Fig. 30.1
Vesicovaginal fistula
VVFs occur 1–6 weeks after gynecological or obstetric surgery. Recurrent fistulas may develop within the first 3 months after primary repair [1]. Cronwell found the success rate was 88.1% after one operation, 81.9% after reoperation, and 68.9% after a second reoperation. The relative risk of needing an additional procedure after a second repair compared with after a first repair was 1.52 (95% CI 0.95–2.41; P = 0.086) [2]. Clinically, the patient presents with urinary incontinence, especially in the standing position. Pelvic exam with speculum has to be performed if there is suspicion of a VVF. Cystoscopy is imperative to assess the characteristics of the fistula and its relationship with the bladder and the ureteral orifices. The presence of a VVF can be confirmed with the instillation of methylene blue into the bladder, which will be present in the vagina. CT urography must be performed to rule out concomitant fistulas [3, 4]. Traditionally, surgical repair is delayed 3–6 months to decrease tissue inflammation and edema and increase the likelihood of success. Conversely, others advocate only waiting long enough to ensure reasonable tissue quality, with repair performed 2–4 weeks after the initial operation [5].
Traditionally, surgical approaches for VVF repair are vaginal or abdominal. Many urologists are relatively unfamiliar with vaginal cuff anatomy, making the transvaginal approach more challenging. For this reason, most urologists prefer the abdominal approach [6]. The selected approach depends on several factors including fistula size, number and location of fistulas, history of repair, and concomitant pathological conditions. An abdominal approach is usually preferred in patients with a large (>3 cm) fistula, supra-trigonal fistula, fistulas in close proximity to ureteric orifices, and especially in patients with complex fistulas or recurrent fistulas after failed transvaginal repair [7]. Fulguration of very small fistulas has been reported with good results [8, 9].
Nowadays, minimally invasive approaches to reconstructive surgery are commonplace. Nezhat et al. first reported retrovesical laparoscopic VVF repair in 1994 [10]. Since then, laparoscopic VVF repair has reported success rates of 86–100% [7]; however, the laparoscopic approach is technically difficult with a steep learning curve [4, 5, 9, 10].
Utilizing the technological advantages of the robotic platform, robotic VVF repair has shown excellent results, while following the basic surgical principles of fistula reconstruction [7, 11]. Robotic-assisted laparoscopic VVF repair was initially described by Melamud et al. in 2005 [11]. Later, Sundaram et al. described their technique in five cases [12]. Hemal et al. also described their technique for repair of recurrent supratrigonal VVFs [13]. All authors concluded that even recurrent supratrigonal fistulas could be repaired successfully with the robotic approach. Robotic surgery often mimics the open transperitoneal approach with creation of a cystotomy and the use of an interposition graft [7, 12–16]. Sotelo et al. [17] and Nunez et al. [18] described a transvesical approach that reaches the fistulous tract without the need for additional vaginal incisions or extensive dissection of the vesicovaginal space. This may potentially reduce the recurrence rate and irritative voiding symptoms. The critical step is the cystotomy to localize the tract. Once the fistula is reached, the vesicovaginal space is dissected, separating both structures.
Robotic Transperitoneal Transvesical Approach
Step 1: Patient positioning
After general anesthesia is administered, the patient is placed in a low lithotomy position.
Step 2: Cystoscopy and catheterization of the ureters and fistula
Cystoscopy is performed, and both ureters are cannulated with 5F ureteral catheters. This facilitates identification of the ureteral orifices and the course of the ureters. A differently colored ureteral catheter is introduced through the bladder, passed through the fistulous tract into the vagina, and retrieved at the introitus. For large fistulas, a Foley catheter can be used instead of a ureteral catheter. Fig. 30.2.
Step 3: Port placement
Access is obtained with the Hasson technique at the umbilicus with a cosmetic incision. A 10–12-mm port is inserted with a 30° down lens, offering improved visualization/angles, although a 0° lens can also be used. Two robotic 8-mm ports are placed symmetrically on the left and right pararectal lines. A fourth robotic port can be omitted, with the intention of minimizing scars. If it is necessary, a fourth port can placed cephalad to the iliac crest on the left side. A 5-mm assistant port is placed cephalad to the iliac crest on the right side between the lens and the 8-mm port. Puppet maneuvers can be applied for inner retraction.
