Rectovesical fistula and rectal anastomotic leak

Case contributed by Ian Bickle
Diagnosis almost certain

Presentation

Rectal cancer with bladder invasion. Inpatient following resection and partial cystectomy. Suprapubic and urethral catheters in situ.

Patient Data

Age: 70 years
Gender: Male

Cystogram.

Bladder filled via suprapubic catheter.

Contrast enters the rectum. However, appearance not entirely fitting with this alone.

The radiologist decides to...

ct

The radiologist decides to clarify anatomical details with CT

CT Cystogram (both catheters clamped)

Three smaller tracts from the posterior wall of the residual bladder with contrast in the rectum.

Large volume of pre-sacral contrast and a large gap with contrast contiguous with the rectum at 9 O'clock at the level of the anastomosis.

The leak from the anastomotic break-down (red arrow) at 9 O'clock from the rectum into the para-rectal and pre-sacral spaces.

Case Discussion

This patient has a T4 rectal tumor with invasion of the posterior bladder wall at surgery.  A partial cystectomy was performed.

In the early post-operative stage, the following developed:

1.  A rectovesical fistula

2.  A rectal anastomotic leak with pre-sacral collection

Contrast was only injected via the suprapubic catheter so after contrast entered the rectum from the bladder through the fistula, it then leaked via the anastomotic breakdown into the pre-sacral space.

The patient returned to theater. Dense adhesions meant an end colostomy had to be performed.

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