V246: Robotic Repair of Complex Vesicovaginal Fistulae
VideoIntroduction and Objectives
Vesicovaginal fistulas are among the most distressing complications of gynecologic and obstetric procedures. The risk of developing vesicovaginal fistula is more than 1% after radiotherapy for gynecologic malignancies, 1% risk for ureteral and vesical injuries associated with radical surgery, and the incidente of concomitant rectovaginal fistula is 1 to 5%. A fistula is defined as complex by size greater than 2,5 cm, proximity to the ureteral orifices, post-radiation, multiple, recurrent, and/or combined with rectovaginal fistula. We present our robotic technique used in the management of complex fistulas.
Three patients were diagnosed with posthysterectomy vesicovaginal fistulae: one with VVF Orly, one with VVF and associated ureteral injury, and 1 patient was a recurrence alter an attempt at Cyanoacrylic glue interpositiion between vagina and bladder. The steps of the technique of robotic repair are (a) cystoscopy wire passage through the fistula tract and ureteral catheterization, (b) placement of robotic ports, (c) lysis of adhesions, (d) colon dissection in case 1 and ureter dissection in case 2, (e) Bladder opening and fistula identification, (f) dissection of the vaginal and bladder wall, (g) closure of the vagina, (h) omental flap interposition, (i) bladder closure, (j) transient loop ileostomy in case 1 and ureteral reimplantation.
Fistula repair was successful in all cases, with a mean operative time of 140 minutes (180 and 120) and estimated blood loss of 216 mL. The length of hospital stay was of 3 days in all cases. The Foley catheter was removed on the 30th day in case 1, 15th day in case 2, and 25 days in case 3. Recurrence at 1 month in case 1 and no recurrence in case 2 and 3.
Robotic assisted closure of complex fistulae to the bladder is feasible. Wristed instrumentation facilitates appropriate dissection and complex suturing required for successful cistula closure.