Laparoendoscopic single-site surgery (LESS) and conventional laparoscopic extravesical repair of vesicouterine fistula: single-center experience

Surgical repair of post-cesarean vesicouterine fistula: A systematic review and a plea for prevention

BACKGROUND

Vesicouterine fistula (VUF) is a iatrogenic injury in the vast majority of cases. The worldwide increase of cesarean delivery rates is expected to lead to increased complications.

OBJECTIVES

To assess current evidence on VUF pathogenesis and surgical management.

SEARCH STRATEGY

Pubmed and Embase databases were searched from January 2000 to January 2023 using relevant key words.

SELECTION CRITERIA

Only original articles including either transabdominal or transvaginal surgical routes for post-cesarean VUF repair, in English language, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the references for eligibility, data extraction, and assessment of methodologic quality. All available surgical outcomes were recorded.

MAIN RESULTS

Of the 1160 studies retrieved, 67 were selected for analysis. Most of these were case reports, case series, or observational cohort studies including a total of 284 patients. The majority (78.6%) of patients had more than one cesarean section, and approximately 10% of them experienced an overt bladder injury and/or uterine rupture at the time of cesarean delivery. The supratrigonal part of the bladder was most commonly involved (92.5%). The majority of patients (88.8%) underwent delayed VUF repair through laparotomy. Length of stay and blood loss were significantly less in patients treated via a minimally invasive approach (P < 0.001 and P = 0.02, respectively). Most patients had double-layer bladder repair and single-layer uterine repair. The overall success rate was 100% on first attempt for each independent combination of different surgical approaches and techniques. Live birth following VUF repair was reported in 23 patients.

CONCLUSIONS

Paying close attention to surgical details is crucial to reduce the incidence of this complication and recurrence rates. Double-layer bladder closure and delayed timing of repair of VUF are recommended.

Vesico-uterine Fistula Following C-section - A Case Report and Literature Review

BACKGROUND/AIM

Vesico-uterine fistulas represent a rare type of genito-urinary fistulas; however, due to the increasing incidence of Caesarean section (C-section) in the last decade, this abnormal communication between the urinary and genital tracts has been reported more often after such surgical procedures. The aim of the current article was to report the case of a 28-year-old patient who was submitted to surgery for a vesico-uterine fistula seven years after a C-section.

CASE REPORT

The 28-year-old patient with a previous history of four vaginal deliveries and one C-section was self-presented to the Gynecology Department for cyclic hematuria and diagnosed with a vesico-uterine fistula after injecting methylene blue in the uterine cavity during hysteroscopy. The patient was further submitted to surgery, and a parcelar myometrectomy en bloc with parcelar cystectomy, cystography, and prophylactic salpingectomy was performed. The postoperative outcome was uneventful.

CONCLUSION

Although vesico-uterine fistulas represent rare events, they should be considered, especially in young patients with a previous history of C-section.

Delayed presentation of postcaesarean section vesicouterine fistula repaired robotically

A premenopausal patient in her late forties presented with a 15-year history of urinary incontinence starting shortly after a caesarean section performed for her fourth delivery and more recently associated episodic light haematuria and passage of clots per vagina. The haematuria was intermittent over several months and associated with per-vaginal bleeding. She had symptomatic anaemia. Flexible cystoscopy and MRI showed a vesicouterine fistula. She underwent a robotic-assisted hysterectomy and multi-layered repair of the bladder with omental interposition. She remained in the hospital for 4 days, though recovered well and underwent catheter removal at 14 days following a normal cystogram. At 3 months, she was well with no incontinence or urinary symptoms. This case demonstrates the need for vigilance in assessing patients with persistent incontinence, particularly in the context of prior caesarean section. It highlights the feasibility of robotic surgery for correcting these defects in a society where minimally invasive surgery is becoming the norm, and cosmesis is a priority for patients.

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.

