Laparoscopic and Robotic-assisted Vesicovaginal Fistula Repair: A Systematic Review of the Literature

The burden of iatrogenic obstetric fistulas in Sub-Saharan Africa: Systematic review and meta-analysis protocol

BACKGROUND

Obstetric fistulas are abnormal open connection(s) between the vagina and the urinary tract or the rectum resulting from tragic injuries sustained by mothers during childbirth that lead to urine and/or faecal incontinence. Due to the rapidly growing middle class in sub-Saharan Africa (SSA) and the corresponding quest for hospital delivery and caesarean section, surgery-related (iatrogenic) obstetric fistulas are on the rise. Worryingly, there is scanty data on surgery-related fistulas. This review aims to collate empirical evidence on the magnitude of iatrogenic obstetric fistulas in SSA, generate country-specific data and explore factors that influence obstetric surgery-related fistulas.

METHODS

All relevant databases, PubMed, LILACS, CINAHL, SCOPUS and Google Scholar will be searched from 1st January 2000 to 31st March 2024 using search terms developed from the major concepts in the title without restrictions by language. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations Including Research (DATAD-R D Space) and preprint repositories will also be searched. Reference lists of relevant studies will be searched and experts in the field will be contacted for additional (unpublished) studies. The search output will be exported to Endnote where duplicate studies will be removed. The deduplicated studies will be exported to Rayyan where study screening and selection will be conducted. At least two authors will independently select studies, extract data and assess quality in the included studies using pretested tools. Disagreements between reviewers will be resolved through discussion. Data analysis will be performed with RevMan 5.4. Comparative binary outcomes will be reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference and standard deviations (SDs) will be used. Non-comparative studies will be analysed as weighted proportions. Heterogeneity between studies will be assessed graphically and statistically, and where a significant level is detected, the random-effects model meta-analysis will be performed. All estimates will be reported with their 95% confidence intervals (CIs). Where data permit, we will conduct subgroup and sensitivity analyses to test the robustness of the estimates on key quality domains. The overall quality of the evidence will be assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

EXPECTED STUDY OUTCOMES

This systematic review and meta-analysis uses rigorous methods and best practices to attempt to collate all empirical evidence and estimate country-specific proportions of iatrogenic (surgery-related) fistulas among obstetric fistula patients across countries in SSA. This review will explore context-specific variables, provide insights into their impact and relate them to the type and experience of personnel performing the obstetric procedures that lead to obstetric fistulas. The findings of the full review are expected to inform the development of national and regional Training Programs for Medical Officers, support the development of a consensus "minimum acceptable standard of care" and inform quality assurance standards for clinicians involved in the provision of surgical obstetric care.

Laparoscopic Uterine Preservation and Vaginal Reconstruction in a 13-Year-Old Girl with Uterus Didelphys, Bilateral Vesicovaginal Fistulas, and Transverse Vaginal Septum

BACKGROUND

Complex female genital tract malformations account for 1.2% of all female genitourinary malformations. Although exceedingly rare, they can cause severe gynecologic symptoms in young women and lead to fertility problems.

CASE

We present the case of a 13-year-old girl with primary amenorrhea referred for cyclic abdominal lower pain and menouria. Detailed diagnostics revealed uterus didelphys, transverse vaginal septum, and bilateral vesicovaginal fistulas. Laparoscopic left hemi-hysterectomy and salpingectomy were performed. The vesicovaginal fistula on the right side was excised, and the proximal vagina was anastomosed with the distal dimple. Since the operation, the patient has been pain-free and menstruating regularly from the right uterus.

SUMMARY AND CONCLUSION

Preservation of the uterus should be considered in any case of complex female genital tract malformation and, as successful laparoscopic treatment advocates, a minimally invasive approach is feasible.

Pneumovesical vesicovaginal fistula repair: Lessons learned from an initial series of 25 patients

OBJECTIVES

This study aims to share the experiences and outcomes of laparoscopic pneumovesical repair for vesicovaginal fistulas (VVF).

MATERIALS AND METHODS

A retrospective review of medical records from a single institution over 10 years was conducted. The focus was on patients who underwent VVF repair using a pneumovesical approach with three 5 mm laparoscopic ports. The study evaluated perioperative parameters, postoperative outcomes, and complication rates to assess the efficacy and safety of this surgical method. Cumulative sum (CUSUM) analysis was used to determine the learning curve based on operative time.

RESULTS

Of the 26 patients with VVF, 23 (88.5%) had successful fistula closure after the first surgery. One patient required open surgery conversion due to challenges in maintaining pneumovesicum, and two experienced recurrences, although successful repairs were achieved in subsequent surgeries. The average patient age was 47.4 years, with a mean operative time of 99.9 min. The postoperative hospital stay averaged 9.1 days, and catheterization lasted about 11 days. The CUSUM chart indicated a learning curve, with fluctuations until the 19th case, followed by a consistent upward pattern.