Step 4: Creation of an omental flap, cystotomy, and dissection of the fistulous tract
A sponge retractor is inserted into the vagina via the introitus. This is then used to retract the vagina posteriorly. Once abdominal access has been achieved, the first step is lysis of adhesions. Next, an omental flap is created based on the right gastroepiploic artery. Dissection of the posterior bladder wall is then performed. A vertical bladder incision is made, creating a small cystotomy, in the direction of the fistula Fig. 30.3a. A cystoscope can be inserted into the vagina and used to provide endoscopic light guidance to the fistula. However, once the bladder is opened, the tract is usually easily visualized because it has been catheterized. The bladder incision is carried deep until the posterior aspect of the catheter and vaginal sponge retractor are exposed. The bladder walls can be retracted laterally to assist with exposure. Stiches are placed on either side of the cystotomy with a Keith needle or a Carter-Thomason device. The two ends of the stitch are anchored outside of the anterior abdominal wall, providing exposure of the fistula tract Fig. 30.3b. Once the communication between the vagina and bladder is apparent, the sponge retractor is withdrawn, and a Foley catheter is placed in the vagina. The balloon is inflated with 70 cc to prevent loss of pneumoperitoneum. Dissection is continued until the fistula is completely separated from the vagina. The fibrous tissue edges of the fistula are carefully excised with scissors Fig. 30.3c. Further dissection is performed to create flaps for adequate tension-free closure of the vagina and the bladder.
Step 5: Closure of the vagina and bladder and tissue interposition.
The vagina is closed horizontally with a running 2–0 monocryl or barbed suture on a CT-1 needle. A suture is then placed in the anterior wall of the vagina, distal to the closure. This is used to anchor the tissue that has been harvested for interposition – omentum, if available, or an epiploic appendix can be used Fig. 30.3d. The bladder is then closed vertically, beginning at the distal apex, with a running 2–0 monocryl or barbed suture on a CT-1 needle. A second layer closure incorporating the bladder serosa is performed with an absorbable suture Fig. 30.3e.
Step 6: Catheter placement.
The ureteral catheters are removed. A 20F urethral catheter is then inserted to maintain bladder drainage . The bladder is then filled with solution colored with methylene blue to confirm a watertight closure. A suprapubic cystostomy tube is not utilized. A drain is placed in the pelvis.
Fig. 30.2
Foley catheter can be used instead of a ureteral catheter to identified fistulous tract
Fig. 30.3
(a) Vertical bladder incision is made, creating a small cystotomy, in the direction of the fistula. (b) Exposure of the fistula tract. (c) Fibrous tissue edges of the fistula are carefully excised with scissors. (d) Interposition of omentum. (e) The bladder is then closed vertically
Postoperative Management
Immediate Care
Two or three additional doses of appropriate intravenous antibiotic
Prevention of urethral catheter obstruction
Irrigation of the bladder only if necessary
Outpatient Care
Drain removal in 2 to 3 days, depending on fluid characteristics
Urethral catheter removal 10 days postoperatively
Oral antibiotic of choice for 10 days
Sexual abstinence for 2 months
Patients are advised to not use tampons
Of note, this operation is often performed after a hysterectomy. VVF with a uterus present is rare and usually occurs after a c-section. The principles of repair are the same; however, it is critical that the bladder be opened first, without attempting to find the plane amid the bladder and the uterus, because of the risk of inadvertently opening the cervix canal. It is also critically important to adequately mobilize the vagina and bladder as much as possible to allow for a tension-free closure. This often requires closing the vagina longitudinally instead of transversally.
Ureterovaginal Fistulas
The incidence of ureteral injury during pelvic surgery is between 2% and 11% and most commonly occurs to the distal ureter during gynecological surgery [19, 20], potentially resulting in ureteral fistula formation. Nonsurgical causes of ureteral injuries are uncommon and include radiation, trauma, retroperitoneal fibrosis, and infection. The incidence of ureterovaginal fistulas due to obstetric causes varies from 5% in the developed world to 68–80% in the developing world. The incidence resulting from iatrogenic injuries during gynecological surgeries is estimated to be 0.5–2.5% [1, 19–22]. The mechanisms of injury include ureteral laceration, avulsion, partial or complete ligation, and ischemia.
The most common presentation is continuous urinary incontinence 1–4 weeks after surgery, similar to VVFs. It is important to distinguish between these because there can be a concomitant fistula in up to 12% of patients [20]. Complete obstruction of the ureter presents with incontinence. If there is partial obstruction of the ureter, urine follows the fistula tract and also partially fills the bladder Fig. 30.4a, b. This can be managed conservatively with stent insertion. Evaluation and diagnosis are made with physical examination, cystoscopy, CT scan, and retrograde pyelography/excretory urogram. Initial management with a ureteral stent, in cases of a patent ureter in continuity, has reported success rates of 55% [22, 23]. With short segmental defects, the success rate with stenting alone was as high as 71% in some series [24]. If ureteral stenting fails or leakage persists, surgical intervention is indicated. Ureteral reimplantation with a psoas hitch, Boari-flap, ileal ureteral substitution, or even auto-transplantation have been used as reliable options [25]. Yohannes et al. reported the first case of robotic ureteral reimplantation for ureteral stenosis after stone disease [26]. Studies focusing exclusively on robotic ureterovaginal fistula repair have been nearly absent.
