Laparoscopic transabdominal transvesical vesicovaginal fistula repair

BACKGROUND AND PURPOSE: Transabdominal transvesical repair has been the standard treatment for difficult vesicovaginal fistulae. We describe a laparoscopic transvesical technique that minimizes operative morbidity while adhering to the principles of transabdominal repair as described by O'Conner. TECHNIQUE: The patient is placed in the lithotomy position using Allen stirrups, and bilateral 5F open-ended ureteral catheters are placed cystoscopically. Using four laparoscopic ports, the prevesical space is accessed. The bladder is bivalved down to the fistula, and stay sutures are placed at the bladder edges for exposure. The fistulous tract and adjacent fibrotic tissue are excised, and the bladder and vagina are closed separately with single layers of full-thickness interrupted 2-0 Vicryl sutures. An omental flap is interposed between suture lines in the bladder and vagina. The ureteral catheters are sequentially removed on the first and second postoperative days. A gravity cystogram is performed 3 weeks postoperatively; if it is normal, the urethral catheter is removed. RESULTS: This procedure has been performed on two consecutive patients who had failed prior Latzko repairs. Both patients were discharged 2 days postoperatively without complications. At a follow-up of 41 months in the first patient and 39 months in the second, no fistula recurrence has been seen. CONCLUSIONS: Laparoscopic transvesical vesicovaginal fistula repair appears to be a safe and effective procedure that adheres to the principles of a transabdominal transvesical fistula repair while decreasing morbidity and improving cosmesis. Continued follow-up is required to determine its long-term efficacy compared with the accepted open transabdominal and transvaginal approaches.     

Early laparoscopic repair for supratrigonal vesicovaginal fistula

Laparoscopic repair of supratrigonal vesicovaginal fistula is less morbid and equally effective compared to open repair. This approach is advisable when transvaginal repair is difficult.     

Simple transvesical repair of vesicovaginal fistula.

A simple transvesical repair of uncomplicated small vesicovaginal fistulas was done successfully on 40 consecutive patients. More extensive procedures using combined intraperitoneal-transvesical approaches with extensive dissection and omental flaps probably are necessary for the repair of large, complicated or irradiated fistulas. However, these are not often encountered in urological practice. The method described herein is recommended for fistulas encountered more frequently.     

经腹径路手术治疗膀胱阴道瘘的临床分析

目的:探讨经腹径路手术治疗膀胱阴道瘘的临床疗效。方法:回顾性分析14例女性膀胱阴道瘘患者资料。患者平均年龄41.36岁。临床表现不同程度阴道漏尿,或伴血尿及膀胱刺激症状。膀胱镜检、膀胱尿道造影及CT三维重建术前确诊。先后行经腹径路膀胱阴道瘘修复手术,其中采取经膀胱径路9例,膀胱外径路5例。结果:14例术后随访9～103个月,平均46.26个月。2例术后出现再次膀胱阴道瘘,行二次修补手术后未再复发,1例出现切口感染,经对症处理后愈合,其余患者均未出现尿瘘复发及其他严重并发症。结论:经腹径路手术治疗膀胱阴道瘘,术中视野暴露充分,易于获取带蒂支持组织,尤其对于复杂性膀胱阴道瘘及合并输尿管等组织损伤可疑患者,是一种可行的手术治疗方式。     

Laparoscopic repair of vesicovaginal fistula

PURPOSE: To describe a methodology for laparoscopic repair of vesicovaginal fistula (VVF), and to provide a comparison of results between a series of laparoscopic repairs, a series of transabdominal open repairs (TAORs), a series of transvaginal repairs (TVRs), and cases successfully managed without surgery. PATIENTS AND METHODS: A total of 16 patients were diagnosed with post-hysterectomy VVF. All patients were first managed conservatively with continuous drainage via a Foley catheter until dry. In 2 of the 16 cases (12.5%) the fistulae healed spontaneously with conservative management. After 4-12 weeks, the remaining 14 patients underwent surgical repair of their fistulas; 2 (14%) by laparoscopy, 6 (43%) by TAOR, and 6 (43%) by TVR. RESULTS: Fistula repair was successful in both laparoscopy cases, all 6 TAOR cases, and 5 of 6 TVR cases (86%). The failed transvaginal repair was repeated, with a successful outcome. Length of hospital stay was 7-10 days (mean, 8.3 days) for the open cases, 3-5 days (mean, 4.1 days) for the transvaginal cases, and 2-12 days for the laparoscopic cases. One patient who underwent laparoscopic repair had a 12-day hospital stay due to extended vaginal drainage lasting 3 weeks, which then resolved. Three of the 6 patients who underwent TAOR (50%) experienced postoperative complications, including 2 cases of ileus and 1 case of fever. One of 6 patients who underwent TVR (16%) experienced recurrent urinary tract infection. CONCLUSIONS: These data suggest that laparoscopic VVF repair is feasible and may result in lower morbidity, shorter hospital stay, and quicker recovery than the abdominal or transvaginal approaches. Additional controlled studies are warranted. The minimally invasive approach of laparoscopy may be a more attractive option for patients who experience VVF following hysterectomy.     

