Laparoscopic repair of vesicovaginal fistula

Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience

INTRODUCTION AND HYPOTHESIS

Laparoscopic repair of different female genitourinary fistulae has been recently reported, including both conventional and laparoendoscopic single-site surgery (LESS). We present our 10-year single-center experience of the laparoscopic repair of different types of female genitourinary fistulae.

METHODS

A retrospective analysis of our records over the last 10 years was performed. Type of fistula, etiology, laparoscopic approach, operative data, postoperative outcome, and follow-up were recorded.

RESULTS

Overall, 46 patients with laparoscopic repair of genitourinary fistulae were reported: 25 had vesicovaginal fistulae (VVF), 14 had vesicouterine fistulae (VUF), and 7 had ureterovaginal fistulae (UVF). Thirty-three patients had conventional laparoscopic repair, whereas 7 VVF and 6 VUF had LESS repair. In all patients with VVF and VUF, extravesical repair was carried out by excising the fistulous tract and closing both the bladder and the vagina or the uterus with interposing tissue in-between. In patients with UVF, extravesical ureteric re-implantation was performed. Mean operative time was 176 ± 25 min. Mean blood loss was 105 ± 25 cc. No intraoperative or postoperative complications occurred. None was converted to open surgery. Mean postoperative hospital stay was 3.2 ± 1.2 days. After a mean follow-up of 6.3 ± 3.1 years, all patients had undergone successful repair, except for one patient with complex VVF.

CONCLUSIONS

Laparoscopic repair of VVF, VUF, and UVF is a feasible procedure with a high success rate and low morbidity. LESS repair of VVF and VUF has a comparable success rate to conventional laparoscopy, but with a shorter hospital stay and fewer analgesic requirements.

Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis

Background

Vesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery.

Objective

To carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs.

Methods

PubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).

Results

We reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively.

Conclusions

Although the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

Comparative analysis of outcome between laparoscopic versus open surgical repair for vesico-vaginal fistula

Objective

Vesicovaginal fistula (VVF) causes detrimental psychosomatic effects on a woman. It is repaired using open abdominal as well as laparoscopic approach. Here we compare a series of open versus laparoscopic VVF repairs done at a single centre.

Methods

Retrospectively data of patients undergoing VVF repair in our department between January 2011 to December 2014 was analyzed. Patients who had a single, primary, simple VVF following a gynaecological surgery were included in the study. 26 patients met all the criteria. Out of these, thirteen patients had undergone a laparoscopic VVF repair (group 1) while thirteen had undergone an open transabdominal VVF repair (group 2).

Results

Mean fistula size was 2.14±0.23 cm in group 1 and 2.18±0.30 cm in group 2, which was comparable. Mean blood loss was 58.69±6.48 mL in group 1 and 147.30±19.24 mL in group 2, which is statistically significant (P<0.0001). Mean hospital stay was 4 days in group 1 and 13 days in group 2 which is statistically significant (P<0.0001). The analgesic requirement (diclofenac) was 261.53±29.95 mg in group 1 and 617.30±34.43 mg in group 2, which is statistically significant (P<0.0001). Fistula repair was successful in all the patients in both the groups.

Conclusion

The present study shows that laparoscopic VVF repair results in reduced patient morbidity and shorter hospital stay without compromising the results. So laparoscopic repair may be a more attractive treatment option for patients with post gynecology surgery VVF.

Laparoscopic vesicovaginal fistula repair: report of five cases, literature review, and pooling analysis

OBJECTIVE

This study assessed the safety and efficacy of laparoscopic repair of vesicovaginal fistula (VVF) by literature review and pooling analysis, and this is the first report of the experience of using this approach in a patient with a history of radiotherapy.

SUBJECTS AND METHODS

Five patients with VVF, including one with a history of cervical cancer and radiation, underwent laparoscopic repair from August 2010 to December 2011 performed by the same experienced surgeon.

RESULTS

The surgical procedure was uneventful in all of the patients, and no conversion to open surgery was required. Mean operation time was 134 minutes (range, 100-185 minutes). Mean blood loss was 300 mL (range, 250-370 mL), and no one required blood transfusion. Mean hospital stay was 4 days (range, 3-6 days). Laparoscopic repair was successful in 4 patients at the mean follow-up period of 8 months (range, 2-15 months), even in the patient with a history of radiotherapy. VVF recurred in 1 subject, who underwent repeat laparoscopic repair, and 2-month follow-up revealed no fistula.

CONCLUSIONS

Laparoscopic surgery may be a good alternative to the open approach to manage even complicated VVF if it is performed by skilled surgeons.

Current trends in minimally invasive reconstructive urology

This paper is a systematic review of the current literature in minimally invasive reconstructive urological surgery. It focuses on the commonest reconstructive procedures in both the upper and lower urinary tracts including laparoscopic and robotic pyeloplasty for ureteropelvic junction obstruction, laparoscopic and robotic bladder diverticulectomy, laparoscopic and robotic partial cystectomy with urinary diversion, laparoscopic and robotic cystoplasty, repair of colovesical fistula, and, in urogynaecology, repair of vesicovaginal fistula. To evaluate the development, current status, feasibility, and safety of minimally invasive surgery (MIS) in reconstructive urology the literature on the topic was collated and reviewed.

