culture showed no growth. Two peripheral blood-culture sets collected later during the admission showed no growth after five days. The later Candida findings were from pelvic or abdominal drainage fluid not blood or urine.

2.3. Diagnostic assessment

Urgent contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed a malpositioned urethral catheter with its tip lying posterior to the inferolateral bladder wall. A 1.3 × 1.0 cm defect in the anterior rectal wall, approximately 10 cm proximal to the anal verge, communicated with the periprostatic space, which contained fecalized material. A second defect measuring approximately 3 cm involved the left inferolateral bladder base and extended to the bladder neck. The defects produced communicating deep pelvic collections that were predominantly extraperitoneal, tracking along the left retroperitoneal space and paracolic gutter, with air foci and reactive change. Significant contrast leakage was seen throughout the delayed acquisition. Possible involvement of the distal left ureter or vesicoureteric junction was noted without significant hydronephrosis. The bladder showed reactive change and disproportionate intraluminal gas, and the bladder dome was intact (Fig. 1).

Fig. 1.

Contrast-enhanced CT at ER presentation. Sagittal (A) and coronal (B) views demonstrate the acute pelvic injury and associated collection.

2.4. Therapeutic intervention

Emergency lower midline laparotomy revealed a deep injury involving the bladder neck, trigone, and posterior bladder wall, with stool present in the bladder and peritoneal cavity. Emergency exploration produced discordant findings. Stool was encountered within the bladder and peritoneal cavity during lower urinary tract exploration. Subsequent colorectal assessment found an extraperitoneal rectal injury without visible intraperitoneal contamination. The route by which stool entered the peritoneal cavity could not be established.

Marked bladder edema prevented identification of either ureteric orifice. The urethral catheter had passed through the bladder-neck injury and was lying posterior to the bladder. Flexible cystoscopy showed marked distortion of the prostatic urethra without clear demarcation from the rectum. The catheter was repositioned under cystoscopic guidance, a suprapubic catheter was inserted, and the bladder was closed in two layers. The anterior rectal injury was deep and could not be directly visualized at laparotomy, and sigmoidoscopy was limited by a stool-filled rectum; no primary rectal repair was therefore attempted. A sigmoid end colostomy was created, and a 19-Fr Jackson–Pratt drain was placed.

Upper-tract diversion followed. Right percutaneous nephrostomy was placed successfully, whereas left-sided access failed because the collecting system was nondilated. Five days later, retrograde cystourethrography confirmed persistent communication from both the urethra and the bladder into the rectum (Fig. 2A). Repeat left-sided access one week later succeeded, completing bilateral diversion.

Fig. 2.

Persistent urinary-rectal communication before reconstruction. Retrograde cystourethrography (A) shows contrast passage into the rectum; sagittal pelvic MRI (B) demonstrates the persistent tract between the lower rectum and prostatic urethra.

Follow-up CT demonstrated persistent communication between the posterior bladder neck and rectum, with a 1.5 cm bladder-neck defect and a 2 cm anterior rectal defect. Rectal contrast also reached the stoma bag through a sigmoid-stump-cutaneous fistula, which subsequently healed. Imaging continued to show a 1.2 cm tract between the lower rectum and prostatic urethra. Cystoscopy demonstrated urethral obliteration. Pelvic magnetic resonance imaging confirmed the tract and showed severe multifocal bulbar and prostatic urethral stenosis, fibrotic seminal vesicles, and tethering of the anterior rectal wall (Fig. 2B).

Definitive reconstruction was undertaken at approximately 13 weeks through a robot-assisted transperitoneal laparoscopic abdominal approach, with retroperitoneal dissection below the bladder. The procedure consisted of primary rectal repair, bladder-neck closure, bilateral double-J ureteric stenting, and suprapubic catheter placement. Initial CT showed equivocal involvement of the distal left ureter. Bilateral ureteric stents were placed successfully during reconstruction. Estimated blood loss was less than 300 mL. The reconstruction admission lasted 19 days, including four days of postoperative intensive-care observation before transfer to the ward.

2.5. Follow-up and outcomes

The ureteric stents were later removed through the suprapubic tract. Follow-up CT showed no residual urinary-rectal fistula, contrast extravasation, or abdominopelvic collection (Fig. 3), and renal ultrasonography showed no hydronephrosis. Bowel continuity was restored by closure of the sigmoid end colostomy at approximately six months; intraoperative colonoscopy showed no perforation. At the latest follow-up, approximately 10 months after the index procedure, oral intake and bowel control were satisfactory, the abdominal scars were well healed without hernia, and examination showed no rectal mass and fair anal tone. Fistula closure and restoration of bowel continuity were achieved. Suprapubic catheter drainage is the definitive urinary management, with catheter exchange every four weeks; regular urology follow-up and renal ultrasonography are planned.

Fig. 3.

Follow-up contrast-enhanced CT obtained after reconstruction showed no residual rectovesical fistula or contrast extravasation.

The clinical course is summarized in Table 1.

Table 1.

Clinical timeline of the index procedure and staged management.

