V10-07: Laparoscopic approach for vesicouterine Fistula: stepped technique
Vesicouterine fistulas (VUF) are the least common type of urogenital fistulas. They may present with vaginal urinary leakage, cyclic hematuria (menouria), amenorrhea or infertility. Spontaneous healing is reported in 5% of cases. We present a video that shows the stepped technique of transperitoneal laparoscopic repair of vesicouterine fistula.
Laparoscopic repair was performed 3 months after cesarean section in 3 female patients that presented with cyclic hematuria and vaginal urinary leakage. MRI and cystoscopy revealed the vesicouterine fistula. The fistula was repaired through laparoscopic transperitoneal extravesical approach using 4 ports and following the next steps: 1. Positioning: The patient was placed in lithotomy position while also in an extreme Trendelenburg position. 2. Cystoscopy: the ureters and the fistula tract are tutorized using simple ureteral catheters and an hydrophilic guidewire. 3. Port position: Pneumoperitoneum was established using a Veress needle in the umbilical region, and a primary 12 mm port was inserted. Another 5 mm port was inserted exactly between the right superior iliac spine and the umbilicus. Two other 5-mm ports were established under laparoscopic guidance in the left iliac fossa and hypogastrium for bladder mobilization. 4. Fistula Tract Dissection: the fistula tract was identified and completely excised using sharp dissection and monopolar energy. Limited cystotomy was performed, and the specific sites of the fistula and the ureteral meatus were identified. The edge of the bladder was excised at the site of fistulas tract. 5. Bladder closure: The urinary bladder was closed in a double layer using single 3-0 barbed continuous suture. 6. Uterine cervix closure: uterine isthmus is tutorized with an hysterometer and the closed with continuous single 2-0 vicryl suture. 7. Omental Flap Interposition: An omental flap was interposed between the bladder and the uterus. 8. End of surgery: Blake like drainage was positioned in the vesicouterine space.
Mean operative time was 150 minutes. Mean blood loss was than 100 ml. There were no intraoperative or postoperative complications. Mean hospital stay was 2 days. Bladder catheter was removed after 14 days in both cases. Clinically, both patients had no more symptoms after 10 months follow up.
Laparoscopic repair appears to be a viable alternative for surgeons experienced with laparoscopic suturing techniques. Both ureteral and fistula catheterization and hysterometer insertion, are maneuvers that make the procedure easier and safer.