Laparoscopic repair of vesicovaginal fistula

Vesicovaginal fistula (VVF) may be a complication of prolonged repair or urogynecologic surgery. Failing conservative management, it may be repaired using an abdominal or vaginal approach. We herein report laparoscopic repair of VVF following vaginal hysterectomy and detail the operative steps.     

Laparoscopic repair of vesicovaginal fistula

PURPOSE: Vesicovaginal fistula may be a complication of urogynecologic surgery. We describe the technique of laparoscopic repair of vesicovaginal fistula as performed at our 2 institutions. MATERIALS AND METHODS: Since August 1998 laparoscopic repair of vesicovaginal fistula was performed in 15 select patients who had clear indications to undergo surgical treatment through an abdominal approach. Hysterectomy had previously been performed in 14 patients (93%). Conservative treatment was initially attempted for more than 2 months in all cases. Four patients had undergone a previous surgical fistula closure attempt with unsuccessful results. Our technique involved cystoscopy, catheterization of the vesicovaginal fistula, laparoscopic cystotomy, opening and excision of the fistulous tract, dissection of the bladder from the vagina, cystotomy closure and colpotomy with interposition of a flap of healthy tissue. Demographic as well as perioperative and outcome data were recorded. RESULTS: Average patient age was 38 years. None of the cases required open conversion. Mean operative time was 170 minutes (range 140 to 240). Mean hospital stay was 3 days (range 2 to 5). The mean duration of bladder catheterization was 10.4 days (range 9 to 15) At a mean followup of 26.2 months (range 3 to 60) 14 patients (93%) were cured. CONCLUSIONS: We believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally invasive approach for the management of this entity.     

Laparoscopic repair of vesicovaginal fistula

PURPOSE: Vesicovaginal fistula (VVF) is one of the most devastating surgical complications that can occur in women. The primary cause remains an abdominal hysterectomy. Approach to this condition can be transvaginal or transabdominal. Laparoscopic repair of VVF may be an alternative approach to this treating rare condition. We present seven cases of VVF treated with transperitoneal laparoscopic technique and our results. METHODS: We retrospectively reviewed the charts of 7 women ranging from 37 to 74 years in age (mean age 52.8 years) at our institution who underwent laparoscopic transperitoneal repair of VVF between February 2004 and March 2006. Etiology of the VVF, surgical technique, operative time, length of hospital stay, and complications were reviewed. RESULTS: Six of the seven VVFs we repaired laparoscopically resulted from gynecologic procedures, and one patient presented with a VVF after a ureterolithotripsy. Mean operative time ranged from 130 to 420 minutes (mean 280 minutes), and mean hospital stay was 7 days. In one patient conversion to open surgery was necessary due to prolonged operative time. Two complications occurred: a urinary tract infection in one patient and an inferior limb compartment syndrome in another. CONCLUSION: Transvaginal laparoscopic repair of VVF is feasible and safe and provides excellent results. It is a good alternative to the abdominal approach. However, advanced laparoscopic skills are mandatory.     

Laparoscopic repair of vesicovaginal fistula

Introduction In developed countries, the majority of vesicovaginal fistulas develop after gynaecologic surgery, with abdominal hysterectomy accounting for 90% of cases. Several techniques are available for repairing the fistulas. Abdominal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair to minimize the surgical morbidity of the transabdominal approach. Methods A 44-year-old female presented with vesicovaginal fistula after abdominal hysterectomy. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed intially to confirm the fistula location and for bilateral ureteric catheterization. A 4-port technique was performed with the patient in the Trendelenburg position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum. Results The operation was uncomplicated. Total operative time was 260 min. Normal diet was resumed on day 1 and patient was discharged on the same day with an indwelling catheter. A cystogram performed 3 weeks post surgery showed resolution of the fistula. Conclusions Laparoscopic repair of vesicovaginal fistula without opening the bladder and using intracorporeal suturing and omentum interpositioning is feasible in selected patients.     

Laparoscopic transperitoneal extravesical repair of vesicovaginal fistula

Introduction and hypothesis  

Laparoscopic repair of vesicovaginal fistula (VVF) has been recently reported. We present our experience of laparoscopic transperitoneal extravesical repair of VVF.     

