Recurrent Vesicovaginal Fistula Research Articles

Minimally invasive transvaginal single-port laparoscopic vesicovaginal fistula repair: a case report and the point of this technique.

The optimal surgical method of vesicovaginal fistula (VVF) remains uncertain. Minimally invasive surgical approaches have become highly popular in line with technological advancements, namely, laparoscopic, robotic, and transvaginal techniques. However, these techniques still require invasiveness. This is the first case report that described a novel "zero-incision" technique for natural orifice transvaginal single-port laparoscopy used to repair a recurrent and high-position VVF. The patient underwent transvaginal single-port laparoscopic repair of a VVF. Methylene blue was used to locate the VVF, and a needle electrode was used to thoroughly remove the scar tissue of the VVF. In addition, this technique for transvaginal single-port laparoscopy provides more working space to expose and repair fistulas conveniently and adequately. One year after surgery, the patient remained asymptomatic and had no fistula recurrence. Minimally invasive transvaginal single-port laparoscopy provides a clear surgical field, is safe and feasible. This novel technique has promising as an additional personalized treatment option for VVF repair.

Vesicovaginal fistula repair: review of surgical technique in a unique case of recurrence

Our video aims to provide an update in the background of vesicovaginal fistulas and demonstrate the Latzko procedure and its application in a case of recurrent vesicovaginal fistula. Vesicovaginal fistula (VVF) is a rare complication of gynecologic surgery, complicating an estimated 0.12% of simple hysterectomies and 1.14% of radical hysterectomies. The Latzko technique is a first line repair approach that involves transvaginal repair and can be highly effective in even complex fistulae. One of the most common complications of fistula repair is recurrence, which often requires a more complex repeat repair using tissue grafts and/or abdominal approach. In our video, we demonstrate the Latzko procedure and its application in a unique case of recurrent VVF. We begin our case by performing a cystoscopy and identifying the fistulous tract in relation to the ureteral ostia, cannulate to aid in dissection, and then proceed with our dissection. We utilize local anesthesia for hydro dissection and stay sutures to aid in closure. Once excised, the fistulous tract is then closed in a tension-free manner with multiple layers and non-overlapping suture lines. A cystoscopy is then performed to confirm a watertight closure and patency of the ureteral ostia bilaterally. Lastly, the vaginal epithelium is closed transversely. In summary, our video provides an update in the background information of vesicovaginal fistula, presentation of a unique case of recurrence, and demonstration of utilizing the Latzko technique for an effective closure of recurrent fistula. We thank you very much for your time and hope that this video aids in your surgical education.

Intravesical repair of vesicovaginal fistula guided by cystoscopy.

Vesicovaginal fistulas (VVF) are an unusual problem that may significantly affect a patient's quality of life. The main causes for this condition are labour complications (mostly in developing countries) and pelvic surgeries (in industrialised countries). Treatment may be conservative or surgical. Regarding surgical treatment, there is still debate about the best approach and surgical technique. To demonstrate a correction of a VVF guided by cystoscopy using intravesical laparoscopic instruments. Case report and surgical video of a recurrent VVF treated with a hybrid technique involving direct transvesical insertion of 3 mm laparoscopic trocars and instruments guided by cystoscopy. As far as we know, although there are some reported techniques that use a combination of transvesical laparoscopic instruments and cystoscopy, this is the least invasive and most ergonomic technique described. Two years after surgery, the patient remains asymptomatic and with no fistula recurrence. The transvesical approach guided by cystoscopy seems to be an effective, safe and ergonomic minimally invasive procedure for VVF repair.

