V2-03: Robot-assisted Repair of Supratrigonal Vesicovaginal Fistulae using a Peritoneal Flap Inlay



Vesicovaginal fistulae (VVF) represent a major health-care problem in low- resourced countries, where most VVF derive from obstetric complications. In the western world, most VVF occur after difficult hysterectomies. A transvaginal approach can be used successfully in low and simple fistulae, while supratrigonal and more complex cases may require a transabdominal approach. To minimize operation trauma laparoscopic or robot-assisted techniques are being used. Though fistulae closure with tension-free, multilayer closure is feasible, the use of tissue interposition can achieve higher closure rates in larger fistulae or where the surrounding tissue is devitalized. Different materials have been described for fistula closure, including peritoneal tissue and gluteal muscle as well as artificial materials._x000D_


Our video presents a robot-assisted technique using a peritoneal flap patch for reconstruction of the VVF. A daVinci SI-system with 4 arms and  6-port access was used. Preoperatively a Fogarthy catheter is placed through the fistula to mark the fistula channel , and the ureters are also stented. After initial adhesiolysis and preparation of the vesicovaginal space, the vagina is incised. Then, the fistula is identified and excised with the surrounding tissue both on the vaginal and bladder side. Following the closure of the vagina, a pedicle peritoneal flap is harvested and interposed between vagina and dorsal bladder wall. Finally, the bladder closure is performed with double-layer sutures. The analysis was performed retrospectively including operative parameters, perioperative complications and functional outcome for all patients._x000D_


Median operative time (skin to skin) was 219 (181-331) minutes without relevant blood loss. Median length of hospital stay was 8 (4-13) days. The indwelling catheter was removed after 10 days and a normal cystogram. Postoperatively all patients (n=10) showed a recurrence-free total continence (0 pad/day). The highest postoperative complication was fever requiring antibiotic treatment (Clavien grade II). _x000D_


Robotic vesicovaginal repair of high vesicovaginal fistulae and peritoneal flap inlay is a safe minimal invasive approach with a high satisfaction rate and no recurrences in this pilot series to date. _x000D_

Funding: none