Robotic-Assisted Laparoscopic Repair of Post-Hysterectomy Vesicovaginal Fistula Using Omental Interposition Flap

Abstract

Study ObjectiveTo demonstrate, via robotic-assisted laparoscopy, a transperitoneal technique for repair of post-hysterectomy vesicovaginal fistula (VVF) using an omental interposition flap.DesignVideo article.SettingUniversity Hospital and referral center for Gynaecological disease.Patients or ParticipantsA 52-year-old woman with VVF after laparoscopic hysterectomy.InterventionsRepair of post-hysterectomy VVF with omental flap interposition.Measurements and Main ResultsA 52-year-old woman with a history of menorrhagia refractory to medical treatment underwent a total laparoscopic hysterectomy and bilateral salpingectomy. Histology of the uterus showed multiple uterine fibroids and adenomyosis. Twelve days following the hysterectomy, she developed leakage of urine per vagina. Computed tomography scan and cystourethrogram demonstrated normal ureters and presence of a vesicovaginal fistula. An indwelling catheter was inserted to rest the bladder and allow the acute inflammation surrounding the fistula to subside prior to definitive surgical repair six weeks later. The repair consisted of seven steps:1.Restoration of anatomy2Opening the vaginal vault3Identification of fistula defect4Resection of fistula tract5Dissection of vesicovaginal space6Closure of vesical and vaginal defects7Interposition of omental graftThe patient was discharged 48 hours after surgery. The indwelling catheter was maintained for 14 days. Cystourethrogram was carried out to confirm the integrity of the bladder prior to catheter removal. There was no further vaginal loss. Clinical follow up at six weeks and three months post-repair showed no bladder or vaginal dysfunction.ConclusionRobotic-assisted laparoscopy is a feasible approach for repair of VVF, which can be performed systematically using seven steps. This technology lends itself well to procedures requiring intricate dissection and multi-layered suturing as demonstrated in this case.