CONCLUSION

Laparoscopic pneumovesical VVF repair is an effective and safe technique, especially suitable for fistulas near the ureteral orifice or deep in the vaginal cavity. The method demonstrates favorable outcomes with minimal complications and allows for easy reoperation if necessary.

Vesicovaginal Fistula and Hydronephrosis Post-radiation for Cervical Cancer: Challenges and Strategies in Management

This report meticulously examines a complex case involving a vesicovaginal fistula (VVF) and hydronephrosis following radiation treatment for stage IV cervical cancer. It highlights the challenges and nuanced treatment strategies essential for addressing such complications, particularly given the patient's comprehensive medical background, including her cancer treatment and subsequent radiation therapy. Through an in-depth case study, the report details the diagnostic process, emphasizing the role of advanced imaging techniques and clinical evaluations in detecting a VVF along with hydronephrosis - illustrating the delayed adverse effects of radiation therapy. The treatment strategy employed a laparoscopic surgical technique, coupled with a carefully devised postoperative care plan focusing on hydration and anti-inflammatory measures to counteract radiation cystitis and prevent further issues. This narrative not only showcases the complex challenges of managing complications such as VVF and hydronephrosis post-radiation but also underlines the critical need for personalized, interdisciplinary care approaches. These approaches strive to effectively treat cancer while prioritizing the patient's quality of life. Furthermore, the report adds valuable insights to the ongoing dialogue on improving care for individuals facing the enduring impacts of cancer treatments. It argues for a comprehensive approach that includes preventive measures, prompt diagnostic procedures, and customized care strategies to improve the health and quality of life for cancer survivors.

Perioperative Outcomes of Vesicovaginal Fistula Repair by Surgical Approach

IMPORTANCE

Data comparing perioperative outcomes between transvaginal, transabdominal, and laparoscopic/robotic vesicovaginal fistula (VVF) repair are limited but are important for surgical planning and patient counseling.

OBJECTIVE

This study aimed to assess perioperative morbidity of VVF repair performed via various approaches.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent transvaginal, transabdominal, or laparoscopic/robotic VVF repair from 2009 to 2020. Associations of surgical approach with baseline characteristics, blood transfusion, prolonged hospitalization (>4 days), and 30-day outcomes (any major or minor complication or return to the operating room) were evaluated with χ 2 , Fisher exact, and Kruskal-Wallis tests. Multivariable logistic regression models assessed the adjusted association of approach with 30-day complications and prolonged hospitalization.

RESULTS

Overall, 449 women underwent VVF repair, including 252 transvaginal (56.1%), 148 transabdominal (33.0%), and 49 laparoscopic/robotic procedures (10.9%). Abdominal repair was associated with a longer length of hospitalization (median, 3 days vs 1 day transvaginal and laparoscopic/robotic; P < 0.001), higher risk of prolonged length of stay (abdominal, 21.1%; transvaginal, 4.0%; laparoscopic/robotic, 2.0%; P < 0.001), major complications (abdominal, 4.7%; transvaginal, 0.8%; laparoscopic/robotic, 0.0%; P = 0.03), and perioperative transfusion (abdominal, 5.0%; transvaginal, 0.0%; laparoscopic/robotic, 2.1%; P = 0.01). On multivariable analysis, the abdominal approach was independently associated with an increased risk of prolonged hospitalization compared with laparoscopic/robotic (odds ratio, 12.3; 95% confidence interval, 1.63-93.21; P = 0.02) and transvaginal (odds ratio, 6.09; 95% confidence interval, 2.87-12.92; P < 0.001) but not with major/minor complications ( P = 0.76).

CONCLUSION

Transvaginal and laparoscopic/robotic approaches to VVF repair are associated with lower rates of prolonged hospitalization, major complications, and readmission compared with a transabdominal approach.

Minimally invasive transvaginal single-port laparoscopic vesicovaginal fistula repair: a case report and the point of this technique

The optimal surgical method of vesicovaginal fistula (VVF) remains uncertain. Minimally invasive surgical approaches have become highly popular in line with technological advancements, namely, laparoscopic, robotic, and transvaginal techniques. However, these techniques still require invasiveness. This is the first case report that described a novel "zero-incision" technique for natural orifice transvaginal single-port laparoscopy used to repair a recurrent and high-position VVF. The patient underwent transvaginal single-port laparoscopic repair of a VVF. Methylene blue was used to locate the VVF, and a needle electrode was used to thoroughly remove the scar tissue of the VVF. In addition, this technique for transvaginal single-port laparoscopy provides more working space to expose and repair fistulas conveniently and adequately. One year after surgery, the patient remained asymptomatic and had no fistula recurrence. Minimally invasive transvaginal single-port laparoscopy provides a clear surgical field, is safe and feasible. This novel technique has promising as an additional personalized treatment option for VVF repair.

