Combined endoscopic management of a postoperative rectocutaneous fistula after cystectomy using modified percutaneous endofistular and transanal endoluminal vacuum therapy

A 79-year-old man presented with a transanal purulent discharge following cystectomy with rectal injury 10 months previously. At that time, surgical closure with suturing of the rectal defect had been performed, along with the creation of a colostomy. Endoscopic examination revealed a perforation 5 cm from the anal verge. An attempt was made to close the perforation with an over-the-scope clip; however, during the follow-up endoscopy, a significant defect was observed in rectum, with an accompanying large cavity. The patient then underwent 6 weeks of inpatient therapy with endoluminal transanal vacuum therapy, which resulted in a reduction of the cavity size. The patient returned to us 4 months later with persistent purulent discharge from the caudal pole of the laparotomy scar and anus (Fig. 1). Endoscopic examination revealed a defect in the anterior wall of the rectum 5 cm from the anal verge, with a cavity full of pus and a rectocutaneous fistula. We opted for a combined approach involving endoluminal and endofistular vacuum therapy for 3 weeks in the hospital setting (Fig. 2).