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

Genitourinary Fistula: 5 Years' Experience of Five Referral Centers in Iran

INTRODUCTION AND HYPOTHESIS

Genitourinary fistula is a devastating ailment that has an impact on women's physical health, mental health, emotional health, and financial security. The management of genitourinary fistula depends on the type, size, and duration of fistula formation. The purpose of this study is to report the features of genitourinary fistula in Iranian women and our experience in the management of fistula.

METHODS

Retrospective chart reviews of 283 patients were performed to determine the cause of the fistula, prior repairs, tissue interposition, and the success rate. The operation was considered successful if the patient did not have any urine leakage during the observation time.

RESULTS

The mean (SD) age of women was 49.51 (19.39; range: 21-70) years, Of these, 137 (52.9%) had a history of previous genitourinary fistula surgery. The average fistula was 1.53 (0.041) cm in size. The median (interquartile range) operation lasted 70 (15) min. The success rate after fistula repair was 91.5%. The typical follow-up period lasted 13.26 (range: 1-88) months. Forty-three (15.2%) patients had a big fistula (>2.5 cm) and 4 patients (1.4%) had a history of pelvic radiation therapy, among other reasons for failure. After a second repair, all patients' initial failures were resolved. There were no significant complications, as classified by Clavien-Dindo class 2 or greater. Additionally, there were no bowel, ureteral, or nerve injuries.

CONCLUSIONS

Our patients with genitourinary fistula had a successful outcome following repair techniques, without any significant morbidity or mortality.

Comparative Analysis Between Laparoscopic Extravesical Repair and Laparoscopic O'Connor Repair for Supratrigonal Vesicovaginal Fistula

OBJECTIVE

The objective of the study was to conduct a comparative analysis of various intraoperative parameters and postoperative outcomes between the laparoscopic extravesical repair versus the laparoscopic O'Connor repair techniques in management of supratrigonal vesicovaginal fistula.

METHODS

A prospective nonrandomized study was conducted from January 2018 to January 2023, in which 36 patients who met inclusion criteria like primary or recurrent, single, simple, supratrigonal vesicovaginal fistula were included. Among these patients 18 patients were operated with laparoscopic O'Connor repair, while 18 were operated with laparoscopic transperitoneal extravesical vesicovaginal fistula repair. Intraoperative and postoperative parameters of these 2 techniques were compared.

RESULTS

Laparoscopic O'Connor repair had longer operative time of 140 minutes, while laparoscopic extravesical VVF repair had an operative time of 117 minutes (P = .026). Mean blood loss was also significantly higher in laparoscopic O'Connor (210 mL versus 95 mL) (P = .004). Postoperative complications and analgesics requirement were less with laparoscopic extravesical repair. Hence, laparoscopic extravesical repair reduced mean hospital stay (3.2 days versus 3.9 days) (P = .003). A success rate of 83.33% for laparoscopic O'Connor and 94.45% for laparoscopic extravesical repair (P = .153) was recorded.

CONCLUSION

Laparoscopic extravesical approach appears to be a convenient and effective method in selective supratrigonal vesicovaginal fistula repair.

Robot-assisted laparoscopic pelvic floor surgery: Review

Minimally invasive surgical techniques have become more common in pelvic floor reconstructive urogynaecological surgery, specifically, robotic-assisted pelvic floor surgery. Female pelvic floor anatomy is complex, and some repairs require highly experienced surgical skills that can be gained more easily using robotic-assisted surgery. A common application of the robotic platform in urogynaecological surgeries includes sacrocolpopexy, which has become the gold standard approach in the last decade for the correction of apical prolapse. Additional procedures include sacrohysteropexy, sacrocervicopexy, fistula repair, and complex procedures involving the bladder and other pelvic organs. Despite its increasing use and clear benefit in our field, data in the literature and, in particular, randomised controlled trials are sparse. This review provides an update, incorporating recently published literature and our personal experience in that field.

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.

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.