Fig. 30.4
(a) Complete obstruction of the ureter presents with incontinence. (b) Partial obstruction of the ureter, urine follows the fistula tract and also partially fills the bladder
Ureteral Reimplantation
Step 1: Patient positioning and trocar placement
The patient is positioned in the dorsal lithotomy position. A 12-mm camera port is placed 5 cm above the umbilicus in the midline. Bilateral 8-mm robotic ports are placed along the midclavicular line 3 cm above the level of the umbilicus. A 5-mm assistant port is placed several centimeters above the right iliac crest. The da Vinci robotic system is brought between the patient’s legs, and the robot is docked.
Step 2: Ureter dissection
The hemicolon is mobilized along the line of Toldt until the psoas muscle is identified. The ureter is dissected in a caudal and cranial direction, with maintenance of its blood supply. The dissection is continued distally until the region of the ureteral lesion is located. The ureter is transected proximal to this fistulous segment.
Step 3: Bladder mobilization
The bladder is filled with 200 mL of saline. The lateral umbilical ligaments are ligated and transected, and the bladder is freed laterally. The urachus is cut with bipolar coagulation. The peritoneum is wiped off, and the dome of the bladder is mobilized until it can reach the psoas muscle without tension.
Step 4: Psoas hitch (optional: in case the ureter cannot reach the bladder)
The psoas muscle is exposed to create enough space for bladder suspension. The genitofemoral nerve is identified and preserved. The psoas hitch is performed with two sutures of 2–0 Vicryl to fix the detrusor to the psoas muscle without tension. These two sutures are placed 2 cm apart. The bladder dome is then incised. Two stay sutures are placed to keep the bladder dome open and anchored outside the abdominal wall.
Step 5: Submucosal tunnel preparation
A submucosal bladder tunnel is created by gently opening and closing the robotic scissors, starting from the level of the fixed bladder dome on the psoas muscle. Because the psoas hitch sutures are already tied, the bladder mucosa is stretched, which facilitates tunnel preparation. A mucosal patch is excised. Next, the pull-through maneuver is performed, in which the ureter is pulled through the submucosal tunnel with a 2–0 Vicryl suture tied at its end.
Step 6: Ureteroneocystostomy
The ureter is spatulated and anchored deep in the detrusor muscle with two sutures at the 5 and 7 o’clock positions. A nonrefluxing ureteroneocystostomy is created using 4–0 monocryl on a 3/8 needle. Four interrupted sutures are placed at the 6, 3, 9, and 12 o’clock positions. Once the anastomosis is completed, a 7F double-pigtail ureteral stent is placed. The bladder is closed in a T-shaped fashion to prevent leakage of urine at the bladder dome . The mucosa is closed with running 4–0 monocryl, and the detrusor is closed with running 2–0 Vicryl sutures. A 21F catheter and a drain are placed.
Postoperative Management
Immediate Care
Two or three additional doses of appropriate intravenous antibiotic
Prevention of urethral catheter obstruction
Outpatient Care
Drain removal in 2–3 days, depending on fluid characteristics
Urethral catheter removal 10 days postoperatively
Double-J stent removal 30 days postoperatively
Oral antibiotic of choice for 10 days
Rectourinary Fistulas
Rectourinary fistulas (RUF) include rectourethral, rectovesical, and enterourinary fistulas. These are rare and occur in men under several circumstances. Rectourethral fistulas are typically a consequence of prostate treatment for benign or malignant disease. Radical prostatectomy for the management of prostate cancer is the most common cause in modern series, with rates as high as 1% of RUF. The risk is increased in patients with a history of previous rectal surgery, pelvic radiation, or TURP (thransurethral resection of the prostate) [27, 28]. Rectourethral fistulas have been reported in approximately 0.3–3% of patients after brachytherapy [29] and 0–0.6% of patients after external bean radiation therapy [30]. The incidence of rectourethral fistulas after HIFU (High intensity focused ultrasound) is 2.2%, most commonly after salvage or repeated sessions of HIFU [31].
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