V2-07: Robotic-assisted vesicovaginal fistula repair and right ureteral reimplant
VideoIntroductions and Objectives
Vesicovaginal fistulas have been described as the result of complications during childbirth, injury during pelvic surgical procedures, following radiation, and after trauma. Numerous techniques for the management of postoperative vesicovaginal fistulas have been demonstrated. Associated genitourinary injuries must be ruled out, and can usually be addressed at the same time as the repair of the fistula. We present the case of a 50-year old female who underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy for benign disease with a delayed diagnosis of a right ureteral injury and bladder injury resulting in a vesicovaginal fistula. Our objective is to demonstrate the use of robotic surgery in the combined repair of a vesicovaginal fistula and right ureteral reimplant.
A cystoscopy was performed which demonstrated a large fistula at the posterior portion of the dome of the bladder. A right retrograde pyelogram was attempted, demonstrating a very short blind-ending ureteral segment, with most contrast returning into the bladder. An antegrade pyelogram was performed through an indwelling right percutaneous nephrostomy tube, demonstrating a distal blind-ending ureter. A Kelly clamp was passed into the vagina and through the fistula, and a ureteral catheter was then passed through the cystoscope and grasped by the clamp, thereby establishing access through the fistula. The fistula was then approached through the abdomen via robotic assistance. The vaginal cuff was entered, exposing the fistula and the lumen of both the vagina and the bladder. The vaginal defect was closed in one layer, while the bladder defect was closed in two layers. A peritoneal flap was created and interposed between the two repairs. The right ureter was then dissected down to the level of dense adhesions and was freed from these attachments and then reimplanted at the dome of the bladder. A Foley catheter was placed and filled with saline, demonstrating no extravasation from either the ureteral reimplant or bladder repair.
The procedure took 270 minutes and estimated blood loss was 200 cc. A Foley catheter was left in place for 15 days, at which time a cystogram demonstrated no extravasation from the bladder repair and reimplanted right ureter, and the catheter was removed. The patient is continent and pleased with her surgical results.
A robotic-assisted laparoscopic approach to combined vesicovaginal fistula repair with ureteral reimplantation is a safe and effective minimally-invasive procedure for a patient with an associated vesicovaginal fistula and ureteral injury.