Robotic Surgical Management of Urinary Fistulae

Abstract

In this chapter, we discuss the robotic handling of urinary fistulas, mainly three types of fistulae: vesicovaginal, ureterovaginal, and rectourinary fistula. Vesicovaginal fistula (VVF) is mostly secondary to urogynecologic procedures in developed countries, abdominal hysterectomy being the main cause of this condition. Conservative management has been described for this type of fistula, where low success rates (7–12%) have been reported. Surgical management includes open, laparoscopic, as well as robotic surgery. Robotic-assisted laparoscopic vesicovaginal fistula repair is feasible and associated with distinct advantages. Although direct comparisons to an open transabdominal, vaginal, or laparoscopic approach are lacking, preliminary data suggests that this technique is at least as effective. Ureterovaginal fistulas may occur following pelvic surgery, particularly gynecological procedures, or as a result of vaginal foreign bodies or stone fragments after shock wave lithotripsy. Patients typically present with global and persistent urine leakage through the vagina; this causes patient discomfort, distress, and typically protection is used to stay dry. Several techniques for the management of ureterovaginal fistulae have been described. Initial management is often conservative but typically fails. When conservative and/or endoscopic approaches fail, formal repair with an open, laparoscopic, or robotic approach is warranted. In this chapter, we will describe the surgical technique of robotic-assisted ureterovaginal fistula repair. Rectourinary fistulae (RUF) are uncommon and can be difficult to manage clinically. Although they may develop in patients with inflammatory bowel disease and perirectal abscesses, they most frequently result as an iatrogenic complication of extirpative or ablative prostate procedures. Rectourethral fistulae can also develop following ablative therapies or surgery for benign prostatic hyperplasia, typically between the prostatic urethra and the rectum. Rectovesical fistula usually develops following radical prostatectomy, and occurs along the vesicourethral anastomotic line or along the suture line of a posterior “racquet-handle” closure of the bladder. Conservative management consisting of urinary diversion, broad spectrum antibiotics, and parenteral nutrition is often initially attempted, but these measures often fail. Timing of repair is often individualized mainly according to the etiology, delay of diagnosis, size of fistula, the first or subsequent repairs, and the general condition of the patient. More than 40 surgical techniques for the management of RUF have been described and there is no data clearly favoring one approach. Transanal, transanorectal, transsphincteric, transabdominal, perineal, and combined approaches are frequently used. Encouraged by our experience in robotic surgery, and having demonstrated feasibility with the laparoscopic approach, we duplicate the fundamental principles of fistula repair with robotic assistance.