Robot-assisted Repair of Complex Vesicovaginal Fistulae: Feasibility and Outcomes

OBJECTIVETo share our experience and techniques of robot-assisted repair of complex vesicovaginal fistulae. METHODSProspectively maintained data of patients undergoing robot-assisted repair of complex vesicovaginal fistula (VVF) from December 2014 to October 2019 were analyzed. Patient characteristics, operative data, postoperative events, and follow-up outcomes were noted. All cases underwent preoperative cysto-vaginoscopy and upper tract imaging. The procedure was completed in a standard fashion. Additional procedures included Boari flap reimplantation, Burch-colposuspension, ureteric reimplantation and Vaginal flap incorporation. On follow-up, successful repair was defined as no urine leak after removal of catheter. RESULTSOut of 73 patients undergoing robot-assisted VVF repair at our institute, 33 were classified as complex VVF. Mean age was 42.7 ± 7.2 years. The most common cause of VVF was posthysterectomy (81.8%) with 21 (63.1%) recurrent VVFs. Thirty patients (90.0%) had supratrigonal fistulae; multiple fistulae were present in 3 cases. Two patients underwent Boari flap ureteric reimplantation for concomitant ureteric stricture and ureteric neocystostomy was required in another patient. One patient underwent our novel technique of vaginal flap incorporation and a Burch colposuspension was performed simultaneously in one patient with stress incontinence. The median follow-up was 35 months (interquartile range 8.5months). Successful outcome was noted in 31 (93.9%) patients; recurrence requiring further repair in 2 patients. CONCLUSIONThe current series presents the largest number of complex VVFs repaired by robotic assistance. Robot-assisted repair can be considered as one stop procedure for such complex and vexing problems.

Platelet-Rich Plasma as Adjuvant Therapy for Recurrent Vesicovaginal Fistula: A Prospective Case Series.

Vesicovaginal fistula (VVF) is the nonphysiological communication between the bladder and vagina, and surgical closure is the gold treatment standard. Despite that successful closure occurs in around 85% of patients after the first repair, recurrence remains a highly distressing complication for patients and surgeons. The aim of our study was to evaluate the efficacy of a platelet-rich plasma (PRP) injection as a supportive treatment in the surgical repair of recurrent VVF. Between January 2018 and July 2019, 16 patients with recurrent VVF were injected with PRP in a tertiary gynecological department. Subsequently, a surgical Latzko procedure for VVF closure was scheduled 6–8 weeks after the PRP injection allowing proper neovascularization and remodeling of surrounding tissues. Patients were considered cured if no leakage was observed after surgery and negative dye test results were indicated at follow-up. All patients who were examined therein remained dry. To the best of our knowledge, this is the first study aiming to assess PRP injections as a supporting treatment prior to surgical procedure for recurrent VVF. Preliminary results are encouraging, and we incorporated this method in our clinical practice. Further reports on a larger group will follow.

Labial Cutaneous Flap Interposition in the Treatment of Recurrent Vesicovaginal Fistula

Abstract Background: Recurrent vesicovaginal fistula (VVF) repair can be very difficult. Most gynecologists prefer the vaginal route because of the complexity of the abdominal approach. This articl...

Recurrent vesicovaginal fistula: Our experience

INTRODUCTION: One of the major complications of vesicovaginal fistula (VVF) surgery is recurrent fistula formation. A repeat repair is undertaken after resolution of the inflammatory response to the initial procedure. We report our experience with recurrent VVF managed at our center. MATERIALS AND METHODS: We retrospectively reviewed the inpatient/outpatient case records of all women who underwent repair of recurrent VVF at our center. The age of the patient at initial presentation of VVF, cause of VVF, and site, size, position, and type of repair were noted. RESULTS: During the study period from January 2000 to December 2016, a total of nine women with a mean age of 38 years underwent repair for a recurrent VVF at our center. All patients were assessed in detail 12 months after the repair. All patients were continent and were voiding well. CONCLUSIONS: It is important to strictly adhere to the basic surgical principles so as to achieve a successful VVF repair. The bladder closure is much more important in achieving a successful repair than vaginal closure. Recurrent VVFs should always be treated with interposition of a tissue graft between the bladder and the vagina.

Buccal mucosal graft interposition in the treatment of recurrent vesicovaginal fistula: A report on two cases

ObjectiveTo present the use of autologous buccal mucosa graft (BMG) in the treatment of recurrent vesicovaginal fistula (VVF). Case reportsIn 2011, two women, aged 45 years and 56 years, were admitted due to recurrent VVF. Both women had previously undergone abdominal hysterectomies for benign conditions and, subsequently, vaginal VVF repair due to vaginal urine leakage. On admission, the younger woman had a round fistula, with a diameter of 1.5 cm, located on the left side, supratrigonally; the other woman had an ellipsoidal fistula measuring 2.5 cm × 1.5 cm, located medially and supratrigonally. Both women underwent suturing of the VVF with the interposition of BMG. After the last treatment, both women were cured. ConclusionTreatment of recurrent VVF with the interposition of BMG is a good alternative to the use of other tissue grafts. Larger series are needed to confirm the advantages of this method.

