Robotic repair of vesico-vaginal fistula with perisigmoid fat flap interposition: state of the art for a challenging case?

Abstract

Since its introduction, robotic-assisted operations have established themselves in an increasingly wide range of procedures. We applied this approach as a viable surgical alternative for the management of a complex vesicovaginal fistula. We present the case of a patient with total urinary incontinence due to the formation of a vesicovaginal fistula, following total abdominal hysterectomy. The fistula was located at the vaginal vault and at approximately one cm from the right ureteric orifice. For this specific scenario a robotic approach was chosen over the vaginal-, laparotomic- and laparoscopic repair, as in our view it offered the best possibility to specifically treat the target anatomy with a reduced risk for involvement of the surrounding structures, while maintaining a low morbidity and a quick postoperative recovery.In our video we show how the vesicovaginal fistula can be repaired by interposition of a vascularized flap of perisigmoid fat, in order to reduce the risk of recurrences [Ezzat et al., Repair of giant vesicovaginal fistulas, 181(3):1184-1188, 2009].The postoperative course was uneventful; on postoperative day 1 the patient reported pain of 2/10 on a VAS scale (0 = no pain; 10 = unbearable pain) and was mobilized. She was discharged on postoperative day two with bladder catheter in situ. The successful repair of the fistulous tract was confirmed via retrograde cystogram on postoperative day 10 and the patient was continent immediately after catheter removal. At the six month follow up visit the patient had no complaints.

Robotic vesico-vaginal fistula repair with no omental flap interposition

“…Surgeons can choose between the traditional transvesical (O'Connor repair) and the extravesical technique [2,3]. Classically, an omental flap is mobilized and interposed between the bladder and the vagina [4,5]. Omental interpositioning has never been proven to result in higher cure rates for VVF repair; nevertheless, few authors report no flap mobilization [2,3].…”

Repair of post-hysterectomy vesicovaginal fistulae: the state of the art

“…Vari tipi di tessuti di interposizione autologhi sono stati sperimentati. Oltre al classico flap di Martius sono stati utilizzati con successo flap peritoneali, flap omentali, flap di musculo gluteo, flap di muscolo retto dell'addome o di muscolo gracile, flap vaginali, flap di tessuto adiposo perisigmoideo, flap di dura madre umana (92–98).…”

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

“…60 This has been followed by publications of various case series which revealed the feasibility and safety of this technique with a reported success rate ranging from 71.4% to 100%. 61–66 However, the series is generally small in number. There are only three studies that included more than 15 patients, with a respective mean operative time of 127.5 min (100–270), 133 ± 48 min and 187 min (151–219 min), and a reported success rate of 100%, 93.3% and 91%.…”

“…60 This has been followed by publications of various case series which revealed the feasibility and safety of this technique with a reported success rate ranging from 71.4% to 100%. [61][62][63][64][65][66] However, the series is generally small in number.…”