Laparoscopic transabdominal transvesical repair of supratrigonal vesicovaginal fistula

INTRODUCTION AND HYPOTHESIS

We investigated the clinical efficacy of early laparoscopic repair of supratrigonal vesicovaginal fistula.

METHODS

Laparoscopic repair of vesicovaginal fistula was performed and retrospectively studied in 18 consecutive patients who had clear indications for iatrogenic supratrigonal vesicovaginal fistula following hysterectomy or obstetric trauma during delivery. All patients underwent laparoscopic surgery via the transabdominal transvesical route. Wide mobilization of the bladder and vaginal wall, complete excision of devitalized tissue, tension-free closure, omental interposition, and efficient postoperative bladder drainage provides dependable support for definitive closure of the path. Success was defined as the disappearance of the fistula.

RESULTS

Average patient age was 36.7 years; none required open conversion. Mean operative time was 135 (range 75-175) min. Mean duration of bladder catheterization was 15 (range 14-16) days. All patients were cured at the first attempt, with no surgical reintervention or recurrence at a mean follow-up of 22.7 (range 3-45) months.

CONCLUSIONS

We believe that laparoscopic repair of supratrigonal vesicovaginal fistula is an excellent alternative to the traditional abdominal approach and provides excellent results.

[Laparoscopic repair of vesico-vaginal fistula without intentional cystotomy and guided by vaginal transillumination]

OBJECTIVES

Repair of vesico-vaginal fistula (VVF) by laparoscopy provides excellent exposure, which facilitates their implementation through small cystotomy. In some cases is difficult to locate the fistula without the prior opening of the bladder. We present a maneuver using vaginal transillumination to locate the fistula and to reduce the size of the opening bladder during laparoscopic repair without intentional cystotomy.

MATERIAL AND METHODS

A total of 4 patients with supra-trigonal FVV produced post-hysterectomy received laparoscopic repair. All patients underwent physical examination, dye test, urethrocystoscopy and intravenous pyelography. Fistula was located using a cystoscope inserted through vagina and placed over the fistula. The emitted light guide laparoscopic dissection in to the plane between the vagina and the bladder just above the fistula, without previous intentional cystotomy.

RESULTS

The mean age of patients was 42 (38-47) years. Bladder opening size did not reach 2cm. The mean operative time was 160 (120-186) minutes and catheterization time was 10 days. There were no recurrences.

CONCLUSIONS

The laparoscopic repair of VVF without intentional cystotomy, by direct dissection of the fistulous tract guided by vaginal transillumination is effective; because it quickly locates the fistula in all cases, reduces the size of the bladder opening, shortens operative times and reduces irritative symptoms.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Immediate laparoscopic nontransvesical repair without omental interposition for vesicovaginal fistula developing after total abdominal hysterectomy

BACKGROUND AND OBJECTIVE

We conducted this study to evaluate the feasibility and efficacy of immediate laparoscopic nontransvesical repair without omental interposition for vesicovaginal fistula (VVF) developing after total abdominal hysterectomy (TAH), which causes not only social and economic misery for the patient but also considerable stress to the physicians who perform the surgery.

METHODS

We performed a retrospective review of 5 women who underwent immediate laparoscopic nontransvesical repair without omental interposition for VVFs, developing after TAH from October 2007 to March 2009. In terms of laparoscopic procedure, cystoscopy was performed to confirm the location of fistula and ureteral openings, initially. Without opening the bladder, the fistula tract was identified, and the bladder was dissected from the vagina. The bladder defect was closed by using intracorporeal, continuous, and double-layer suturing, laparoscopically. The vaginal defect was closed using interrupted and single-layer suturing, vaginally. A Foley catheter was inserted for 2 weeks and removed after bladder integrity was confirmed with a retrograde cystogram.

RESULTS

The median age and body mass index of the patients were 47 years and 22.3 kg/m², respectively. Operating time, hemoglobin change, and hospital stay were 95 minutes, 1.1 g/dL, and 5 days, respectively. There were no complications or laparoconversions. During follow-up (median 56.1 weeks; range 26.6 to 74.0), there was no evidence of recurrence.

CONCLUSIONS

Immediate laparoscopic nontransvesical repair without omental interposition might be an effective, feasible alternative to the traditional methods in select patients with small sized (<1 cm) VVF developing after TAH.

Lower urinary tract fistula: the minimally invasive approach

PURPOSE OF REVIEW

A variety of fistulas occur involving the lower urinary tract with adjacent organs namely the vagina, uterus, rectum and colon. Most of these arise out of surgical complications and contribute significantly to the morbidity of the procedures. Surgical reconstruction remains the mainstay in the management. This article reviews the use of minimal-access procedures in reconstruction of lower urinary tract fistulas focusing on the bladder.

RECENT FINDINGS

Recently, numerous reports of laparoscopic and robot-assisted surgical repair of these fistulas have shown that these techniques can be used with efficacy and safety with added advantages of short hospital stay, reduced morbidity associated with surgical incision and lower blood loss. Robot-assisted surgery has the advantage of facilitating intracorporeal suturing, making laparoscopic reconstruction easier. However, the steep learning curve and the high cost of robotic surgery are limiting factors.

SUMMARY

Prevention of lower urinary tract fistula requires improvement in the quality and technique of surgery and minimizing surgical errors. Minimal access procedures offer surgical treatment with low morbidity but with higher cost. Open surgical repair is being used widely for treating these fistulas at this time, worldwide.