For robotic laparoscopic rectovesical fistula repair with a combined retrovesical and transvesical approach, the patient is initially positioned in dorsal lithotomy position for cystoscopy and passage of a nonconductive wire (or ureteral catheter) through the fistula into the rectum to help later identify the fistula tract intraoperatively.

The bladder is entered transurethrally with a 22 F ridged cystoscope and 30° lens. Both ureteral orifices are identified as well as the fistula tract. A 6 F double J ureteral stent is placed into each ureter over a guidewire. Care is taken to place an appropriately sized stent to prevent the coil from obscuring the fistula site. This measurement is performed by using an end hole catheter to determine the distance from the ureteral orifice to the ureteropelvic junction. Two centimeters are subtracted from this measurement to choose the appropriate stent length. The placement of open-ended ureteral catheters is not optimal as they would obscure visualization of the fistula.

A nonconductive hydrophilic wire is then passed through the fistula tract cystoscopically. The surgeon’s finger is placed into the rectum to pull the wire out and clamp it to the urethral end of the wire to achieve through-and-through access across the fistula tract. The external portion of the nonconductive wire is wrapped in a sterile towel, as this will be within the field during the robotic portion of the procedure. The patient is then undraped and repositioned as seen in Fig. 18.​2 in the supine split leg position. Refer to the section on patient positioning for specific directions on safely positioning the patient. An 18 F urethral catheter is placed transurethrally into the bladder on the sterile field.

Pneumoperitoneum is generally established with the Veress needle or alternatively the Hassan technique if there is concern for abdominal wall adhesions from prior surgery. The Veress needle is placed in the midline just below the umbilicus. Once sufficient insufflation to 15 mmHg is obtained, a 12-mm camera port is placed with a visual obturator and 0° camera lens just superior to the umbilicus, taking care to stay within 17 cm above the pubis as the robotic instruments are limited to a working length of 25 cm. Once inside the abdomen, the Veress needle is identified and removed. Inspection of the surroundings for injury secondary to Veress needle placement or bowel adhesions is quickly performed. The remaining trocars are placed under laparoscopic vision.

As shown in Fig. 18.​3, a total of six trocars, including the camera port, are used: one 12 mm trocar for the camera, three 8 mm metal robotic trocars for the robotic arms, and a 5 and 12 mm trocar on the patient’s right side for the assistant ports. Refer to the section on trocar configuration for specifics regarding trocar location.

Prior to making incisions for the robotic and assistant trocars, insufflation to 15 mmHg is established, 0.25% Marcaine is injected at each site, and the trocars are placed. Care is taken to adjust the assistant trocars based on the patient’s body habitus to give the assistant a straight access to the pelvis. If the 12 mm assistant trocar is placed too laterally, there will be difficulty working along the ipsilateral side of the patient within the pelvis. Also, the 5 mm assistant trocar must be placed cephalad enough to allow the assistant to use both the 12 and 5 mm ports simultaneously without clashing with the external robotic arms. In many patients, the 5 mm assistant trocar will be within a several centimeters of the costal margin.

Once the trocars are placed, the patient is placed in a steep Trendelenburg position . The robot is moved into position between the patient’s legs taking care to bring the base of the robot in close enough so that the camera port is within the working limits. Next, the robotic arms and instruments are inserted as well as a 30° lens in a downward configuration. The monopolar scissors are placed in the first robotic arm while the bipolar forceps are inserted into the left robotic arm. Both monopolar and bipolar electrocautery are set at 45 W throughout the procedure.

The initial step, after abdominal access, is mobilization of the omentum. Any adhesions between the omentum and the anterior abdominal wall or small bowel segments are lysed. Care must be taken to preserve the distal omentum and its blood supply for later use as a vascularized flap for interposition. A long tag suture may be placed in a dependent portion of the omentum to assist in bringing the omentum down to the pelvis when needed for interposition between the bladder and rectum.

Next, attention is turned to the pelvis and the fourth arm is used to retract any redundant colon or small bowel that is lying in the pelvis. Adequate lysis of any adhesions may be necessary at this point to allow good mobility of bowel structures out of the pelvis.