Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Robotic Fistula Repair of Seminal Vesicle to Ileoanal Anastomosis Anthony Chaknis, OMS-II; Dr. Harry Clarke, MD, Ph.D.; Dr. Gabrielle Yankelevich, DO Edward Via College of Osteopathic Medicine, Spartanburg, SC; Medical University of South Carolina Urology, Charleston, SC

Introduction

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• Seminal vesicle fistulas represent a rare pathologic finding with reported causes including Crohn's disease, diverticulitis, and complications from prostate surgery. 1 • A fistula is abnormal connection between two body parts o Often arise post-injury, surgery, or infection o Most common GU fistula in males is a colovesical fistula ▪ Account for 1 in every 3000 hospital admissions 2 • More common in diverticular disease and Crohn's disease o Symptoms include pneumaturia, fecaluria, abdominal pain, and recurrent UTIs. 1 • Our case involves a fistula between the seminal vesicle and J-pouch o A surgical procedure commonly performed to treat Ulcerative Colitis and other hereditary conditions without requiring a stoma 3 o J pouch connects the ileum to the anus after removal of the large intestine and rectum. • Peritoneal flaps are typically used in urinary fistula repair o The flap serves to cover the internal opening of the abnormal channel, effectively preventing ongoing communication and promoting healing. 4 • Our case displays the first ever reported seminal vesicle – J-pouch fistula repair under robotic assistance through a multidisciplinary approach

Figure 6 . MRI shows resolution of prior fistula. To date, the patient has had imaging and a cystoscopy without evidence of fistula recurrence.

Figure 2. MRI enterography showing T2 hyperintense tract extending from anterior aspect of J-pouch to the left seminal vesicle

Discussion

Conclusions • The literature on seminal vesicle fistulas, particularly those involving a connection with a J-pouch, is scarce. o Existing literature predominantly focuses on seminal vesicle-rectum fistulas, with management typically involving conservative measures such as IV fluids, parenteral nutrition, and antibiotics. 5 o However, a significant number of patients eventually required surgical drainage or colostomy. 5 • Our case diverges from the usual course, as the patient had previously undergone total proctocolectomy with J pouch reconstruction. • Following an extensive literature review, our case stands out as the first successful repair of a seminal vesicle fistula involving a J pouch under robotic assistance. • Management of fistulas remain a multidisciplinary approach, and future studies should aim to emphasize closure of the connection with a flap to prevent recurrence • Provides generalizability to patients with Crohn's disease • If a urinary fistula is suspected and colovesical fistula is ruled out, further advanced imaging or endoscopic management should be considered • This case report can translate to the growing field of fistula management • The literature demonstrates seminal vesicle fistulas are rare, however seminal vesicle fistulas should be on the differential in patients with extensive bowel pathology and recurrent urinary tract infections. • There is a large paucity of data for surgical approaches, and we describe the first successful surgical repair of a fistula between the seminal vesicle and J-pouch. The patient provided informed consent to use data in a case report. Acknowledgements and References

Figure 3 . The robotic port setup and traditional approach are the same as a robotic prostatectomy

Figure 1 . Relevant anatomy in this case. 3

Figure 4 . Theleft seminal vesicle was dissected and both ends were suture ligated with cautery.

Case Presentation

The patient was a 66-year-old male with past medical history of: o Crohn's disease complicated by colovesical fistula status-post repair o Colectomy for dysplasia status-post J-pouch o Primary sclerosing cholangitis complicated by cholangiocarcinoma status-post liver transplant • Was found to have a fistula from the left seminal vesicle to the J-pouch causing recurrent urinary tract infections and urosepsis (Figure 2). • Through a multidisciplinary approach with Urology , Colorectal , and Plastic Surgery teams, planned for Robot-assisted laparoscopic fistula repair with peritoneal flap

Figure 5 . A layer of peritoneum was used as a flap between the 2 transected areas

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2024 Research Recognition Day