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques

INTRODUCTION AND OBJECTIVES

Almost two decades after the description of robotic vesicovaginal fistula repair (R-VVF), the literature remains limited. The aims of this study are to report the outcomes of R-VVF and to compare the transvesical versus extravesical techniques.

METHODS

We performed an observational, retrospective, multicenter study, including all patients who underwent R-VVF from March 2017 to September 2021 at four academic institutions. All abdominal VVF repair over the study period were performed using a robotic approach. The success of R-VVF was defined as the absence of clinical recurrence. The outcomes of the extravesical versus transvesical techniques were compared.

RESULTS

Twenty-two patients were included. The median age was 43 years old (IQR 38-50). Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. Five patients had undergone previous attempts of fistula repair (22.7%). The fistulous tract was systematically excised, and an interposition flap was used in all but two cases (90.9%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. There were four postoperative complications, three minor and one major. None of the patients had vesicovaginal fistula recurrence after a median follow-up of 15 months.

CONCLUSIONS

The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approaches yielded similar outcomes.

Quality of life, voiding & sexual dysfunction following robot-assisted vesicovaginal fistula repair: a tertiary care centre experience

Robot-assisted VVF (RA-VVF) repair has the advantage of small cystotomy, precise dissection and minimal surrounding tissue trauma. Translation of this to better functional outcomes is not studied so far. This study aims to evaluate the quality of life, voiding, and sexual dysfunction following robot-assisted VVF repair. Women with successful RA-VVF repair were screened using UDI-6, IIQ-7, FSFI, and WHOQOL-BREF questionnaires. The preoperative assessment was done in the prospective cohort only. Of the 75 women who underwent RA-VVF repair, 47 were enrolled, 33 in retrospective, and 14 in a prospective cohort. Overall, 28 (60%) women had urinary complaints with a median UDI-6 total score of 4 (0-100) and  IIQ-7 score (0-23) in 5 (10%) women. However, UDS (15 women) showed no DO with cystometric capacity (352 ± 98.12) ml and normal compliance in 14 (93%) women. Mean BOOI and DCI were 11.90 ± 7.01 and 44.25 ± 8.60 respectively, with PdetQmax ranging from 17 to 44. None had difficulty in voiding (Qmax 13.85 ± 4.90). Twenty (43%) women were sexually active, and 2 had sexual dysfunction (FSFI score < 26.55). Quality of life was "good" to "very good" in all domains (score > 90) except for the social domain. The prospective cohort showed significant improvement in UDI-6 score (p < 0.05), IIQ-7 score (p < 0.05), and quality of life (p < 0.05) postoperatively. RA-VVF repair results in minimal voiding dysfunction and significant improvement in overall quality of life. For sexual dysfunction assessment, a longer follow-up is required.

Vaginal-Laparoscopic Repair (VLR) of Primary and Persistent Vesico-Vaginal Fistula: Description of a New Technique and Surgical Outcomes

The main aim of our study was to describe the surgical technique and evaluate the feasibility, efficacy and safety of a vaginal-laparoscopic repair (VLR) of iatrogenic vesico-vaginal fistulae (VVF). Between April-2009 and November-2017, we retrospectively reviewed all clinical, radiological and surgical details of surgery for benign or malignant disease and ended up with VVF. All patients were diagnosed by CT urogram, cystogram and clinical test. The surgical technique was standardised and is described here. Eighteen patients developed VVF after hysterectomy, three after caesarean section and three after hysterectomy and pelvic lymphadenectomy. Twenty-two patients had an average 3 (range 1-5) attempts at fistula repair in other hospitals. In one patient, five attempts were made. The mean size of the fistula was 2.4 cm (range 0.7-3.1 cm). A median 8 weeks (6-16) conservative management with Foley catheter failed in all patients. No conversion to laparotomy and no complication occurred at VLR. Median hospitalisation was 1.4 days (range 1-3). The latter confirmed all patients were dry and tested negative at a repeated filling test. At 36 months follow-up, all patients remained dry. In conclusion, VLR successfully repaired VVF in all patients with primary and persistent VVF. The technique was safe and effective.

Vesicovaginal Fistula Repair by Transvaginal Route: Comparison of Resource Utilisation and Outcome with Literature Reported Population Matched Cohort of Patients Operated by Minimally Invasive Route

Introduction and Objectives

VVF is conventionally repaired by open transvaginal or transabdominal routes. In last few decades, minimally invasive techniques (laparoscopic/robotic) for VVF repair have gained popularity. We have reported our experience of transvaginal vesicovaginal fistula (VVF) repair and compared it with the literature reported population matched cohort of VVF repair done by laparoscopic or robot-assisted techniques.

Material and Methods

Intraoperative and post-operative parameters including aetiology of fistula, location, operative time, blood loss, major complications, hospital stay and success rate of 202 patients with simple VVF undergoing transvaginal repair at a tertiary care hospital from 1999 to 2019 were recorded. We also compared our transvaginal repair cohort (n = 202) with the literature reported cohort of 260 patients undergoing VVF repair by minimally invasive (laparoscopic and robot assisted) techniques in the systematic review by Miklos et al.

