Supratrigonal Vesicovaginal Fistula Research Articles

Comparative Analysis Between Laparoscopic Extravesical Repair and Laparoscopic O'Connor Repair for Supratrigonal Vesicovaginal Fistula.

The objective of the study was to conduct a comparative analysis of various intraoperative parameters and postoperative outcomes between the laparoscopic extravesical repair versus the laparoscopic O'Connor repair techniques in management of supratrigonal vesicovaginal fistula. A prospective nonrandomized study was conducted from January 2018 to January 2023, in which 36 patients who met inclusion criteria like primary or recurrent, single, simple, supratrigonal vesicovaginal fistula were included. Among these patients 18 patients were operated with laparoscopic O'Connor repair, while 18 were operated with laparoscopic transperitoneal extravesical vesicovaginal fistula repair. Intraoperative and postoperative parameters of these 2 techniques were compared. Laparoscopic O'Connor repair had longer operative time of 140 minutes, while laparoscopic extravesical VVF repair had an operative time of 117 minutes (P = .026). Mean blood loss was also significantly higher in laparoscopic O'Connor (210 mL versus 95 mL) (P = .004). Postoperative complications and analgesics requirement were less with laparoscopic extravesical repair. Hence, laparoscopic extravesical repair reduced mean hospital stay (3.2 days versus 3.9 days) (P = .003). A success rate of 83.33% for laparoscopic O'Connor and 94.45% for laparoscopic extravesical repair (P = .153) was recorded. Laparoscopic extravesical approach appears to be a convenient and effective method in selective supratrigonal vesicovaginal fistula repair.

Prevalent practices and changing trends in the management of vesicovaginal fistula: a cross-sectional study from a nationwide questionnaire-based survey of urologists from a developing country

Vesicovaginal fistula (VVF) management is primarily backed by evidence from retrospective studies and expert opinions and therefore lacks standardization. Newer generations of surgeons are more proactive toward changing clinical practices in domains lacking good-quality evidence. This survey-based cross-sectional study aims to elicit consensus on management practices regarding various domains of VVF management and look for any changes in clinical practice trends. A nationwide survey of urologists was conducted, and responses were grouped into 3 categories (overall response, response from young urologists, and response from experienced urologists) and compared. Based on the level of overall consensus, the responses were categorized as highly preferred, preferred, and somewhat preferred. Consensus was noted in conservative and endoscopic management of VVF, timing of VVF repair, definition of simple/complex VVF, approach for surgical repair for trigonal and supratrigonal VVF, use of interposition tissue for repair, and patient positioning in the postoperative period. A lack of consensus was noted in other domains. Changing trends in clinical practices were noted in attempts at conservative and endoscopic management, investigations considered mandatory for evaluation, surgical approach for complex VVF with bladder neck involvement and radiation-induced fistulas, the use of interposition grafts during surgical repair, the use of cystograms during follow-up, and the definition of a successful repair. There is uniformity in practices regarding many domains of VVF management. Those areas, where discordance in opinions is noted, require further research to bring standardization into practice. Regarding certain aspects of VVF management, there appears to be a change in trends among the younger generation of urologists.

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

Post Hysterectomy Vesicovaginal Fistula Repair Without Vaginal Vault Closure - A Simple Laparoscopic Extravesical Repair Approach

Purpose: The purpose of this study is to describe a simple extravesical laparoscopic approach for supratrigonal vesicovaginal fistula (VVF) repair without cystotomy and closer of the vaginal vault. Materials and Methods: This retrospective observational study reviewed data of 36 patients from January 2015 to January 2020. In our technique, the fistula tract was identified without cystotomy with the help of preplaced ureteric catheter in VVF tract. After meticulous extravesical dissection of the fistula tract, the bladder wall was closed in a single layer using polyglactin 2.0 sutures. The omental flap was approximated over the vaginal vault without primary closer of the vault. Results: In most of the patients the fistula opening were located 2 cm away from ureteric orifice while in 4 patients it located within 2 cm of orifice. The mean operative time was 86 min (65–125) and estimated blood loss was 94 ml (40–130). The mean size of fistula was 7.1 mm (5–15 mm). Omental flap was approximate over vaginal opening in most of the patients. The average hospital stay of patients was 5 days. In all patients, Foley catheter was removed on day 14 after cystogram. The mean follow-up of patients was 4.2 months (3–7). All patients remained continent and symptom free during the follow-up periods. Conclusion: Our technique without suturing of the vaginal vault in laparoscopic VVF repair is safe in a simple supratrigonal fistula with good results and avoiding added suturing.