Repair of complex vesicovaginal fistulas by combining a rotational bladder flap and full thick vascular peritoneal interposition.

To present the experience of repairing iatrogenic vesicovaginal fistulas (VVFs) using a rotational bladder flap and peritoneal interposition technique. Between January 2009 and June 2014, a total of 18 patients (mean age, 44.0 years; age range, 29-51 years) with VVFs were treated using a transperitoneal approach. All VVFs were complications of gynecologic procedures. Twelve patients experienced recurrent VVFs and one patient had a concomitant rectovaginal fistula after radiotherapy. The fistula was approached transabdominally. The peritoneum covering the bladder was isolated to expose the bladder and prepare for the interposition. The bladder was opened along the sagittal plane to the fistula and a bladder flap was rotated downward to fill the fistula defect. The vaginal defect was closed, then a flap using the isolated peritoneum was interposed and fixed between the vagina and bladder. A ureteral re-implantation was performed in one patient. All VVF procedures were performed by one urologist (SW). Repair of the rectovaginal fistula was performed by a general surgeon at the same time. Seventeen patients (success rate = 94% [100% for primary cases and 92% for recurrent cases]) had no evidence of recurrent VVF at a mean follow-up of 20 months (range, 6-36 months). The only patient who had previously undergone a repair procedure failed. A transperitoneal approach with the use of a rotational bladder flap and peritoneal interposition might be a feasible and reliable procedure for surgical management of iatrogenic VVFs, especially in complicated cases. Neurourol. Urodynam. 35:934-938, 2016. © 2015 Wiley Periodicals, Inc.

Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience.

Introduction and hypothesisTwo types of laparoscopic vesicovaginal fistula (VVF) repairs, the traditional transvesical (O’Conor) and extravesical techniques, dominate the literature. We present our 15-year experience of primary and recurrent cases of VVF utilizing an extravesical technique, which we first described in 1999.MethodsAn IRB approved retrospective study revealed 44 female patients with either primary or recurrent VVF. Laparoscopic extravesical repair was performed without an omental flap in the majority of cases. A three-layer closure technique was performed utilizing a double-layer bladder closure and a single-layer vaginal closure followed by bladder testing. A suprapubic catheter was utilized for 2–3 weeks postoperatively for bladder decompression.ResultsA review of our experience reveals a 97 % (32 out of 33) cure for primary VVF and 100 % (11 out of 11) rate for recurrent fistulas, with an overall cure rate of 98 % (43 out of 44) at a mean follow-up of 17.3 months (range 3–64). An omental flap was not utilized in 98 % of patients (43 out of 44), with a success rate of 98 % (42 out of 43). The mean estimated blood loss was 39 mL (range 0–450), mean hospital stay was 1.1 days (range 1–3), and none of the patients suffered any major intra- or postoperative complications. None of the patients required a conversion to open laparotomy.ConclusionsBased upon our experience we believe that performing laparoscopic extravesical VVF repair using a three-layer closure technique without an interposition omentum is a safe, effective, minimally invasive technique with excellent cure rates in an experienced surgeon’s hands.

V11-11 ROBOTIC CLOSURE OF A RECURRENT VESICO-VAGINAL FISTULA AFTER EMERGENCY CESAREAN SECTION, HYSTERECTOMY AND FAILED PRIMARY CLOSURE OF THE FISTULA.