Results

Most common aetiology of VVF in our series was post hysterectomy in 122 (60.39%) cases followed by trauma during emergency caesareans section in 80 (39.60%) cases. Transvaginal route had higher success rate than minimally invasive approach (99.50 vs. 96.50%, respectively). Mean operative time was lesser in transvaginal group than the minimally invasive group (63 ± 16 min vs. 161.56 ± 41.02 min, p < 0.01) with shorter mean hospital stay in transvaginal group (3 ± 1 days vs. 3.5 ± 1.16 days, respectively, p < 0.01). Mean estimated blood loss was significantly lesser in transvaginal repair (p < 0.01). 62% patients were sexually active at last follow-up. The cost of transvaginal VVF repair is significantly lower compared to repair by minimally invasive approach.

Conclusion

Transvaginal VVF repair is comparable to minimally invasive approach in terms of post-operative outcomes and morbidity; however, transvaginal repair performs better in terms of cost and resource utilization.

Natural Orifice Transurethral Endoscopic Vesicovaginal Fistula (NOTE-VVF) Treatment for Early and Small Fistulas: Case Report and the Point of Technique

Minimally invasive surgical approaches have become highly popular in line with technological advancements. In vesicovaginal fistula (VVF) repair, numerous minimally invasive surgical techniques have been described, namely, laparoscopic, robotic, and transvaginal techniques, and used. However, these techniques still require invasiveness. In this report, we present a patient with iatrogenic VVF on whom we applied a novel “zero-incision” technique, Natural Orifice Transurethral Endoscopic Vesicovaginal Fistula (NOTE-VVF) treatment, to repair the fistula tract by advancing the laparoscopic trocar through a natural orifice, i.e., urethra. 

Complications After Vesicovaginal Fistula Repair Based on Surgeon Specialty in the United States: Analysis of a National Database

OBJECTIVES

This study aimed to compare the rates of major and minor complications for vesicovaginal fistula (VVF) repair based on surgeon specialty and to identify risk factors for adverse outcomes.

METHODS

This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program between the years 2014 and 2019. Cases were identified using Current Procedural Terminology codes for VVF repair. Minor and major complication rates for VVF repair were compared between 2 cohorts defined by surgeon specialty: gynecology versus urology. Additional outcomes included readmissions and reoperations. Multivariable logistic regression analysis was performed to investigate risk factors for complications.

RESULTS

A total of 319 VVF repairs were included in the analysis, of which 115 (36.1%) were performed by gynecologists and 204 (63.9%) by urologists. There were no significant differences in the demographic or medical characteristics between the gynecology and urology cohorts except for race. Gynecologists performed more concomitant hysterectomies (10.4% vs 1.0%, P < 0.001) and apical suspension procedures (6.1% vs 0%, P < 0.001). There were no differences in minor (7.8% vs 6.4%, P = 0.623) or major (2.6% vs 3.4%, P = 1.000) complications between the cohorts. The overall readmission rate was 4.7%, and the reoperation rate was 2.2% with no differences between specialties. On multivariable logistic regression analysis, body mass index and concurrent hysterectomy were risk factors for major or minor complications with no increased risk associated with surgeon specialty or route of surgery.

CONCLUSIONS

Complication rates did not differ for VVF repairs performed by gynecologists compared with urologists. Readmission and reoperation rates were low for both groups.

Benign Hepatic Tumors and Liver Transplantation: A Literature Review

Management of benign liver tumors represents still an open debate, with no clear guidelines for patient selection, treatment options, and indications to surgical intervention. Usually, most of these diseases are conservatively treated, in view of their low potential malignancy and incidental diagnosis. However, when the lesions are symptomatic, with a major hepatic parenchyma involvement or life-threatening complications, liver transplant represents the only curative option. The scope of this review is to present an up-to-date state of the art of transplantable benign hepatic neoplasms.

Contemporary Outcomes of Surgery for Primary and Recurrent Genitourinary Fistulae in a Well-resourced Country

Background

Urinary fistula (UF) is a global health problem but less common in well-resourced countries. Over the past decade there has been a trend toward managing UF in dedicated centres. Most of the evidence for surgical treatment is from individual case series, with few publications that involve high numbers. We describe the repair of recurrent and complex UF cases and outcomes in a tertiary referral setting.

Objective

To describe UF aetiology, repair techniques, and outcomes.

Design setting and participants

This is a retrospective study of a series of patients undergoing UF repair at a specialist unit.

Outcome measurements and statistical analysis

We describe the aetiology, cure rate, complications, and postoperative urinary incontinence rates for the series of UF cases.

