Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
Da Vinci Single Port (SP) technology has recently been approved by the FDA for the urological procedures that are appropriate for a single port approach. Herein, we aim to report our initial experience with SP robotic-assisted vesicovaginal fistula (VVF) repair.
A 31-year-old female presented due to continuous urinary incontinence. She had a history of placenta accreta which necessitated hysterectomy at an outside hospital 2 months before. Hysterectomy was complicated with bladder wall injury and primary repair together with bilateral ureteral reimplantation had been performed at the same session. She then started to complain of continuous urinary leakage per vagina and was referred to us. She was noted to have VVF on pelvic examination and cystoscopic evaluation. Transvaginal VVF repair with Martius flap interposition was performed. However, urinary incontinence did not resolve and persistent fistula was detected on cystogram and cystoscopy 3 months after the transvaginal repair. There was a large defect on the posterior bladder wall, close to the left ureteral orifice. Based on these findings, she was scheduled for a definitive repair with the SP robotic-assisted laparoscopic route owing to its proposed benefits such as; the flexible camera providing improved visualization deep within the pelvis, minimal risk of instrument collision, and a single abdominal incision ensuring better cosmesis and potentially less pain.
She was positioned in lithotomy and Trendelenburg. Cystoscopy was repeated, double-j stents were replaced with 5-Fr. open-ended ureteral catheters. Fistula tract was cannulated with a 10-Fr. foley catheter. Then, a 3-cm skin incision was made through the umbilicus. The SP robotic trocar was located at the umbilicus and the robot was docked. Once the pelvis was reached, the fistula tract was identified. Cystotomy was made and carried down to the ostium of the fistula. Traction on the catheter within the fistula tract enabled ready identification of the bladder and vaginal boundaries and aided in dissection. Bladder wall and vaginal wall were separated from each other at the level of fistula. Fistula tract was completely excised. The defects on the bladder and vaginal walls were closed and then omental interposition was performed. A 20-Fr. foley catheter was placed to drain the bladder effectively. The ureteral catheters were left in place. A drain was placed in the pelvis. The robot was undocked and the fascia was closed. Ureteral catheters were removed on postoperative day (POD) 2. Postoperative course was complicated by paralytic ileus which resolved by conservative measures. She was discharged home with the indwelling foley catheter after removing the drain on POD 3. Foley catheter was removed on POD 21 after confirming the absence of urinary extravasation on cystography.
This case represents the first use of the SP platform in robotic-assisted vesicovaginal fistula repair. We found the flexible camera benefitted identification and dissection of the tissue planes, which was critical in this complicated patient with a history of pelvic surgeries and failed transvaginal VVF repair.