V250: ROBOTIC-ASSISTED LAPAROSCOPIC CYSTORRHAPHY FOR IATROGENIC CYSTOTOMY DURING RADICAL HYSTERECTOMY

Video

Introduction and Objectives
Injury to the urinary tract is a common complication of minimally-invasive gynecologic surgery, occurring in up to 8% of cases. In the current era of robotic gynecologic surgery, proper identification and management of bladder and other concomitant urinary tract injuries while navigating one’s way on and around the robot is a new challenge for the consulting urologist who may or may not be familiar with robotic-assisted surgery.

Methods
The patient is a 44-year-old gravida 2, para 2 who presented to the gynecologist with history of menorrhagia, dysmenorrhea, and a left ovarian mass. She was taken to the operating room to undergo a robotic-assisted laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Intra-operatively, the gynecologist noticed a small cystotomy nearing completion of the case. The colpotomy, uterine extraction, and vaginal cuff closure were completed prior to urologic involvement. Upon entering the operating room, the patient already was positioned in dorsal lithotomy with the table in steep Trendelenburg. The robot was docked head-on between the patient’s legs. Port placement included a 12-mm camera port, two 8-mm robotic ports, and a 5-mm assistant port. A cystoscopic assistant was seated with arms outstretched over the patient’s left leg in close proximity to the second robotic arm. Robotic-assisted laparoscopy and rigid cystoscopy were performed concurrently.

Results
The cystotomy was successfully closed in a single layer with running 4-0 V-Loc suture by a virgin robotic surgeon. No other concomitant bladder or ureteral injuries were identified. Diagnosis and treatment were performed under dual cystoscopic and laparoscopic guidance. Total robotic time was 32 min, and total cystoscopic time was 22 min. An 18-French Foley catheter was left indwelling for 10 days post-operatively, at which time the cystogram showed no leak, and the catheter was removed without issue. There were no post-operative complications.

Conclusions
To our knowledge, this is the first documented case of a combined robotic-assisted laparoscopic and cystoscopic approach to cystorrhaphy for the indication of iatrogenic cystotomy. This approach is feasible – even for the novice robotic surgeon – convenient, and offers both diagnostic and technical advantages with limited morbidity and exceptional outcomes.

Funding: None