Results and limitations

A consecutive series of 98 patients was identified, all of whom were tertiary referrals. Of these, 31 (31.6%) had at least one prior attempt at repair at another centre. The median age was 48 yr (interquartile range [IQR] 40-60.25). The median time from occurrence to repair was 12 mo (IQR 6-12). UF occurred most commonly following hysterectomy (48.0%), Caesarean section (9.2%), other gynaecological surgery (7.1%), and anti-incontinence surgery (7.1%). Complex fistulae (eg, repeat cases, radiation, ureteric involvement) comprised 41 of the cases (41.8%). Most patients with vesicovaginal fistula underwent repair via a transabdominal approach (70.4%). Tissue interposition was used in 96 cases (98%). There were no Clavien-Dindo grade >3 complications. Two patients (2%) had a persistent UF postoperatively. Two patients (2%) developed recurrence more than 2 yr after their initial repair, and both were successfully repaired at our centre. Twelve patients (12.3%) developed de novo overactive bladder, 22 (22.5%) developed stress urinary incontinence (13 had subsequent incontinence surgery), and two (2%) developed bladder pain (both had a subsequent cystectomy).

Conclusions

Despite a high rate of recurrent and complex UF, successful lasting closure was achieved in 96% of our cases. A minority of patients developed other problems such as de novo overactive bladder and stress urinary incontinence that may require further treatment.

Patient summary

Urinary fistula is an abnormal opening or connection in the urinary tract and is less common in well-resourced countries. As a consequence, management of this condition is more frequently undertaken at specialist units. Even patients with a complex fistula and those who have had multiple attempts at repair can experience a cure. Urinary leakage is a common complication after the operation but can be successfully managed with surgery.

Vesicouterine Fistula: A Robotic Approach

INTRODUCTION AND HYPOTHESIS

This video demonstrates surgical repair of a vesicouterine fistula via a robotic, uterine-sparing approach.

METHODS

In this video, we present a vesicouterine fistula, which occurred after cesarean delivery. The patient presented with cyclical hematuria 4 years following delivery. She underwent uterine-conserving robotic repair via excision of the fistula tract through an intentional cystotomy. The uterus and bladder were closed in multiple layers.

RESULTS

The patient tolerated the procedure well, and CT cystogram 6 weeks following surgery demonstrated no concern for defect or recurrent fistulization. The patient was asymptomatic 9 months following her procedure.

CONCLUSION

Repair of a vesicouterine fistula may be safely completed via a minimally invasive approach without need for routine hysterectomy.

Laparoscopic repair of vesicovaginal fistula caused by radiation therapy: Use of a perirectal fat interposition graft

INTRODUCTION

We present a case of laparoscopic repair of vesicovaginal fistula caused by radiation therapy using a perirectal fatty tissue interposition graft.

CASE PRESENTATION

A 72-year-old woman was diagnosed with vesicovaginal fistula induced by radiation therapy. Repair of the vesicovaginal fistula was achieved via laparoscopic approach. The fistula was exposed, followed by excision of fistula tract, fine dissection to achieve a traction-free approximation of bladder mucosa, then water-tight closure. An interposition graft derived from the perirectal fat was inserted to reduce the risk of repair failure. The patient did not have the incontinence problem at 1-year follow-up.

CONCLUSION

The laparoscopic approach for vesicovaginal fistula repair is minimally invasiveness. Preparation of the interposition graft derived from the perirectal fatty tissue was easy and its mobility to achieve closure of the fistula was acceptable. Thus, this procedure is feasible for the repair of poorly vascularized tissues such as radiation-induced fistulas.

Transvesical versus extravesical approach to laparoscopic posthysterectomy vesicovaginal fistula repair: A retrospective study from two medical centers

BACKGROUND

The controversy on the best surgical approach for vesicovaginal fistula (VVF) repair remains due to the scarcity of high-level evidences. We aim to analyze the efficacy and safety of the laparoscopic transvesical (LT) and laparoscopic extravesical (LE) approaches to posthysterectomy VVF (PH-VVF).

METHODS

Data of 64 patients with PH-VVFs who were laparoscopicly treated in the First Affiliated Hospital of Nanchang University and the Hangzhou Third Hospital from January 2011 to November 2019 were retrospectively collected. The operative time (OT), estimated bleeding volume (EBV), postoperative bladder function and complications, hospital stay length (HSL), surgery success rate, and recurrence were compared between the two groups.

RESULTS

In all, there were no significant differences in baseline characteristics between those two arms. Both approaches were successfully performed without open conversion in either group. The LT group was significantly corrected with a shorter mean OT than the LE group (p < 0.001), regardless of the fistula's position. No significant differences existed in the mean EBV and HSL between the two interventions (p = 0.136 and p = 0.210, respectively). The tendency of postoperative complications and success rates of surgery were also comparable in both groups. The patients in the LT group had similar bladder functions to those in LE group. The recurrence occurred in one patient in each arm during the follow-up periods of 12-36 months.

CONCLUSIONS

The LT approach is significantly related to a shorter OT than the LE approach without compromising the safety and success rates in repairing PH-VVF.

