ČESKÁ UROLOGIE / CZECH UROLOGY – 2 / 2019

99 VIDEO Ces Urol 2019; 23(2): 97–100 KLÍČOVÁ SLOVA Vezikovaginální píštěl, laparoskopie, robotická chi‑ rurgie, jednoportový přístup. SUMMARY Schraml J, Hlavička M, Broul M, Cihlář F. Mini‑ mally invasive closure of a vesicovaginal fistula using robotic single‑site surgery. We report our experience with the closure of a vesicovaginal fistula using a highly minimally invasive technique – using a single‑port approach with the da Vinci Xi robotic system: a video. Introduction: Vesicovaginal fistulas (VVPs) are amongmuch‑feared gynaecological complications. A VVP in itself is not life‑threatening for the patient, but the resulting urinary incontinence significantly impairs her quality of life. The extent and nature of urine leakage depend on the size of the VVP. A VVP closure can be performed via both the vaginal and abdominal routes. In the era of open surgery, the vaginal approach was used as the first step due to its minimal invasiveness, and an invasive abdominal approach with laparotomy was only adopted after a failure of the vaginal approach. The introduction of laparoscopy reduced the invasiveness of the transabdominal approach, and, due to a higher effectiveness of this procedure in comparison with the vaginal approach, lapa‑ roscopy has become the method of first choice in most centres. The subsequent introduction of robot‑assisted surgery has helped to overcome some of the obstacles of classic laparoscopy, while maintaining all the advantages of minimal invasive‑ ness (it is a higher‑grade laparoscopy). This is even more enhanced when the single‑port technique of the da Vinci Xi Single‑Site technology is used. Indications for and the operating procedure of a single‑port robot‑assisted closure of a vesi- covaginal fistula: We report a 50-year‑old patient who underwent laparoscopy‑assisted vaginal hys‑ terectomy with right adnexectomy. The procedure was carried out under general anaesthesia in the Trendelenburg position of 31°. We use this position by default in this type of surgery. The abdominal cavity was openedwith a 25-mm semi‑lunar incision at the umbilical margin and by carefully dissecting the individual layers. Once the abdominal cavity was inspected with no pathology found, the single‑site working disk was deployed into the abdomen through the incision in its folded configuration, and then unfolded and self‑secured in the wound. Using this disk, an optical port for a standard 8-mm robotic 3D camera with oblique optics and two curved 5-mmworking ports for flexible robot‑ ic instruments were placed through prefabricated openings. There is one more site in the disk for an 8-mm or 10-mm assistant port; we used the 8-mm one, and completed robot docking. The fistula location and its relation to the ure‑ teric orifices were identified transvesically. Next, the fistula canal was resected and the vaginal wall was dissected from the bladder which was mobilized as far as possible from the vaginal wall with the fistula. Closure of the vagina and bladder was performed with non‑absorbable V‑LOC 90 R sutures and Strata‑ fixTM sutures on an indwelling Foley catheter Ch 20 that was kept in situ for 21 days. At our cen‑ tre, removing an indwelling urinary catheter in 3 weeks’ time is a standard procedure. According to the literature (1, 2, 4, 5), a catheter can be removed earlier than that (in 7 to 10 days). The abdominal drain was removed on postoperative day 2. The total duration of surgery (skin to skin) was 135 minutes, with the robotic console time being 65 minutes. Result: The postoperative course was unevent‑ ful. On day 21 after surgery, the indwelling catheter was removed, and since then, the patient has been completely free from urological complaints, with the umbilical scar being firm and healed to such an extent that it is unnoticeable at first glance. Discussion: When the abdominal approach is indicated in the management of VVF, we recom‑ mend considering the use of robotic or laparoscopic approach in order to minimize the morbidity asso‑ ciated with major incisions. The first case of robot‑assisted repair of VVF was reported by Melamud et al in 2005 (1). Since then, a number of small studies and case reports have been published (2, 3, 4, 5, 6). Although no direct comparisons of VVF repair using robot‑assisted vs. open vs. laparoscopic ap‑ proach are available, the benefits of robot‑assisted