You have accessJournal of UrologySingle Port Surgery/LESS/NOTES/Robotics1 Apr 2014V11-11 ROBOTIC CLOSURE OF A RECURRENT VESICO-VAGINAL FISTULA AFTER EMERGENCY CESAREAN SECTION, HYSTERECTOMY AND FAILED PRIMARY CLOSURE OF THE FISTULA. Clemens Georg Wiesinger, Mathias Stockhammer, and Walter Pauer Clemens Georg WiesingerClemens Georg Wiesinger More articles by this author , Mathias StockhammerMathias Stockhammer More articles by this author , and Walter PauerWalter Pauer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Repair of a recurrent vesico-vaginal fistula mostly is a challenging surgical problem. The video shows the outstanding advantages of robot assisted approach in a difficult case of a recurrent vesico-vaginal fistula. METHODS After failure of the primary attempt to close a vesico-vaginal fistula created during an emergency cesarean section and hysterectomy, robot assisted closure of the fistula was performed by the urologist. 4 robotic trocars and 2 assistant trocars were used similar to the position in radical prostatectomy. The intervention was performed transperitoneally in 45 degrees Trendelenburg position. The fistula was resected free and excised, both ends were closed and a peritoneal flap was interposed. RESULTS Docking-time was 17 min., time at the console 130 min., overall operating time 160 min., blood loss almost none. Follow-up after 10 months was uneventful, the fistula remained closed. CONCLUSIONS Robot assisted surgery for recurrent vesico-vaginal fistula repair is a safe and effective method with the advantage of fast recovery and optimal cosmesis. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e953 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Clemens Georg Wiesinger More articles by this author Mathias Stockhammer More articles by this author Walter Pauer More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Laparoscopic transperitoneal extravesical approach to vesicovaginal fistula repair without omental flap: a novel technique

The O'Connor bladder bivalving technique remains the traditional abdominal approach to vesicovaginal fistula repair whether performed via laparotomy or laparoscopy. This video depicts a new surgical technique utilizing a laparoscopic transperitoneal extravesical approach without invasive bladder bivalving or an omental flap. This technique was first described in 1999 and has been utilized on >40 patients with either primary or recurrent vesicovaginal fistulas. A 98% success rate is reported. This alternative technique can be performed using either a laparoscopy or the traditional laparotomy approach.

Is Tissue Interposition Always Necessary in Transvaginal Repair of Benign, Recurrent Vesicovaginal Fistulae?

To evaluate and compare the outcomes of transvaginal repair of benign, primary, and recurrent vesicovaginal fistulas (VVFs) treated without tissue interposition because, historically, tissue interposition with a vascularized flap has been advocated in both transabdominal and transvaginal repairs of recurrent VVFs. A retrospective chart review was conducted of 73 consecutive women with VVF and treated by a single surgeon (B.J.F.) between January 2003 and May 2012. Patients with a malignant etiology and/or prior irradiation were excluded as they required a more complex repair. All included VVFs were treated by a transvaginal approach with partial vaginal cuff excision without a tissue interposition. Patients were followed in our clinic postoperatively for 1 year and by telephone survey thereafter. Forty-nine patients met inclusion criteria: 25 primary and 24 recurrent. There was no statistical difference in patient age, fistula size, time to repair, or fistula etiology between the 2 groups. There has been no fistula recurrence in either group. Forty-one of 49 patients (84%) were discharged the same day as their surgery. Benign, recurrent VVFs are not synonymous with other complex fistulas that typically require tissue interposition. Our study demonstrates that transvaginal repair of benign, recurrent VVFs without tissue interposition can be equally successful as primary repairs without tissue interposition. The number of prior repairs should not be an independent factor in the use of tissue interposition, as previously suggested. We advocate an individualized approach to each VVF, only using tissue interposition when appropriate.

Editorial Comment

Tenets of fistula repair are a good tension-free closure with healthy tissue and especially for “complex” fistulas, an interposition flap. A peritoneal or omental flap is relatively easily attained abdominally, but not so easy vaginally where a peritoneal flap can be found if you are fortunate or a Martius flap can be used if the fistula is distal. Is Tissue Interposition Always Necessary in Transvaginal Repair of Benign, Recurrent Vesicovaginal Fistulae?UrologyVol. 82Issue 3PreviewTo evaluate and compare the outcomes of transvaginal repair of benign, primary, and recurrent vesicovaginal fistulas (VVFs) treated without tissue interposition because, historically, tissue interposition with a vascularized flap has been advocated in both transabdominal and transvaginal repairs of recurrent VVFs. Full-Text PDF