Laparoscopic transvesical vesicovaginal fistula repair with the least invasive way: Only three trocars and a limited posterior cystotomy

ObjectiveTwo conventional approaches for vesicovaginal fistula (VVF) repair are transabdominal repair for supratrigonal VVF and transvaginal approach for low lying fistulae. Laparoscopic surgery was introduced to duplicate the surgical steps of the transabdominal approach with reduction in morbidity. We report a series of patients treated with a modified laparoscopic technique which includes the use of only three trocars and a limited posterior cystotomy. MethodsWe retrospectively reviewed the data of eight patients who underwent laparoscopic VVF repair with our standardized technique from January 2015 to April 2018. Only cases with a supratrigonal fistula were included. We constantly used only three trocars. A limited 2 cm midline posterior cystotomy was performed using ultrasonic energy. A stay suture on a straight needle was passed percutaneously in the abdomen, then on either side of the cystotomy and finally was exteriorized to maintain countertraction. The cystotomy was extended downwards to include the fistula site. The fistula was dissected circumferentially to raise the bladder and vaginal flaps. The vaginal defect was closed in a transverse fashion and the cystotomy was closed vertically. ResultsMean operative time was 178±31.6 min and estimated blood loss was 60±18.7 mL. Flap interposition was performed in six cases. No intraoperative complications were recorded. Mean hospital stay was 2.25±0.89 days. During hospitalization two patients experienced postoperative complications (Clavien grade I). Mean follow-up was 20.9±11.1 months (6.0–39.0 months). All patients remained continent during the follow-up period. ConclusionsThis minimally invasive laparoscopic approach with only three trocars and limited posterior cystotomy provides excellent results with minimum morbidity.

Transvaginal Repair of Vesico Vaginal Fistula: A 10-Year Experience with Analysis of Factors Affecting Outcomes

Objectives: To highlight the transvaginal route as an excellent approach for repair of a simple trigonal, supra-trigonal vesico-vaginal and urethrovaginal fistulae without compromising on the successful patient outcomes. We also determine factors affecting outcomes in such patients. Materials and Methods: A retrospective analysis was carried out on 58 patients with simple trigonal, supra trigonal and urethrovaginal fistula who underwent transvaginal repair in the last 10 years. Simple fistulas were defined as fistula less than 3 cm in size or recurrent fistulae less than 1.5–2 cm in size and located either supra-trigonally (above the bar of mercier) or sub-trigonally (below the bar of mercier) as determined by cystoscopy. Results: Obstetric cause, due to obstructed labour, was the most common cause of fistula formation (68.96%), while remaining (29.31%) were attributed to hysterectomy. Primary fistulae were found in 68.9% of patients and recurrent fiistulae in 31.1% patients. The mean age of patients was 33.4 years. Average fistula size was 1.5 cm. The success rate of primary operation was 84.12% (50/58). On using a multivariate regression model, the underlying aetiology (OR 2.2), fistula location (OR 2.5) and history of previous repair (OR 2.4) were found to be significant factors affecting outcome. Conclusion: The transvaginal approach is less invasive and achieves comparable success rates as compared to other methods of vesico-vaginal fistula repair. This surgery with Foley catheter has a high success rate with reduced morbidity. We postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible vesico vaginal fistulae, both of obstetrical and gynaecological origin.

Robotic repair of vesicovaginal fistula - initial experience.

ABSTRACTObjective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy.Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally.Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF.Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Laparoendoscopic single site surgery for extravesical repair of vesicovaginal fistula using conventional instruments: Our initial experience.

