V242: Robot-assisted repair of recurrent vesicovaginal fistula
VideoIntroduction and Objectives
Vesicovaginal fistula (VVF) remains a challenge to surgeons and a burden on patients, especially when it is recurrent or associated with complications. While there is no consensus on the best approach, an abdominal approach is often preferred in patients with large or recurrent fistulas following transvaginal repair. We describe our technique of robot-assisted repair for recurrent VVF in two patients.
Patient 1 is a 59-year-old lady with a VVF after complicated total abdominal hysterectomy and bilateral salpingo-oopherectomy, rectosigmoid resection, peritonectomy and omentectomy for stage IV ovarian cancer. Patient 2 is a 52-year-old morbidly obese lady with a VVF after complicated hysterectomy for fibroid uterus. Both patients had unsuccessful vaginal repair of VVF. The technique of robot-assisted repair demonstrated is a 6-port transperitoneal technique for pelvic surgery, with patient in steep Trendelenburg. Cystotomy was performed to access the fistula. The fistula was excised and margins freshened to separate the bladder from vagina. The vaginal defect and cystotomy were closed using running 3-0 barbed suture (V-Loc, Covidien, Mansfield, MA). In order to prevent re-fistulization, suture lines were at opposing angles. In patient 2, a porcine dermal collagen matrix biomesh was used as an interpositional layer between bladder and vagina.
Operative time was 135 minutes. Mean estimated blood loss was 100 mL. Both patients were discharged from hospital postoperative day 2. There were no complications. Cystogram performed at 14 days demonstrated no leak. Foley catheter was removed after 28 days in patient 1 and 21 days in patient 2. At 4 and 12 months respectively, both patients are dry with no evidence of VVF recurrence.
Robot-assisted repair of recurrent VVF is technically feasible with an excellent success rate. Interposition with vascularized tissue is not essential for success; an alternative method for interposition is porcine dermal collagen biomesh. Advantages of the robotic repair are less pain, shorter hospital stay and lower morbidity, making it an attractive option for patients with recurrent VVF.