V263 ROTATIONAL LABIAL AND INFERIOR PUDENDIAL ARTERY BASED INNER THIGH FLAPS IN VAGINAL RECONSTRUCTION

You have accessJournal of UrologyFemale Voiding Dysfunction (Pelvic Reconstruction & Incontinence)1 Apr 2013V263 ROTATIONAL LABIAL AND INFERIOR PUDENDIAL ARTERY BASED INNER THIGH FLAPS IN VAGINAL RECONSTRUCTION Forrest Jellison, Gladys Ng, Lisa Rogo-Gupta, Leah Nakamura, Denise Chow, Ja-Hong Kim, Larissa Rodriguez, and Shlomo Raz Forrest JellisonForrest Jellison Los Angeles, CA More articles by this author , Gladys NgGladys Ng Los Angeles, CA More articles by this author , Lisa Rogo-GuptaLisa Rogo-Gupta Los Angeles, CA More articles by this author , Leah NakamuraLeah Nakamura Los Angeles, CA More articles by this author , Denise ChowDenise Chow Los Angeles, CA More articles by this author , Ja-Hong KimJa-Hong Kim Los Angeles, CA More articles by this author , Larissa RodriguezLarissa Rodriguez Los Angeles, CA More articles by this author , and Shlomo RazShlomo Raz Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1646AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The rotational inner thigh flap is well vascularized, maintains sensation, and provides reliable cosmetic and functional results for complex vaginal reconstruction. The purpose of this video is to describe the technique with the rotational flap. METHODS All women, from 2002–2012, requiring vaginal reconstruction were retrospectively reviewed. Patients who had a rotational inner thigh flaps performed were included in this analysis. Demographics, pre-operative and operative findings, postoperative sexual function and validated body image perception questionnaire, recurrence of vaginal fistula, or vaginal stenosis were analyzed. RESULTS A total of 486 women underwent vaginal reconstructive procedures of which 30 patients required rotational inner thigh flaps. Indications were vaginal defects that were difficult to access and or required large amount of coverage. The flap was utilized for (7) recurrent vesicovaginal fistula (VVF) repair or (6) rectovaginal fistula (RVF), (14) vaginal stenosis, (6) complex posterior vaginal wall defects, and (13) prior radiation. The median number of prior surgeries was 3. The operative times (mean 173 minutes + 59), EBL (193 + 92 mL), median LOS (3 days), and perioperative complication (6%- superficial soft tissue infection (1), blood transfusion (1) were observed. Graft survival was 100% and all had good cosmesis with no dehiscence. Successful repair of VVF or RVF occurred in 13 (100%) with 8 (62%) requiring 1 surgery, and 5 (38%) two operations. Those that failed primary repair with recurrent VVF (1) and RVF (4) had a history of radiation in 3 (60%) and bowel diversion was not performed in 3 out of the 4 RVF (75%). Complex posterior defects were successfully repaired in all patients (6) with one patient developing vaginal stenosis. Vaginal depth and width were adequate in 82% overall, with 93% (13) patients with vaginal stenosis successfully repaired. Sexual function was maintained in all except 2 patients. Post-operatively patients completed the body image disturbance questionnaires (BIDQ) which examines negative body image. Patient post-operative body image was maintained with a low (BIDQ) score of 1.96 +.92 which is comparable to the non-surgical general population with a 30% response rate. CONCLUSIONS The rotational inner thigh flap is a versatile option for complex vaginal reconstruction. Reliable functional and cosmetic results are achieved while maintaining body image with minimal morbidity. Not performing fecal diversion and a history of radiation were associated with risk of recurrence of fistula. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e108 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Forrest Jellison Los Angeles, CA More articles by this author Gladys Ng Los Angeles, CA More articles by this author Lisa Rogo-Gupta Los Angeles, CA More articles by this author Leah Nakamura Los Angeles, CA More articles by this author Denise Chow Los Angeles, CA More articles by this author Ja-Hong Kim Los Angeles, CA More articles by this author Larissa Rodriguez Los Angeles, CA More articles by this author Shlomo Raz Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcome of Repeat Supratrigonal Obstetric Vesicovaginal Fistula Repair after Previous Failed Repair