Objective:Vesicovaginal fistula (VVF) is a major complication with psychosocial ramifications. In literature, few VVF cases have been managed by laparoendoscopic single site surgery (LESS) and for the 1st time we report VVF repair by LESS using conventional laparoscopic instruments. We present our initial experience and to assess its feasibility, safety and outcome.Patients and Methods:From March 2012 to September 2015, LESS VVF repair was done for ten patients aged between 30 and 65 (45.6 ± 10.15) years, who presented with supratrigonal VVF. LESS was performed by modified O’Conor technique using regular trocars with conventional instruments. Data were collected regarding feasibility, intra- or post-operative pain, analgesic requirement, complication, and recovery.Results:All 10 cases were completed successfully, without conversion to a standard laparoscopic or open approach. The mean operative time was 182.5 ± 32.25 (150–250) min. The mean blood loss was 100 mL. The respective mean visual analog score for pain on day 1, 2, and 3 was 9.2 ± 1, 5 ± 1, and 1.4 ± 2.3. The analgesic requirement in the form of intravenous tramadol on days 1, 2, and 3 was 160 ± 51.6, 80 ± 63.2, and 30 ± 48.3, mgs respectively. No major intra- or post-operative complications were observed. The mean hospital stay was 2.6 ± 0.7 (2–4) days.Conclusion:In select patients, LESS extravesical repair of VVF using conventional laparoscopic instruments is safe, feasible with all the advantages of single port surgery at no added cost. Additional experience and comparative studies with conventional laparoscopy are warranted.

Chronic vaginal discharge due to vesicovaginal fistula.

We would like to report an additional case of a supratrigonal vesicovaginal fistula (VVF) characterized by long-term misdiagnosis, ultimately resolved through the use of computed tomography (CT) and cystoscopy. A 42-year-old woman presented with a case of dysuria and chronic vaginal discharge, which had begun 6 years previously, following a routine total abdominal hysterectomy (TAH) performed to treat a myoma. The patient had frequently sought treatment at a variety of local clinics, with her symptoms generally diagnosed as either chronic cystitis and vaginitis or pelvic inflammatory disease, despite the absence of abnormal urine or vaginal cultures. Following referral to our hospital, we performed a pelvic examination, revealing a whitish vaginal discharge emanating from an area deep in the upper vagina. Cystoscopy of the affected area revealed the presence of a chronic foreign material in the bladder (Fig. 1). These findings were confirmed by CT, revealing a metallic substance lodged within the bladder. We examined the patient and repaired the vagina in the lithotomy position under general anesthesia. First, we inserted a guidewire into the pinpoint fistula in the upper vagina and into the bladder, with the assistance of cystoscopy (Fig. 2). We removed the foreign body from the bladder by cystoscopy with grasping forceps. The histopathology revealed that the foreign body was non-absorbable suture material. Upon removal of the object, we performed vaginal repair of the VVF in a manner similar to that of Rajamaheswari et al. [1]. The metallic foreign body removed from this patient is thought to have been left behind following TAH, ultimately penetrating the bladder owing to the nature of the substance.

Laparoscopic repair of urogenital fistulae: A single centre experience.

CONTEXT:Sparse literature exists on laparoscopic repair of urogenital fistulae (UGF).AIMS:The purpose of the following study is to report our experience of laparoscopic UGF repair with emphasis on important steps for a successful laparoscopic repair.SETTINGS AND DESIGN:Data of patients who underwent laparoscopic repair of UGF from 2003 to 2012 was retrospectively reviewed.MATERIALS AND METHODS:Data was reviewed as to the aetiology, prior failed attempts, size, number and location of fistula, mean operative time, blood loss, post-operative storage/voiding symptoms and episodes of urinary tract infections (UTI).RESULTS:Laparoscopic repair of 22 supratrigonal vesicovaginal fistulae (VVF) (five recurrent) and 31 ureterovaginal fistulae (UVF) was performed. VVF followed transabdominal hysterectomy (14), lower segment caesarean section (LSCS) (7) and oophrectomy (1). UVF followed laparoscopy assisted vaginal hysterectomy (18), transvaginal hysterectomy (2) and transabdominal hysterectomy (10) and LSCS (1). Mean VVF size was 14 mm. Mean operative time and blood loss for VVF and UVF were 140 min, 75 ml and 130 min, 60 ml respectively. In 20 VVF repairs tissue was interposed between non-overlapping suture lines. Vesico-psoas hitch was done in 29 patients of urterovaginal fistulae. All patients were continent following surgery. There were no urinary complaints in VVF patients and no UTI in UVF patients over a median follow-up of 3.2 years and 2.8 years respectively.CONCLUSION:Laparoscopic repair of UGF gives easy, quick access to the pelvic cavity. Interposition of tissue during VVF repair and vesico-psoas hitch during UVF repair form important steps to ensure successful repair.