Vesicouterine fistula presenting with cyclical haematuria mimicking bladder endometriosis: A case report

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Vesicouterine fistula is pathological communication between the bladder and uterus or cervix.

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Symptoms of VUF were secondary amenorrhea and cyclic hematuria with history of previous cesarean section (concluded as Youssef’s syndrome).

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Surgical approach is contemplated as definitive management of the VUF following caesarean section.

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A group of women was able to have normal period after fistula repair.

Vesicouterine fistula (VUF) is an abnormal communication between the bladder and uterus, occurring 1–4% of all urogenital fistulas. Diagnosis is still a challenge because symptoms may appear late or fistula may be missed even after repeated examination. A 37-year old woman who has two children born through caesarean section complained of the absence of menstruation for the past three years. At the same time point, she experienced cyclic haematuria and amenorrhea. The diagnosis was made through ultrasonography, cystoscopy and hysteroscopy. She was then managed with laparoscopic bladder fistula repair continued with total laparoscopic hysterectomy. The VUF can present as an undesirable consequence of caesarean section.

Uptake and outcomes of robotic gynaecological surgery in England (2006-2018): an account of Hospital Episodes Statistics (HES)

This was a retrospective study to review the uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018, analysing Hospital Episode Statistics form National Health Service hospitals in England. Women aged 18 years and above who had elective gynaecological surgery were included and those who had undergone robotic gynaecology surgery were included. Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS healthcare regions. Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates were calculated by year and procedure type. Overall 527,217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in the uptake of robotic surgery but there was a marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate was 0.3% and 30-day emergency readmission rate was 4.7%. LOS was statistically, but not clinically, different across time. Other outcomes did not differ by year. Robotic gynaecological procedures are increasingly being used in the English NHS, predominantly for hysterectomy, although in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.

Laparoscopic transvesical vesicovaginal fistula repair with the least invasive way: Only three trocars and a limited posterior cystotomy

Objective

Two conventional approaches for vesicovaginal fistula (VVF) repair are transabdominal repair for supratrigonal VVF and transvaginal approach for low lying fistulae. Laparoscopic surgery was introduced to duplicate the surgical steps of the transabdominal approach with reduction in morbidity. We report a series of patients treated with a modified laparoscopic technique which includes the use of only three trocars and a limited posterior cystotomy.

Methods

We retrospectively reviewed the data of eight patients who underwent laparoscopic VVF repair with our standardized technique from January 2015 to April 2018. Only cases with a supratrigonal fistula were included. We constantly used only three trocars. A limited 2 cm midline posterior cystotomy was performed using ultrasonic energy. A stay suture on a straight needle was passed percutaneously in the abdomen, then on either side of the cystotomy and finally was exteriorized to maintain countertraction. The cystotomy was extended downwards to include the fistula site. The fistula was dissected circumferentially to raise the bladder and vaginal flaps. The vaginal defect was closed in a transverse fashion and the cystotomy was closed vertically.

Results

Mean operative time was 178±31.6 min and estimated blood loss was 60±18.7 mL. Flap interposition was performed in six cases. No intraoperative complications were recorded. Mean hospital stay was 2.25±0.89 days. During hospitalization two patients experienced postoperative complications (Clavien grade I). Mean follow-up was 20.9±11.1 months (6.0–39.0 months). All patients remained continent during the follow-up period.

Conclusions

This minimally invasive laparoscopic approach with only three trocars and limited posterior cystotomy provides excellent results with minimum morbidity.

Best Practices in Robotic-assisted Repair of Vesicovaginal Fistula: A Consensus Report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology

CONTEXT

Surgical repair of a vesicovaginal fistula (VVF) has been described extensively in the literature for several decades. Advances in robotic repair have been adopted since 2005.

OBJECTIVE

A consensus review of existing data based on published case series, expert opinion, and a survey monkey.

EVIDENCE ACQUISITION

This document summarizes the consensus group meeting and survey monkey results convened by the European Association of Urology Robotic Urology Section (ERUS) relating to the robotic management of VVF.

EVIDENCE SYNTHESIS

Current data underline the successful robotic repair of supratrigonal nonobstetric VVF. The panel recommends preoperative marking of the fistula by a guidewire or ureteral catheter, and placement of a protective ureteral JJ stent. An extravesical robotic approach usually provides a good anatomic view for adequate and wide dissection of the vesicovaginal space, as well as bladder and vaginal mobilization. Careful sharp dissection of fistula edges should be performed. Tension-free closure of the bladder is of utmost importance. Tissue interposition seems to be beneficial. The success rate of published series often reaches near 100%. An indwelling bladder catheter should be placed for about 10 d postoperatively.

CONCLUSIONS

When considering robotic repair for VVF, it is essential to establish the size, number, location, and etiology of the VVF. Robotic assistance facilitates dissection of the vesicovaginal space, harvesting of a well-vascularized tissue flap, and a tension-free closure of the bladder with low morbidity for the patient being operated in the deep pelvis with delicate anatomical structures.