Transperitoneal laparoscopic repair of vesicovaginal fistula for patients with supratrigonal fistula: comparison with open transperitoneal technique

Introduction and hypothesis

We investigated the treatment outcomes of laparoscopic vesicovaginal fistula repair (LVVFR) in patients with supratrigonal vesicovaginal fistula (VVF) in contrast with open transperitoneal vesicovaginal fistula repair (OVVFR).

Methods

We analyzed 58 VVF repairs from June 2005 to July 2014, with 22 patients in the LVVFR group and 36 in the OVVFR group. Demographic parameters, operative variables, and perioperative outcomes were retrospectively collected and analyzed. The chi-square test, Fisher’s exact test, Student’s t test and the Mann–Whitney U test were used for statistical analysis.

Results

Patients in both groups had comparable preoperative characteristics. Significantly shorter hospital stay (5.6 vs. 13.2 days, p?<?0.05) and less blood loss (52 vs. 103 ml, p?<?0.05) were observed in LVVFR group. Patients in the LVVFR group achieved a higher overall VVF success rate (95.5 % vs. 83.3 %, p?>?0.05) and recurrent VVF success rate (90.0 % vs. 75.0 %, p?>?0.05) than OVVFR group, but it was not statistically significant. Patients who underwent OVVFR experienced more postoperative symptomatic bladder spasms (8.3 % vs. 4.5 %, p?>?0.05), urinary tract infections (UTIs) (5.6 % vs. 0.0 %, p?>?0.05), and stress urinary incontinence (SUI) (5.6 % vs. 4.5 %, p?>?0.05), but fewer incidents of postoperative ileus (0.0 % vs. 4.5 %, p?>?0.05) than the LVVFR group; differences were not significant.

Conclusions

Judging from this initial trial, LVVFR should be recommended as the primary intervention to treat supratrigonal VVF patients in view of its reduced blood loss and hospital stay.

     

经阴道辅助单孔腹腔镜下经膀胱入路膀胱阴道瘘修补术一例报告

膀胱阴道瘘是指膀胱和阴道之间存在的异常解剖通道,以反复阴道漏尿为主要症状,对患者的身心健康造成了极大的影响,是最常见的泌尿生殖瘘类型。在发达国家中,膀胱阴道瘘多见于妇科手术造成的医源性损伤,发生率约1/1800[1]。一些研究报道单纯子宫切除术后,膀胱阴道瘘发生率0.5%;而根治性子宫切除术后膀胱阴道瘘发生率高达10%[1-2],其他原因还包括难产、盆部肿瘤放疗、车祸外伤、炎症感染等[3-4]。约有5%~11%的患者可以通过早期留置导尿管等保守治疗,使得瘘口愈合,大部分患者仍需要手术治疗[5]。经阴道、经腹腔以及经膀胱入路是治疗膀胱阴道瘘常用的方式。单孔腹腔镜经膀胱入路手术创伤小,但因“筷子效应”导致手术难度较大,在临床中开展较少;为此我们探讨经阴道辅助单孔腹腔镜经膀胱入路膀胱阴道瘘修补术手术方法,报道如下。     

Ball repair of vesicovaginal fistula

Eighteen patients with vesicovaginal fistula (15 fistulas resulted from vaginal and 3 from abdominal hysterectomy) were all successfully treated using the ball counter-pressure technique.     

Robotic uterine-sparing vesicovaginal fistula repair

Introduction and hypothesis

The objective was to describe a technique for the robotic repair of complex vesicovaginal fistula (VVF) with uterine preservation.

Methods

From 2015 to 2017, two patients underwent the procedure. Following placement of the patient in the lithotomy position, catheterization of the fistulous tract and laparoscopic omental harvesting is performed. Then, the robotic system is docked. A transverse incision was made in the peritoneum above the uterus was made to provide access to the bladder, the uterus is mobilized, and a cystotomy is performed to identify the structures. Subsequently, the cystotomy is extended toward the fistulous tract, the plane between the organs is dissected to proceed with the vaginal closure, the vagina is closed, the omental flap is interposed, and the bladder is closed.

Results

Mean operative time (OT) was 219 min. Mean estimated blood loss (EBL) was 75 ml. One of the patients had an intraoperative cervix canal injury that was identified and repaired. The postoperative course was uneventful, and the mean length of hospital stay (LOS) was 1 day. A mean follow-up of 17 (±9.89) months showed no recurrence at cystoscopy or imaging evaluation.

Conclusions

Uterine-sparing VVF repair is feasible and safe. More studies are needed to assess equivalence compared with other procedures.