Long-Term Functional Outcomes Following Nonradiated Vesicovaginal Repair

We investigated the long-term impact on bladder and sexual symptoms in women with prior vesicovaginal fistula repair, particularly those previously treated before referral. After receiving institutional review board approval we reviewed the charts of women who underwent nonradiated vesicovaginal fistula repair for demographics, surgical approach (vaginal or abdominal) and functional outcomes with a minimum 6-month followup. Patients lost to followup were reached by a structured phone interview and/or mailed validated lower urinary tract questionnaires, including the UDI-6 (Urogenital Distress Inventory-6), IIQ-7 (Incontinence Impact Questionnaire-7) and FSFI (Female Sexual Function Index). Three surgical groups were compared, including naïve-no prior repair, recurrent-1 prior repair and other-more than 2 repairs with the hypothesis of worse outcomes with more repairs. From 1996 to 2011 vesicovaginal fistula repair was performed in 66 patients, including in 42 as primary treatment (vaginal vs abdominal approach in 31 vs 11), in 14 as secondary treatment, and in 10 who underwent more than 2 repairs. Mean patient age was 45 years (range 24 to 87), mean body mass index was 29 kg/m(2) (range 19 to 43) and mean followup was 55 months (range 6 to 198). The overall repair success rate was 97%. There was no difference in functional outcomes in questionnaire responders among the 3 groups for lower urinary tract symptoms (62% on UDI-6/IIQ-7). However, for FSFI (33% of patients) there was female sexual dysfunction in patients who underwent transabdominal repair and in women with 2 repairs. Long-term followup of patients with vesicovaginal fistula repair indicated no differences in lower urinary tract outcomes at a mean 7-year followup between primary and recurrent repairs. There was a difference in sexual function, although it was not statistically significant. Sexual activity among responders was low.

Laparoscopic transabdominal transvesical repair of supratrigonal vesicovaginal fistula

We investigated the clinical efficacy of early laparoscopic repair of supratrigonal vesicovaginal fistula. Laparoscopic repair of vesicovaginal fistula was performed and retrospectively studied in 18 consecutive patients who had clear indications for iatrogenic supratrigonal vesicovaginal fistula following hysterectomy or obstetric trauma during delivery. All patients underwent laparoscopic surgery via the transabdominal transvesical route. Wide mobilization of the bladder and vaginal wall, complete excision of devitalized tissue, tension-free closure, omental interposition, and efficient postoperative bladder drainage provides dependable support for definitive closure of the path. Success was defined as the disappearance of the fistula. Average patient age was 36.7 years; none required open conversion. Mean operative time was 135 (range 75-175) min. Mean duration of bladder catheterization was 15 (range 14-16) days. All patients were cured at the first attempt, with no surgical reintervention or recurrence at a mean follow-up of 22.7 (range 3-45) months. We believe that laparoscopic repair of supratrigonal vesicovaginal fistula is an excellent alternative to the traditional abdominal approach and provides excellent results.

Vaginal repair of supratrigonal vesicovaginal fistulae—a 10-year review

A 10-year retrospective study was done to determine the outcome of vaginal repair for supratrigonal vesicovaginal fistulae (VVF). One hundred thirty-two urinary fistulae were managed from 2001 to 2011 which include 34 ureterovaginal and 98 lower urinary tract fistulae. Fifty-three out of 98 were supratrigonal VVF, 49 were of benign etiology and 4 were malignancy induced. Further analysis of 49 supratrigonal VVF of benign etiology revealed that 38 (77.5%) were of gynecological origin and 11 (22.5%) obstetric. Forty-three were primary and six were recurrent VVF. Thirty (61.2%) supratrigonal VVF were repaired vaginally and 19 (38.8 %) abdominally. Mean follow-up period was 51.7 months. The successful outcome for vaginal and abdominal repair was 86.7% and 100%, respectively (p value = 0.26). Overall, 91.8% supratrigonal VVF were cured at our first attempt. Majority of supratrigonal VVF can be approached vaginally with success rate comparable to abdominal approach.

Trans-vaginal repair of gynecological supratrigonal vesicovaginal fistulae: A worthy option!

