RECONSTRUCTIVE UROLOGY

Cyanoacrylic Glue: A Minimally Invasive Nonsurgical First Line Approach for the Treatment of Some Urinary Fistulas
Muto G, D’Urso L, Castelli E, Formiconi A, Bardari F
Department of Urology, S. Giovanni Bosco Hospital, Turin, Italy
J Urol. 2005; 174: 2239-43

• Purpose: We evaluated the adaptability and the efficacy of cyanoacrylic glue for the conservative treatment of urinary fistulas of different etiologies using an endoscopic, percutaneous or endovaginal approach.
• Materials and Methods: From May 1998 to July 2004, 13 patients with long lasting iatrogenic and/or inflammatory urinary fistulas were treated conservatively with endoscopic, percutaneous or endovaginal application of 1 to 3 cc of cyanoacrylic glue.
• Results: The complication rate in this cohort of 13 patients was low. Occlusion therapy failed in 2 genitourinary fistulas, which were wider (diameter greater than 1 cm) and short. In the remaining 11 cases, urinary fistulas were successfully sealed and at a median followup of 35 months, no relapses were observed.
• Conclusions: Cyanoacrylic glue is suitable for endoscopic, percutaneous and endovaginal use. This occlusion therapy represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas, especially narrow and long tract fistulas.
  
  
• Editorial Comment
  After failed conservative therapy (at least by two months catheterization), Muto et al. treated iatrogenic and/or inflammatory urinary fistulas with the use of cyanoacrylic glue. The established therapeutic approach in all reported cases (anastomotic neovesicoilial-, neovesicourethral-, anastomotic neovesivocutaneuos-, prostatoperineal-, vesicosigmoid and vesicovaginal-fistula) is open surgery. In times where economic aspects play an increasing role in medicine, new minimal invasive approaches with decreased hospitalization and surgical time needs to be evaluated. In recent times, new sealants became available and modified endoscopic techniques promised a satisfying result in fistula repair. Independent of fistula location and diameters (from 0.5 – 2.0 cm), 13 patients were treated with the use of cyanoacrylic glue. After a median follow-up of 35 months, 11 patients (85%) had successful outcomes. Treatment failed in 2 patients with short fistulas larger than 1.5 and 2.0 cm in diameter. Occlusion therapy represents a safe and minimally invasive approach that may be offered as a first option for fistulas of the urinary tract with a diameter less than 1.5 cm.
  Those iatrogenic fistulas might be prevented by the use of Gelatine Matrix Haemostatic Sealant (GMHS). GMHS with thrombin is used in surgical procedures to adjunct haemostasis when control of bleeding by conventional procedures is ineffective or impractical. In addition, the stable matrix expands up to 20% in volume when in contact with blood, resulting in a closure of the access tract and compressing the surrounding tissue. Recently, we used this sealant very successful close to the vesicourethral anastomosis (radical prostatectomy) or the neovesicourethral anastomosis (cystoprostatectomy) as an additional sealant after PCNL (1) and mini-PCNL (2). This modified technique might help to prevent iatrogenic induced epithelialized urinary fistula. Muto et al. report offers a new choice to treat occurred ones less invasive.

References
1. Lee DI, Clayman RV: Use of gelatin matrix to rapidly repair diaphragmatic injury during laparoscopy. Urology. 2004; 63: 4192.
2. Nagele U, Schilling D, Kuczyk M, Anastasiadis A, Stenzl A, Sievert KD: The use of floseal to close the track of the mini-PCNL shortens the hospital stay. Eur Urol. 2005; Suppl. 4: 197 (#779).

Dr. Udo Nagele, Dr. Karl-Dietrich Sievert,
Dr. Markus Kuczyk & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany