Small nonirradiated rectourethral fistula (RUF) without tissue necrosis or peri-fistula abscess are often treated via a trans-sphincteric or transperineal approach. Attempts at transanal rectal advancement flap to reduce associated morbidity have been widely abandoned due to poor visualization, inability to close the urethral defect in a watertight fashion, and compromise of rectal flap vascularity. Robotic transanal minimally invasive surgery (R-TAMIS) has emerged as a useful tool to address distal rectal lesions as it provides enhanced visualization and surgical dexterity.

Here we describe a novel R-TAMIS approach to address simple rectourethral fistula.

The patient is placed in prone jackknife position. An Applied Medical GelPOINT Path Transanal Access Platform is placed in the intra-anal position which is secured to a Lone Star retractor system. Three robotic trocars are placed as well as an AirSeal System to ensure adequate insufflation with suctioning. The fistula is dissected, and the rectum and urethra are separated. Following excision of the fistula tract, the urethra and rectum are closed independently with absorbable suture.

In this initial series, both patients were discharged by post-operative day two. The Foley catheter was removed at 4 weeks. The repair was evaluated and intact via endoscopy at 3 months at time of diverting loop ileostomy reversal. No fistula recurrence or major morbidity occurred at a minimum follow up of 15 months.

R-TAMIS provides an incisionless, minimally invasive reconstructive approach for well selected simple non-irradiated RUF. Additional data and long term follow up is needed before widespread application of this approach.