Objective:To determine the appropriateness of vaginal approach for gynecological supratrigonal vesicovaginal fistulae.Patients and Methods:Retrospective review of consecutive women with gynecological supratrigonal Vesico Vaginal Fistulae (VVF) repaired at the fistula unit of Urogynecology department between 1996 and 2011 was done.Out of 48 cases of supratrigonal VVF of gynecological origin identified; 34 (70.8%) cases were repaired vaginally and 14 (36.8%) abdominally with a mean follow-up period of 52.8 (2-132) months.Results:Overall 95.8% were successfully cured at first attempt. The success rate of vaginal repair (94.8%) at first attempt was comparable to that of abdominal repair (100%) (P value = 0.8946). Amongst two failed vaginal repairs, one was successfully cured by subsequent vaginal repair and other by abdominal repair.Conclusion:Three fourth gynecological supratrigonal VVF can be repaired vaginally in first attempt with success rate comparable to abdominal approach. On the basis of this study we postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible supratrigonal VVF of gynecological origin.

Laparoendoscopic Single-site Surgery Extravesical Repair of Vesicovaginal Fistula: Early Experience

To describe for the first time the technique of laparoendoscopic single-site surgery (LESS) for repair of vesicovaginal fistula (VVF). LESS has recently been described as an alternative to conventional laparoscopy for the treatment of various urologic pathologic features. The present study included 5 female patients with supratrigonal VVF who presented with urinary leakage per vagina after obstetric and gynecologic procedures. Extravesical LESS repair of VVF was done using the TriPort and prebent instruments. The fistulas tracts were identified and excised extravesically using sharp dissection. The edge of the bladder was trimmed at the site of fistula tract. The vagina was closed in 1 layer with continuous 3-0 Vicryl sutures, and the urinary bladder was closed in 2 layers using 3-0 Vicryl sutures. An additional 5-mm extraport was added at suturing to allow triangulation and hand-free extracorporeal suturing. An omental flap was interposed between the bladder and vagina. The urinary bladder was drained by an indwelling urethral catheter for 3 weeks. The operative time was 198±27.7 minutes. The blood loss was 90±25 mL. No intraoperative or postoperative complications developed. No conversion to conventional laparoscopy or open surgery was necessary. The postoperative hospital stay was 2 days. No postoperative urinary leakage occurred. The follow-up examination at 8±3.2 months showed complete continence and no recurrence of VVF. LESS extravesical repair of VVF is a technically feasible and effective procedure that adheres to the principles of transabdominal open surgical repair. The technique has significant low morbidity; however, it requires advanced laparoscopic skills.

V678 LAPARO-ENDOSCOPIC SINGLE-SITE (LESS) EXTRAVESICAL REPAIR OF VESICOVAGINAL FISTULA

You have accessJournal of UrologyFemale Voiding Dysfunction (Pelvic Reconstruction & Incontinence)1 Apr 2011V678 LAPARO-ENDOSCOPIC SINGLE-SITE (LESS) EXTRAVESICAL REPAIR OF VESICOVAGINAL FISTULA Aly Abdel-Karim, Ahmed Moussa, and Salah Elsalmy Aly Abdel-KarimAly Abdel-Karim Alexandria, Egypt More articles by this author , Ahmed MoussaAhmed Moussa Alexandria, Egypt More articles by this author , and Salah ElsalmySalah Elsalmy Alexandria, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1630AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In this video we describe for the first time the technique of laparo-endoscopic single-site (LESS) extravesical repair of vesicovaginal fistula (VVF). METHODS The case that we present in this video is a 52 years old female that presented with persistent urinary leakage per vagina following abdominal hysterectomy. Computed tomography (CT) of the abdomen and pelvis and cystoscopy revealed a supratrigonal vesicovaginal fistula. The fistula was repaired through extravesical LESS surgery using the R-port and curved instruments. The fistulas tract was identified and completely excised extravesically using sharp dissection. The edge of the bladder was trimmed at the site of fistulas tract. The vagina was closed in one layer with continuous 3/0 vicryl sutures, while urinary bladder was closed in 2 layers using 3/0 vicryl suture. An additional 5-mm extraport was added at time of suturing to allow triangulation and hand-free intracoprporeal suturing. An omental flap was interposed between the bladder and vagina. The urinary bladder was drained by an indwelling urethral catheter for 3 weeks. RESULTS The operative time was 240 minutes. Blood loss was 90c.c. There were no intraoperative or postoperative complications. Postoperative hospital stay was 2 days. There was no postoperative urinary leakage. Follow up of the patient for 10 months showed complete continence and no recurrence of VVF. CONCLUSIONS LESS extravesical repair of VVF is technically feasible and effective procedure that adheres to the principles of transabdominal open surgical repair. However, the technique requires advanced laparoscopic skills. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e274 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aly Abdel-Karim Alexandria, Egypt More articles by this author Ahmed Moussa Alexandria, Egypt More articles by this author Salah Elsalmy Alexandria, Egypt More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Laparoscopic transperitoneal extravesical repair of vesicovaginal fistula