PATIENT SUMMARY

Robotic repair of a vesicovaginal fistula can be applied safely with an excellent success rate and very low morbidity. This confirms the use of robotic surgery for vesicovaginal fistula repair, which is recommended in a consensus by the European Association of Urology Robotic Section Scientific Working Group for reconstructive urology.

The cost effectiveness of vaginal versus abdominal repair of vesicovaginal fistulae

Introduction and hypothesis

The objective was to assess the comparative provider costs of vaginal and open abdominal repair of vesicovaginal fistula (VVF) and to determine the most cost-effective means of managing VVF.

Methods

A prospectively acquired database of all women undergoing VVF repair by a single surgeon between 2007 and 2015 was retrospectively reviewed to determine operating time, perioperative complications, inpatient stay and 30-day readmissions. The success and cost of the VVF repair were identified. Statistical analysis was by unpaired t test, Chi-squared test and Mann–Whitney U test.

Results

Forty-seven consecutive women of mean age 51 years (range 21–88) undergoing a first attempt at VVF repair at our institution were included; 32(68%) had vaginal repair with Martius fat pad interposition and 15 (32%) had open abdominal repair with omental interposition. There were no perioperative complications or 30-day readmissions in either group. Mean operative time was longer for open abdominal (223.4 min) than vaginal repair (196.9 min). Median inpatient stay was longer for an open abdominal (8 days) than for a vaginal approach (4 days). Successful anatomical closure was achieved in 91% of vaginal and 86% of open abdominal repairs at first attempt, and in 100% after second repair, where required. Mean/median costs for an abdominal repair were significantly higher, at £4,608.69/£4,169.20 than for vaginal repair at £3,381.50/£3,009.24 (P<0.05).

Conclusions

Vesicovaginal fistulae were successfully repaired in 89% of cases at first attempt. The success rate did not differ between approaches. Vaginal repair is significantly more cost-effective than abdominal repair owing to the shorter operative time and length of stay.

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.

Robotic Repair of Supratrigonal Vesicovaginal Fistula with Sigmoid Epiploica Interposition

Introduction and Hypothesis:

In the United States, vesicovaginal fistula (VVF) most often results from gynecologic surgery causing significant morbidity and distress to both the patient and surgeon. The use of tissue interposition at time of primary repair has been advocated to decrease the risk of recurrence. The aim of this study is to describe our experience with interposition of sigmoid epiploica during robotic extravesical repair of supratrigonal VVF.

Methods:

This is a retrospective case series from June 2015 to September 2016. Features of the surgical technique include 1) cystoscopic ureteral catheterization, 2) cannulation of the fistula, 3) mobilization of the bladder from the vagina, 4) removal of the epithelialized edges of the fistulous tract, 5) single-layer closure of the vagina, 6) tension-free layered closure of the bladder, 7) retrograde fill of the bladder to ensure water-tight repair, 8) interposition of sigmoid epiploica appendage(s), and 9) prolonged bladder drainage with indwelling transurethral catheter.

Results:

In total, 5 women underwent successful robotic VVF repair with epiploic appendage interposition. Mean surgical time was 218 minutes with an average console time of 147 minutes and an estimated blood loss of 49 mL. Most the patients were discharged to home on postoperative day 1 with no untoward effects due to the epiploica interposition. There have been no recurrences to date.

Conclusions:

Robotic repair of VVF with sigmoid epiploica interposition is efficient and well tolerated. Use of this technique may increase the number of patients eligible for tissue interposition.

Vesicovaginal fistula: Review and recent trends

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Prompt diagnosis and timely repair are essential for successful management of these cases. As the clinical scenario is variable, it is difficult to frame uniform guidelines for the management of VVF. Hence, the management protocol is dependent on the treating surgeon and the available resources. Conservative methods should be used in carefully selected patients. Delayed repair is better than the early repair of VVF. Transvaginal route for repair is preferred as it has low morbidity, higher success rates, and minimal complications. Anticholinergics should be used in the postoperative period for better chance of bladder healing. When facilities are available, all the patients may be referred to a tertiary care center where expertise and advanced resources are available. Trained surgeons adapting the new trends should refine the art of VVF repair.

Laparoscopic repair of vesicovaginal fistulae with a transperitoneal approach at Universitas Gadjah Mada Urological Institute: a case report

BACKGROUND

A vesicovaginal fistula is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In addition, the sequelae from these fistulae have a profound effect on the patients in view of their physical, psychological, and social dimensions. The treatment of vesicovaginal fistula is surgical in most cases and the choice of the repair technique is controversial. We evaluated the benefits of a laparoscopic approach in a patient with vesicovaginal fistulae. Here, we present our first experience using a simplified laparoscopic approach technique to repair vesicovaginal fistulae in our country.

