Robot Helps Fix Vesicovaginal Fistulas

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Surgeons successfully used a novel technique on seven women who were not helped by prior surgeries.

Robot-assisted repair of recurrent supratrigonal vesicovaginal fistulas achieves excellent results with few complications, according to researchers.

From August 2006 through October 2007, they used the robotic technique to treat seven cases of supratrigonal vesicovaginal fistula. An important aspect of the procedure, which involves a five-port transperitoneal approach, is placement of patients in a low lithotomy position with a 60° Trendelenburg tilt.

Peritoneoscopy and adhesiolysis are performed with minimal posterior cystotomy encircling the fistulous opening, and mobilization of bladder and the vaginal flaps allows for a tension-free closure. The fistulous rim is excised and the bladder and vaginal edges freshened. Bladder and vaginal closure is accomplished, as well as omental, peritoneal, or sigmoid epiploic tissue interpositioning, followed by insertion of a Foley catheter and drain.

All subjects had undergone previously unsuccessful surgeries. Five had at least two failed prior procedures. These patients would normally undergo abdominal surgery requiring a large incision. Instead, centimeter-sized instruments and a small camera were inserted through five small incisions in the abdomen.

The mean hospital stay for the seven patients was three days, the researchers reported in the Journal of Urology (2008;180:981-985). Catheters were removed from all patients 14 days postoperatively. All had a successful outcome and were continent after catheter removal. The patients were prescribed antibiotics for five days and anticholinergic medications for six to eight weeks, along with bladder training.

The average size of the fistulas was 3 cm. The mean operative time was 141 minutes (range 110-160 minutes). Mean blood loss was 90 cc (range 50-150 cc). No significant intraoperative or postoperative complications were reported.

“There was less blood loss with this procedure than the conventional surgery and there is the potential for a faster recovery,” said investigator Ashok Hemal, MD, professor of urology at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. “The results were outstanding and suggest that robot-assisted surgery is an attractive option for fistulas that would normally require abdominal surgery.”

The main difficulty with the robotic approach, according to Dr. Hemal, is the safe establishment of pneumoperitoneum and the need for extensive adhesiolysis.

“Robot-assisted surgery has promise to bridge the limitations of laparoscopic surgery and allow more women with fistulas, urinary incontinence, or prolapsed pelvic organs to benefit from a minimally invasive approach,” Dr. Hemal said.
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