Introduction: Currently, surgical repair for vesicovaginal fistula (VVF) provides excellent results, but the recurrent VVF is difficult to treat as compared to primary. Patients and Methods: Sixty-eight patients (44 primipara and 24 multipara) with recurrent VVF repair from January 2002 to December 2007 were included in present study. The mean size of fistula was 2.8 cm (1.0–6.5). The previous surgical repair was through the abdominal route in 50 patients (73.53%) and through the vaginal route in the remaining 18 patients (26.47%). Results: The procedure was successful in 62 of 68 patients (91.17%). The mean duration of surgery was 146.6 min (100–210). Mean blood loss was 160 ml (110–400) and mean hospital stay was 5.6 days (4–10). Eight patients developed complications. Conclusion: Recurrent VVF is difficult to treat, but excellent results can still be achieved by strictly sticking to the principals of surgical repair for VVF.

Comparative Analysis of Outcome Between Open and Robotic Surgical Repair of Recurrent Supra-Trigonal Vesico-Vaginal Fistula

Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons. Group I-12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II-20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram-kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets. In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant. The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.

Vesico-vaginal fistula: report of 220 cases

To present the major causes, diagnosis, indications, and basic principles of surgical treatment of vesico-vaginal fistulas (VVF). From 1978 to 2004, 235 surgical procedures in 220 women with vesico-vaginal fistulas were performed at the Clinical Center of Serbia, Urological Clinic, due to primary or recurrent VVF. There were 220 primary procedures: 129 transvesical approaches (TVES), 59 transvaginal repairs (TVAG), and 32 transperitoneal approaches with flap interposition (TPA). Transvesical approach was the most common procedure in the early period (1978-1993) and less frequent in the late period (1994-2004). The main causes of VVF were hysterectomy for benign conditions (62.7%), hysterectomy for malignant conditions (30.4%), cesarean section (5.9%), and obstetric injuries (0.9%). There was no perioperative mortality. There were fifteen recurrent fistula formations: twelve after the first operation and three after the second. The recurrence rates between the procedures were comparable: TVES 6.6%, TVAG 6.4%, and TPA 5.4%. The total recurrence rate of 6.4% did not differ significantly between various procedures. However, TVAG is less invasive and suitable for uncomplicated cases, whereas TPA should be recommended for great and recurrent VVF.

Robotic Reconstruction for Recurrent Supratrigonal Vesicovaginal Fistulas

We report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome. From August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue. The average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome. Our experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.

Vesicovaginal Fistula Repair with Rectus Abdominus Myofascial Interposition Flap

Complex, recurrent vesicovaginal fistulas (VVFs) can be very challenging to repair and often require interposition of nonirradiated, well-vascularized tissue between the urinary system and vagina. We report our experience using a rectus abdominus myofascial (RAM) interposition flap for VVF repair. A retrospective analysis was performed to identify patients who had undergone VVF repair with RAM interposition. Data were collected focusing on preoperative patient characteristics, etiology of VVF, intraoperative parameters, including surgical techniques, and postoperative patient outcomes. We used a RAM interposition flap for VVF repair in 5 patients. All VVFs had developed postoperatively; no patient had received radiotherapy. VVF developed after total abdominal hysterectomy (TAH) or radical cystectomy in 3 and 2 cases, respectively. Both cases of VVF after radical cystectomy occurred in conjunction with orthotopic diversion (neobladder-vaginal fistula). In 3 patients with post-TAH VVF, a total of five previous failed repairs were attempted before RAM interposition. In 1 patient with a neobladder-vaginal fistula, who had received adjuvant chemotherapy, RAM interposition failed, and the patient ultimately required cutaneous urinary diversion after two subsequent failed attempts at repair (68 months of follow-up). The remaining 4 patients (80%) had no evidence of recurrent VVF or voiding abnormalities at a mean follow-up of 19 months (range 8 to 32). Rectus abdominus muscle can be a successful interposition flap during repair of complex, recurrent VVF. In our experience, this has been successful in most cases, particularly in younger patients with nonmalignant processes.