CASE PRESENTATION

A 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy 3 months earlier and received laparoscopic repair. A cystoscopy was performed to confirm the fistula orifice and a stent was inserted into the fistula tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina. She had adhesions; therefore, adhesiolysis was performed using a combination of sharp and blunt dissection to expose the vaginal stump and the superior aspect of her bladder. A simple cystotomy was performed and extended to include the fistulae site, and then the defect was repaired by using a running stitch. A second layer of closure was performed in an imbricating fashion with the same suture. The vagina defect was not closed separately but covered with an omental flap. This procedure takes approximately 2.5 hours; estimated blood loss was minimal and there were no intraoperative complications. She had no recurrent symptoms 6 months after surgery.

CONCLUSION

Our case report concludes that the simplified laparoscopic approach to vesicovaginal fistulae is a viable option for successful repair and that it reduces the size of bladder opening, causes minimal bleeding, and gives successful relief.

The choice of surgical approach in the treatment of vesico-vaginal fistulae

Vesico-vaginal fistula is a global healthcare problem that has a high prevalence in sub-Saharan Africa, where obstetric complications lead to the development of this condition. Despite this, comparatively few fistula repairs are performed in well-resourced countries, where iatrogenic injury is the leading aetiological factor. As a consequence, much of our knowledge results from the experience of relatively few fistula surgeons in areas of high prevalence borne out of large case series or retrospective cohorts rather than high level evidence. At present, debate surrounds the exact timing of repair and the most appropriate surgical approach for this condition. Certain fistulae can be selected for conservative management, while those that do not demonstrate factors associated with spontaneous closure can be selected for surgery. Fistula surgeons should be aware of several potential repair options and the principles of contemporary fistula surgery, as the first attempt at repair is likely to be the best opportunity to achieve a successful outcome. We review the available literature and provide evidence on the optimal timing of repair, the appropriate surgical approach and the use of tissue interpositioning in fistula surgery.

Laparoscopic Approach for Intravesical Surgery Using Pneumovesicum in Urology: Literature Review

Minimally invasive laparoscopic surgical procedures are increasingly being used in the management of various urological diseases. In particular, the laparoscopic approach for intravesical surgery using pneumovesicum (LPV) is a minimally invasive alternative with potential advantages including decreased morbidity, shorter hospital stays, and improved cosmesis. We review the applications of LPV in urology, summarize data for different surgical approaches, and provide an overview of patient management, as well as other considerations. This narrative review focused primarily on articles indexed in PubMed, Google Scholar, Scopus, and Embase databases. No formal search strategy was used, and no meta-analysis of data was performed.

State of the Art for Treatment of Vesicovaginal Fistula

BACKGROUND

Vesico-vaginal fistulae (VVF) remain the most prevalent genitourinary fistula detrimentally impacting quality of life.

PURPOSE OF THE REVIEW

The purpose of this review is to examine relevant literature on management of VVF.

RECENT FINDINGS

Obstructed labor is the leading cause of VVF in the developing world with most repairs performed via the transvaginal approach. Conversely, the predominate etiology in industrialized nations is iatrogenic injury with an increasing trend towards abdominal repair via a minimally invasive (laparoscopic and robotic) approach. No studies have compared transvaginal repair to minimally invasive transabdominal approaches. Further, an increasing number of authors have developed algorithms to determine optimum surgical approaches and risk factors for persistent incontinence. As surgeons become more facile with laparoscopic and robotic skills, there is a growing trend for minimally invasive surgical management of VVF in developed countries, perhaps widening the disparity gap between developing nations where transvaginal approaches predominate with good success. Further studies are needed to compare transvaginal to minimally invasive transabdominal approaches.

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.

The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review

CONTEXT

Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series.

OBJECTIVE

We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide.

EVIDENCE ACQUISITION

We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries.

EVIDENCE SYNTHESIS

Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176).

CONCLUSIONS

It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful.

PATIENT SUMMARY

Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

Robotic repair of a vesicovaginal fistula in an irradiated field using a dehydrated amniotic allograft as an interposition patch

We report the case of a 66 year old female with a supratrigonal vesicovaginal fistula (VVF) that developed after undergoing radical hysterectomy, chemotherapy and pelvic radiation therapy for advanced cervical cancer. VVF repairs in an irradiated field are known to be complicated procedures with significant morbidity and a high rate of failure due to the effect of radiation. Amniotic membranes have been demonstrated to improve healing rates in difficult to heal wounds. To decrease morbidity a minimally invasive robotic procedure was performed and a dehydrated amniotic allograft patch was used to augment tissue healing. The VVF was repaired using the da Vinci Surgical System and the amniotic membrane was used as an interposition patch over the repair. There were no operative or postoperative complications and the patient was discharged home on postoperative day one. A cystogram performed 3 weeks postoperatively demonstrated a healed fistula. Follow-up at 5 months revealed no incontinence. This is the first reported case of a robotic VVF repair performed in an irradiated pelvis and the first use of an amniotic membrane allograft in the repair a VVF.