Laparoscopic repair of vesicovaginal fistula (VVF) has been recently reported. We present our experience of laparoscopic transperitoneal extravesical repair of VVF. Fifteen females with supratrigonal VVF were included. Patients with malignant radiation and recurrent fistulas were excluded. Laparoscopic transperitoneal extravesical repair was done using four to five ports. The bladder was closed longitudinally, while the vagina was closed transversally with interposition of omentum in between. Bladder was drained by a urethral catheter for 3 weeks. Mean operative time was 171.6 ± 19.5 min. There was no conversion to open in all patients. Mean blood loss was 110 ± 17 cc. No intraoperative or postoperative complications. Mean hospital stay was 3 ± 1 days. At a mean follow-up of 18.9 ± 8.6 months all patients were cured. Laparoscopic transperitoneal extravesical repair of VVF is a safe and effective minimally invasive procedure for treatment of 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.

Our Experience with Genitourinary Fistulae

Introduction: Our objective was to analyze the incidence, etiopathology, diagnosis and therapeutic aspects of the genitourinary fistula in an Indian population. Methods: This is a retrospective analysis of the genitourinary fistulae repaired at the Department of Urology, Institute of Medical Sciences, Banaras Hindu University, between January 1990 and December 2006. The surgical approach varied in each patient. Interposition grafts or flaps were used as and when required. The main outcomes analyzed were the incidence, etiology, surgical approaches, accessory procedure required, need for tissue interposition, cure rate per repair and overall success rate. Results: Out of 558 cases, 403 were vesicovaginal, 84 ureterovaginal, 43 urethrovaginal and 28 vesicouterine fistulae. The most common etiology was obstructed labor (72.2%), followed by hysterectomy. The transvaginal route was preferred for repair wherever possible. The transabdominal route was adopted for the repair of supratrigonal vesicovaginal, ureterovaginal and vesicouterine fistulae and if bladder augmentation was required. Conservative management was successful in 1.9% of the vesicovaginal fistulae and in 8 cases of ureterovaginal fistula. The remaining cases were managed surgically with excellent results. Conclusion: Genitourinary fistulae are not life-threatening but are socially debilitating. Surgical repair provides the definitive cure, but expectant treatment can be tried in selective patients.

Transperitoneal Laparoscopic Repair of Iatrogenic Vesicovaginal Fistulas: Heilbronn Experience and Review of the Literature

Vesicovaginal fistula (VVF) continues to be a distressing problem in urogynecology. Laparoscopy has become increasingly popular in the field of reconstructive urologic surgery. We describe our technique of laparoscopic VVF repair for iatrogenic VVFs, discuss our technique and outcomes, and review the related literature. After hysterectomy for a benign condition, an iatrogenic VVF developed in three women (41, 48, and 34 years old, respectively) that persisted despite conservative therapy. Preoperative urethrocystoscopy demonstrated supratrigonal VVFs. Laparoscopic surgery was performed for the three patients after 3, 8, and 4 months of the previous abdominal operations. Patients were placed in a deflected supine position, and a transperitoneal five-port approach was used. The bladder was bivalved, and the fistula tract was excised. The fistulous tract was successfully repaired by closing the vagina and bladder separately. An interposing peritoneal flap was placed and fixed between the bladder and vagina. The patients recovered uneventfully and were discharged from the hospital after 4, 9, and 5 days, respectively. Retrograde cystography on postoperative day 10 revealed no contrast leakage via the vagina. The urethral catheters were removed on the same day. After 30, 17, and 14 months of follow up, respectively, the patients were voiding without any urine leakage. Laparoscopic repair can be applied effectively in the management of VVFs. The approach is safe and provides all advantages of minimally invasive surgery. Shorter hospital stay and shorter recovery time have a positive effect on the patients' well being.