Ces Urol 2020, 24(1):15-17

Robotic‑assisted vesicovaginal fistula repair: step by step

Markéta Matějková

Urologické oddělení, ÚVN Praha

Matějková M. Robotic-assisted vesicovaginal fistula repair: step by step.

Introduction: Vesicovaginal fistula is a pathological communication between the bladder and the vagina. It most commonly occurs as a postpartum complication in developing countries and as an iatrogenic postoperative complication in developed countries. The presented video illustrates the surgical procedure in individual steps.

Material and methods: In the period from 11/2005 to 05/2019, a total of 15 patients underwent robotic-assisted vesicovaginal fistula repair using the da Vinci S and Si systems at our centre. All the patients developed a fistula after previous gynaecological surgery, with their symptoms developing within 2 to 6 weeks following the procedure. In nine patients, it was previous surgery for a benign condition (uterine fibroids); three patients had hypermenorrhoea; another three patients were indicated for surgical management of malignant disease - two for endometrial cancer and one for cervical cancer. Ten patients underwent laparoscopic-assisted vaginal hysterectomy; four patients had classic abdominal surgery. One of the patients had laparoscopic surgery first. Because of postoperative bleeding, an open revision was performed within 24 hours of the procedure with a bladder suture. In two patients, previous attempts at closing the fistula (laparoscopic and open - abdominal approach) failed. In another patient, only one laparoscopic attempt at closing the fistula failed.

Results: The average operation time was 151 (105-192) minutes; blood losses were unmeasurable in all the patients. The average duration of hospital stay was 12 (6-19) days. The average catheterization time was 12 (9-18) days. We intentionally left an indwelling catheter in place for 12 days initially, sometimes even longer for a sense of security, and based on the surgeon's decision, decreased the catheterization time gradually. On day 11, one of the patients pulled out her catheter accidentally and experienced bleeding; thus, the catheter was left in place for additional 7 days. No early or late postoperative complications were noted in any of the patients. All the patients underwent follow-up cystoscopy at three months after surgery and no fistula recurrence was observed in any of them. We performed this on a routine basis to check the general condition and capacity of the bladder, as well as the status of the scar and ureteral orifices.

Conclusion: In developed countries, a vesicovaginal fistula occurs as a complication following gynaecological surgery for benign disease in 80%, due to obstetric trauma in 10%, after radiotherapy in 5%, and as a complication of gynaecological oncological surgery in 5%. Given the increasing number of gynaecological procedures, complications will certainly be on the rise and their management will require adequate care. The robotic approach is among the most up-to-date methods, allowing for a more rapid and accurate surgical procedure and reducing the recovery time. Our five-year results show a 100% efficacy of this method in patients with a fistula due to previous surgery.

Keywords: Vesicovaginal fistula, robotic surgery.

Received: October 10, 2019; Revised: January 31, 2020; Accepted: February 7, 2020; Prepublished online: January 31, 2020; Published: March 19, 2020