Radiation-Induced Recurrent Vesicovaginal Fistula-Treatment with Adjuvant Platelet-Rich Plasma Injection and Martius Flap Placement-Case Report and Review of Literature

Vesicovaginal fistula is the non-physiological connection between the urinary bladder and vagina. This results in continuous urine leakage. In developed countries, the prevalence of this condition is low and affects (mainly) women with a history of gynaecological procedures or radiotherapy. The aim of this study was to present the therapeutic process of a patient with radiation-induced, recurrent vesicovaginal fistula. The thirty-eight-year-old patient underwent radical hysterectomy with follow-up radiotherapy due to cervical cancer. Five years after the therapy, she was diagnosed with vesicovaginal fistula. After two unsuccessful Latzko procedures and two adjuvant platelet-rich plasma injections, a third Latzko reconstructive surgery was performed with additional transposition of the Martius flap—with successful closure of the fistula.

Cost-effectiveness Analysis of Universal Cystoscopy at the Time of Benign Laparoscopic Hysterectomy

STUDY OBJECTIVE

To estimate the rate of lower urinary tract injury (LUTI) and percentage of LUTI needing to be recognized intraoperatively to make universal cystoscopy cost-effective and cost-saving during laparoscopic hysterectomy.

DESIGN

A decision tree model was used to estimate the costs and quality-adjusted life years associated with delayed or intraoperative recognition of LUTI at the time of laparoscopic hysterectomy. Probabilities and utilities were estimated from published literature. Costs were estimated from Medicare national reimbursement schedules. Threshold analyses estimated the LUTI rate and cystoscopy sensitivity that would make universal cystoscopy cost-effective or cost-saving. Monte Carlo simulations were performed.

SETTING

US healthcare system.

PATIENTS

Individuals undergoing laparoscopic hysterectomy for benign indications.

INTERVENTIONS

Theoretic implementation of a universal cystoscopy policy.

MEASUREMENTS AND MAIN RESULTS

The total direct medical costs of laparoscopic hysterectomy under usual care were $8831 to $9149 and under universal cystoscopy were $8944 to $9068. When low LUTI rates (0.44%; estimated using sample-weighted estimates of retrospective and prospective data) were assumed, universal cystoscopy was only cost-effective in 17.1% of the simulations; the incremental cost was estimated to be $111 to $131. With median LUTI rates (2.3%) or high LUTI rates (4.0%; estimated using only prospective data with universal screening), the universal cystoscopy strategy was cost-effective in 93.9% and 99.6% of the simulations, respectively, and potentially cost-saving if the sensitivity of intraoperative cystoscopy for ureteral injury exceeded 65% or 31%, respectively. The estimated potential savings were $18 to $95 per hysterectomy. In threshold analysis assuming the average cystoscopy sensitivity rate, universal cystoscopy is estimated to be cost-effective when the LUTI rate exceeds 0.80%.

CONCLUSION

In our model, universal cystoscopy is the preferred approach for laparoscopic hysterectomy and is estimated to be cost-effective in contemporary clinical settings where the LUTI rate is estimated to be 1.8% and potentially cost-saving among higher-risk populations, including those with endometriosis or pelvic organ prolapse. If the LUTI rates are less than 0.75%, the estimated incremental costs are modest-up to $131 per case. Administrators and providers should consider the local LUTI rates and practice patterns when planning implementation of a universal cystoscopy policy.

Transvesicoscopic Bipolar Sealing of Vesicovaginal Fistula

Introduction: Vesicovaginal fistula (VVF) is a problem that physically and psychologically debilitates the patient. Options for treatment of VVF include transabdominal, transvaginal, transvesical, laparoscopic, and robotic repair or minimally invasive methods such as fulguration. We describe a novel minimally invasive technique: transvesicoscopic bipolar sealing of the vesicovaginal fistula (TBSF).

Case Presentation: We carried out the transvesicoscopic sealing of VVF with 5 mm of diameter on a 46-year-old woman, who had a failed conservative treatment with a Foley catheter placement. The patient was informed about the modified surgical procedure before operation. The fistula tract was sealed by using an electrothermal bipolar vessel sealer through a 5-mm transvesical ports. The patient was discharged on the first postoperative day and was on anticholinergic medications after the operation. The patient remained dry after the removal of the catheter at the third postoperative week.

Conclusion: In select cases of VVF, TBSF may be effectively used for closure of the fistula tract.

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.