Urinary Abnormality Treated with Robot-Assisted Surgery

Robot-assisted laparoscopic surgery has been shown to be successful in reconstruction of recurrent supratrigonal fistulas between the bladder and the vagina.

Researchers from Wake Forest University Baptist Medical Center (Winston-Salem, NC, USA) and the All India Institute of Medical Sciences (New Delhi, India) operated on seven women who had previously undergone unsuccessful surgeries to repair vesicovaginal fistulas (VVFs) located in the supratrigonal region, between August 2006 and October 2007. The surgeons used the da Vinci surgical system, which has four robotic arms with centimeter-sized instruments attached, and a miniature camera that were inserted through five small incisions in the abdomen. Preliminary preparations included vaginoscopy and cystoscopy with bilateral Double-J stent and patient positioning in a low lithotomy position with a 60o Trendelenburg tilt. Difficulties were 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 researchers found that the average size of the supratrigonal VVFs was three cm. Mean operative time was 141 minutes (range 110-160), and mean hospital stay was three days. Mean blood loss was 90 cc, and no significant intraoperative or postoperative complications were observed. The catheter was removed 14 days postoperatively, and all patients had a successful outcome. The study was published in the September 2008 issue of the Journal of Urology.

"There was less blood loss with this procedure than with conventional surgery, and there is the potential for a faster recovery,” said lead author Ashok Hemal, M.D., director of the robotic and minimally invasive urologic surgery program at Wake Forest Baptist. "The results were outstanding, and suggest the robot-assisted surgery is an attractive option for fistulas that would normally require abdominal surgery.”

Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF) that allows the continuous involuntary discharge of urine into the vaginal vault. It is often caused by childbirth, when a prolonged labor presses the unborn child tightly against the pelvis, cutting off blood flow to the vesicovaginal wall. The affected tissue may necrotize, leaving a hole; it can also be associated with a Z hysterectomy. Vaginal fistulas can also result from violent rape, and has become common in some war zones, where rape is used as a weapon against civilian populations. VVFs are usually not repaired with manual laparoscopy since the physician must work at an extreme angle.

Related Links:
Wake Forest University Baptist Medical Center
All India Institute of Medical Sciences