Relative time	Clinical phase	Key event
Procedure day	Index surgery	HoLEP performed at an outside facility
Within four days	Acute presentation	Urinary-rectal communication; CT confirmed combined rectal and lower urinary tract injury
Same admission	Emergency source control	Laparotomy, bladder closure, suprapubic drainage, sigmoid end colostomy
Weeks 2 to 4	Early urinary diversion	Staged bilateral nephrostomy drainage; cystourethrography confirmed persistent communication
Weeks 5 to 11	Pre-repair reassessment	Serial imaging and cystoscopy defined the tract, urethral obliteration, and surrounding fibrosis
Approximately week 13	Definitive reconstruction	Robot-assisted fistula repair, rectal repair, bladder-neck closure, ureteric stenting, suprapubic drainage
Months 4 to 5	Follow-up	Stents removed; imaging showed no residual fistula, leakage, collection, or hydronephrosis
Approximately 6 months	Bowel restoration	Sigmoid end colostomy closed
Approximately 10 months	Later outcome	Bowel control maintained; suprapubic drainage definitive

3. Discussion

Rectourethral fistula after HoLEP is rare enough that the published experience is confined to a single dedicated report.³ Related fistulous injuries have been described after HoLEP and after suprasymphyseal adenoma enucleation.^4,5 What distinguishes this case is that the injury was not a discrete fistulous tract but a simultaneous disruption of the bladder neck, prostatic urethra, and anterior rectal wall, with fecal contamination of the bladder and peritoneal cavity. That distinction drove every subsequent decision, because a single-tract repair was never anatomically available.

The precise mechanism of injury remained uncertain. Full-thickness capsular perforation during posterior or apical enucleation, direct laser injury, and morcellator injury are the plausible candidates, and the finding of a urethral catheter traversing the bladder-neck defect raises the additional possibility that catheter passage extended an existing injury. That the rectal defect lay at the level of the prostate and below the peritoneal reflection is consistent with direct posterior perforation through the surgical capsule rather than with a more distant thermal injury. Recognition of capsular perforation intraoperatively, and a low threshold for cross-sectional imaging when postoperative pain and distension exceed the expected course, are the practical lessons available from this case.

Urinary and fecal diversion are commonly incorporated into staged management when inflammation, contamination, or complex pelvic injury makes immediate definitive repair unsuitable.^7,8 Diversion also buys an interval for imaging and endoscopic reassessment, which here materially changed the operative plan: only on delayed assessment did urethral obliteration, seminal vesicle fibrosis, and rectal tethering become apparent. Importantly, emergency source control did not by itself separate the urinary and fecal streams, since cystourethrography five days after right nephrostomy placement still demonstrated urine entering the rectum; upper-tract diversion was therefore necessary rather than precautionary.

The choice of repair should reflect the structures involved and the available reconstructive expertise. Robot-assisted repair is feasible in experienced centers, but current evidence does not demonstrate superiority over open, transperineal, or transsphincteric approaches,⁹ and its use here should be read as one component of coordinated reconstruction rather than as a preferred approach for post-HoLEP fistula.

The decision to close the bladder neck deserves to be stated as a deliberate endpoint rather than reported as a shortfall. Posterior urethral reconstruction at the time of fistula repair is described and can preserve urethral voiding in selected patients,¹⁰ but severe multifocal bulbar and prostatic stenosis with established periurethral fibrosis in a patient in his early 80s made a durable functional urethra improbable and a further major reconstruction unattractive. Bladder-neck closure with permanent suprapubic drainage was therefore chosen over attempted urethral reconstruction and over a continent catheterizable channel or ileal conduit, on the grounds of operative burden and expected reliability. Framed this way, continued suprapubic drainage is the planned result of that decision and not simply a consequence of urethral obliteration.

Fistula closure does not equate to functional recovery. Retrospective series show that preservation of urinary and bowel function does not necessarily accompany successful closure,¹¹ and posterior stenosis or tissue loss can limit urinary recovery despite an anatomically successful repair.¹⁰ Here, fistula closure and bowel recovery were achieved while urinary independence was not. Reporting fistula status, bowel function, and urinary function as three separate outcomes gives a more honest account than a composite success rate.

Limitations include the single-patient design, unavailable operative details from the index procedure, and approximately 10 months of follow-up, which may not capture late recurrence or stomal and incisional complications.

4. Conclusion

Combined bladder-neck, prostatic-urethral, and rectal injury is a rare but serious complication of HoLEP. Emergency source control with fecal diversion, staged upper-tract urinary diversion, deliberate reassessment before reconstruction, and coordinated urological and colorectal repair achieved fistula closure and restoration of bowel continuity. Bladder-neck closure with permanent suprapubic drainage was an appropriate definitive urinary endpoint in this elderly patient. Outcomes after rectourethral fistula repair should be reported as fistula status, bowel function, and urinary function separately.

CRediT authorship contribution statement

Yahya Ghazwani: Supervision. Zeyad Alkhenizan: Supervision, Writing – review & editing. Abdulmalik Faqihi: Writing – original draft, Writing – review & editing. Sultan Alhadi: Writing – original draft, Writing – review & editing. Faisal Alrabah: Supervision, Writing – review & editing. Naif Alanazi: Supervision, Writing – review & editing.

Patient consent

Consent was obtained from the patient for publication of this case report and accompanying images.

Data availability

All relevant clinical information is included in the article. Additional patient data are not publicly available to protect patient confidentiality.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.