Vesicouterine Fistula (VUF) as a Rare Urogenital Complication Managed with Delayed Surgical Repair: A Case Report and Review of the Literature

Vesicouterine fistula (VUF) represents a rare urogenital complication. It is considered to be the least common type of urogenital fistulas. Iatrogenic reasons have been shown to be the most prominent cause, with lower segment caesarean section accounting for approximately two-thirds of the cases. The highest incidence concerns young females of reproductive age. VUF can present with clinical symptoms varying from cyclic hematuria, amenorrhea, and vaginal leakage of urine to secondary infertility and first-trimester abortion. Quality of life (QoL) for patients having this pathology is strongly affected due to the psychological burden. Surgical excision of the fistula remains the mainstay of treatment, as less than 5% of patients respond to conservative therapy. Recently laparoscopic and robotic-assisted VUF repair started gaining ground with comparable results to open surgery. Herein, we presented the successful delayed surgical repair of VUF in a 32-year-old female patient. A review of the published literature was also performed, summarizing all the available evidence regarding this rare clinical entity.

Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study

OBJECTIVES

To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies.

PATIENTS AND METHODS

Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics, and visual analog pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS).

RESULTS

Sixty patients were randomized into two equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy, and repair of retrocaval ureter. Operative time was 167 ± 24 and 145 ± 39 minutes in LESS and ML groups, respectively (p = 0.09). Estimated blood loss was 59 ± 34 and 43 ± 42 mL in both groups, respectively (p = 0.2). VAS was 1.7 ± 0.6 and 2.8 ± 0.5 in both groups, respectively (p = 0.02). PSAS and OSAS were 5.9 ± 0.85 and 10.6 ± 1.98 vs 8.9 ± 0.9 and 13.5 ± 6.3 in both groups, respectively (p > 0.05). There were no intraoperative complications, conversions to open surgery, or conventional laparoscopy in both groups. Mean postoperative Diclofenac Na was 151.7 ± 35.6 and 169.7 ± 47.3 mg in both groups, respectively (p = 0.04). Postoperative complications rate and hospital stay were comparable between both groups.

CONCLUSION

Both LESS and ML have comparable operative time, blood loss, complication rate, and hospital stay in treatment of upper urinary tract pathologies. However, LESS is associated with less analgesic requirement and better cosmetic outcome.

A Case of Type 2 Youssef's Syndrome following Caesarean Section for Placenta Previa Totalis

Vesicouterine fistula is a rare type of urogenital fistulas. It is most commonly observed after cesarean section (C/S) due to iatrogenic reasons. In this article, a case of a vesicouterine fistula which developed after C/S operation is presented. This was the patient's second C/S and this time placenta previa totalis was the primary pathology. Since it is a rare complication, we found it interesting, and, in this article, this clinical problem was discussed with details about diagnosis and treatment in light of the literature.

Management of genitourinary fistula

PURPOSE OF REVIEW

To review current literature on the management of genitourinary fistulae, specifically, the techniques for diagnosis, timing to repair, surgical approach and recent advancements in surgical technique.

RECENT FINDINGS

Recent advancement in minimally invasive surgery has prompted surgeons to perform fistula repairs with laparoscopic or robotic-assisted laparoscopic techniques. Whereas there is a role for transabdominal fistula closure, the majority of fistulae are still best approached via a transvaginal route.

SUMMARY

Genitourinary fistulae from obstetric trauma have received increased attention and funding to treat and prevent this devastating condition in developing countries. Despite multiple classification systems, a standardized classification that accurately identifies predictors of successful repair is lacking. In industrialized nations, genitourinary fistulae are rare and are most frequently associated with pelvic surgery, pelvic radiation, cancer or trauma. Surgical techniques to repair these fistulae have shifted from transabdominal laparotomy to minimally invasive laparoscopic procedures. Vascularized tissue flaps can play an important role in successful closure of complex fistulae. Despite advancements in surgical technology, overarching principles of fistula closure remain. The majority of fistulae can be closed through a transvaginal approach, with a tension-free, watertight, multilayer closure.

Vesicouterine fistula, a rare cause of genitourinary fistula

Uterovesical fistulas are rare genitourinary fistulas developing secondary to iatrogenic etiologies. In this article, we report a a post-cesarean vesicouteri fistula with review of the literature.