Robotic-assisted laparoscopic repair of a vesicovaginal fistula: a time-consuming novelty or an effective tool?

Advancements in robotic surgery: innovations, challenges and future prospects

The use of robots has revolutionized healthcare, wherein further innovations have led to improved precision and accuracy. Conceived in the late 1960s, robot-assisted surgeries have evolved to become an integral part of various surgical specialties. Modern robotic surgical systems are equipped with highly dexterous arms and miniaturized instruments that reduce tremors and enable delicate maneuvers. Implementation of advanced materials and designs along with the integration of imaging and visualization technologies have enhanced surgical accuracy and made robots safer and more adaptable to various procedures. Further, the haptic feedback system allows surgeons to determine the consistency of the tissues they are operating upon, without physical contact, thereby preventing injuries due to the application of excess force. With the implementation of teleoperation, surgeons can now overcome geographical limitations and provide specialized healthcare remotely. The use of artificial intelligence (AI) and machine learning (ML) aids in surgical decision-making by improving the recognition of minute and complex anatomical structures. All these advancements have led to faster recovery and fewer complications in patients. However, the substantial cost of robotic systems, their maintenance, the size of the systems and proper surgeon training pose major challenges. Nevertheless, with future advancements such as AI-driven automation, nanorobots, microscopic incision surgeries, semi-automated telerobotic systems, and the impact of 5G connectivity on remote surgery, the growth curve of robotic surgery points to innovation and stands as a testament to the persistent pursuit of progress in healthcare.

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.

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.

Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study

PURPOSE

To assess the outcomes of continent urinary diversion according to the Mitrofanoff principle by robot-assisted laparoscopic surgery in terms of continence, catheterization and repeat surgery.

METHODS

All adult patients who underwent procedures for continent urinary diversion via a robot-assisted laparoscopic route between October 2014 and November 2018 were enrolled retrospectively. Abdominal continence and clean intermittent catheterization ability were noted, as well as patient characteristics, details of the technique, intra- and perioperative parameters, and complications.

RESULTS

Ten patients were included. Bladder-sphincter disorders were due to neurological causes in nine patients, and one patient had idiopathic bladder sphincter dyssynergia. A continent catheterizable channel was created using the appendix in six cases and the ileum in four cases. The median operative duration was 245 min (IQR 228-370). Two patients had a Clavien 3 complication requiring laparoscopy to separately drain a haematoma and a pelvic abscess. The median follow-up was 21 months (IQR 17-27). Abdominal continence without further intervention was obtained in 6/10 patients (60%). Two patients needed an open revision of the continent urinary diversion, one required injection of Deflux^® and one an intradetrusorian injection of botulinum toxin type A (Botox^®). Further surgery was needed for two patients to improve urethral continence. At the end of follow-up, all patients were continent and clean intermittent catheterization was possible.

CONCLUSION

Continent urinary diversion performed according to the Mitrofanoff principle is possible via a robot-assisted laparoscopic route and yields good outcomes on abdominal continence in the short term in patients with clean intermittent catheterization ability.

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.

Feasibility of Transvesical Robotic VVF Repair in Porcine Model

Extraperitoneal transvesicoscopic vesicovaginal fistula (VVF) repair has received limited use because of its narrow working space, longer operation time, and technical difficulty. The present study describes the feasibility of robotic-assisted transvesicoscopic VVF repair in an animal model. Two Yorkshire swine underwent robotic-assisted laparoscopic (RAL) VVF repair. With the 4 trocars, an artificial VVF was made in the supratrigonal area and VVF repair was performed in 3 layers as in open VVF repair methods. The mean operation time was 108 minutes. The operation time was prolonged in 1 case due to weak fixation of bladder to anterior abdominal wall. Equipment interference did not occur. Tissue manipulation and suturing were easy. The results of this study suggest that extraperitoneal RAL procedures for VVF repair may be an effective minimally invasive modality with reduced morbidity. A shorter operation time and easy suturing technique were the distinct merits of the extraperitoneal RAL technique.

Robotic-assisted vesicovaginal fistula repair using an extravesical approach without interposition grafting

BACKGROUND

Post-hysterectomy vesicovaginal fistula (VVF) is rare. In addition to conventional abdominal and vaginal approaches, robotic-assisted VVF repairs have recently been described. We present a case of an extravesical, robotic-assisted VVF repair, without placement of an interposition graft performed in a Canadian teaching center.

CASE

A 51-year-old woman presented with urinary incontinence 5 days after laparoscopic hysterectomy. Computed tomography cystogram, cystoscopy, and methylene blue dye test, confirmed a VVF above the bladder trigone. The patient underwent a robotic-assisted VVF repair 3 months after presentation, without complication. An abdominal, extravesical approach was used. Operative time was 116 min and repeat CT cystogram showed no evidence of persistent.

CONCLUSION

We have demonstrated that a VVF repair, using a robotic-assisted, extravesical approach without interposition graft placement, can be safe, less invasive and have a successful outcome at 1 year of follow-up.

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.

Genitourinary Fistula: An Indian Perspective

BACKGROUND

In developing countries, obstetric trauma is the most common cause of genitourinary fistulae. But over the last two decades, health care facilities have been improved and the scenario has been changed.

PURPOSE

The aim of the present study is to share our experience with genitourinary fistula in terms of mode of presentation, diagnostic modality, and management with the emphasis on the surgical approach and a parallel review of the available literature.

MATERIALS AND METHOD

During a 6-year period from January 2007 to December 2013, 41 cases of genitourinary fistula, who admitted and treated in the urology department of a tertiary care center, were retrospectively analyzed for etiology, site, size and number of fistulae, clinical presentation, diagnostic modalities, and management. The literature search was done using the Medline database.

RESULT

Mean age of the patient was 27 years (range 16-51). Primary and simple fistulae were common. Obstetric trauma was the most common etiology (56.09 %) followed by iatrogenic (39.03 %). Vesicovaginal fistula was the most common type (78.37 %) and trigone was the most common site involved (51.72 %). 51.35 % of patients were approached successfully by the vaginal route. Ancillary procedures were required in patients for various other associated anomalies at the time of fistula repair. The success rate on follow up was 94.5 %. In the mean follow up of 3 years, 35 patients were sexually active.

CONCLUSION

Genitourinary fistula is a frustrating entity with potentially devastating psychosocial consequence. Its management poses a tricky challenge to the surgeon. Accurate and timely diagnosis, adhering on basic surgical principle, and repair by an experienced surgeon provide the optimum chance of cure.

Robotic surgery in gynecology

FDA approved Da Vinci Surgical System in 2005 for gynecological surgery. It has been rapidly adopted and it has already assumed an important position at various centers where this is available. It comprises of three components: A surgeon's console, a patient-side cart with four robotic arms and a high-definition three-dimensional (3D) vision system. In this review we have discussed various robotic-assisted laparoscopic benign gynecological procedures like myomectomy, hysterectomy, endometriosis, tubal anastomosis and sacrocolpopexy. A PubMed search was done and relevant published studies were reviewed. Surgeries that can have future applications are also mentioned. At present most studies do not give significant advantage over conventional laparoscopic surgery in benign gynecological disease. However robotics do give an edge in more complex surgeries. The conversion rate to open surgery is lesser with robotic assistance when compared to laparoscopy. For myomectomy surgery, Endo wrist movement of robotic instrument allows better and precise suturing than conventional straight stick laparoscopy. The robotic platform is a logical step forward to laparoscopy and if cost considerations are addressed may become popular among gynecological surgeons world over.