Abstract
Introduction:
Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons.
Materials and Methods:
Group I—12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II—20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram–kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets.
Results:
In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant.
Conclusion:
The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.
Introduction
There are various techniques of VVF repair, and all of them can be performed either through abdominal or vaginal route. The abdominal route is preferred, especially for recurrent VVF, as it provides reproducible and durable results. 3,4 The disadvantage of the abdominal route is the associated morbidity and complication, which are much higher than those found in the vaginal route. The above disadvantage has been overcome with the advent of laparoscopic and robotic VVF repair. Another advantage of these minimal invasive procedures is that the results are as good as open VVF repair through the abdominal route. 5 Laparoscopic repair is technically demanding and can be performed by highly skilled surgeons, but this has been overcome by robot-assisted VVF repair. We have started performing robotic VVF repair since August 2006; and till June 2008, 12 robot-assisted VVF repairs have been performed for recurrent supra-trigonal VVF in our department. We, hereby, share comparative analysis of robotic versus open VVF repairs.
Materials and Methods
Twelve patients with recurrent VVF (group I), offered robot-assisted VVF repair from August 2006 to June 2008, were included in the present study. Twenty patients (group II) matched in all possible parameters with those of recurrent VVF with previous open surgical repair, which were performed in the same time period, were taken as controls (Table 1). Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, USG–kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and cysto-urethroscopy (to assess the site, size, number, relation to ureteric orifices, bladder neck, and the condition of surrounding tissues). The patients' details were retrospectively recorded from the case sheets (Table 1).
obst = obstetric; UTI = urinary-tract infection; VVF = vesico-vaginal fistula; TBA = trained birth attendant; pre-op = pre-operative; BA = birth attendant.
Surgical technique
Open repair
Surgery was performed in standard lithotomic position through abdominal approach. The abdomen was opened by lower midline incision. The bladder was mobilized from the vagina as much as possible followed by elevation of the bladder and anterior vaginal wall by stay sutures. The bladder was bivalved (extra-vesical approach) starting from the dome up to the level of fistula as described by O'Connor and Sokol 6 by a vertical midline incision, taking all precaution to avoid ureteral injury. The patency of both the ureters were confirmed by inserting 6/7F infant feeding tube through both the ureteric orifices up to the kidney. The fistula was excised and the bladder was well mobilized from the vagina. The anterior vaginal wall was closed water tight by 3-0 polyethylglycol interrupted stitches. The bladder was closed water tight over both supra-pubic and urethral catheter by 3-0 polyethylglycol interrupted stitches. J-shaped omental or peritoneal flap depending on availability was interposed between the bladder and vagina from above. After achieving complete hemostasis, a drain was placed in the recto-vaginal pouch, and the abdomen was closed by 1-0 loop Nylon. Postoperatively, the drain was removed in 48 hours or when it was <50 mL, whichever was later. The suprapubic catheter (SPC) was removed at 2 weeks, and the catheter was removed 4 to 7 days later by that time SPC tract used to heal.
Robotic VVF repair
The patient was placed in the low lithotomy position. A Double-J stent 6F, 26 cm was inserted in both the ureteric orifices. A 16F two way Foley catheter was transvaginally inserted in the urinary bladder through the fistula. The patient was tilted in steep Trendelenburg. Pneumo-peritoneum was established using a Veress needle in left hypochondrium in five cases and by open technique in seven cases. A 12-mm camera port was placed in midline ∼20 cm above the pubic symphisis supra-umbilical. Two 8 mm robotic ports were placed on either side at the para-rectus location over the spinal-umbilical line. A 5 mm port was placed on the right side 1 inch above and medial to the anterior superior iliac spine for assistance. Another 5 mm port was placed on the right side between the camera and the robotic port for suction. We transferred sutures through the robotic or camera port after removing the instrument, avoiding need for another 12 mm port. The dissection started with adhesion-lyses, after which anterior surface of the uterus and superior surface of the bladder were exposed by blunt and sharp dissection with Maryland fenestrated bipolar forceps and monopolar curved scissors to expose the anterior surface of the uterus. The sigmoid colon and small intestine were removed away from the urinary bladder and uterus. The fistula was localized by manipulating the Foley catheter, which was passed through the vagina. A small incision was made in the bladder. The vaginally placed Foley catheter was pulled intra abdominally through the cystotomy incision and was used to retract the anterior wall of the bladder, which improved the visualization of the fistula and the ureteric orifices. Loss of pneumo-peritoneum was prevented by externally clamping the Foley catheter and packing the vagina with wet sponge. The bladder was separated from the lower uterine segment and vagina by blunt and sharp dissection. The margin of fistula was freshened, and both the vagina and urinary bladder were repaired by intermittent stitches with 3-0 polyglactin. Tissue interposition between the bladder and vaginal suture lines was performed with omentum, peritoneal flap, or epiploic appendices of the sigmoid colon depending on its availability. A 14F suction drain was placed in the recto-vaginal pouch. Postoperatively, the drain was removed 24 to 48 hours after surgery when drainage was <50 mL. The urethral catheter was removed after 2 to 3 weeks.
Results
The result in detail is described in Table 2. Statistical analysis was performed using chi-square test for qualitative variables and Student's t-test for quantitative variables. p-Value <0.05 was considered significant. All the patients in group I (robotic repair) were successfully managed (100% success rate) as compared with 90% in group II. Although success rate was higher for robotic repair, it was not statistically significant. Mean blood loss was significantly less (mean 88 mL) in group I than in group II (170 mL). The mean hospital stay was also significantly less in group I (mean 3.1 days) compared with group II (mean 5.6 days). None of the patients had complications in group I, whereas two patients in group II developed complications (one each wound infection and dyspareunia). None of the patients in either group developed incontinence.
Discussion
The most common causes of VVF are obstructed labor (obstetrical cause) and abdominal hysterectomy in developed countries. 6 Recurrent VVF poses a great challenge to the treating surgeon due to the associated technical difficulty. There are various techniques for managing the VVF, claiming success rate from 88% to 100%. 7 Although the open surgical repair is claimed to provide reproducible and durable results, the associated morbidity remains the major problem with it. 8 Success rate of open surgical repair in present series is similar to as reported in literature. 9 –11 Robotic (da Vinci surgical system; Intuitive Surgical, Sunnyvale, CA) and laparoscopy-assisted repair through abdominal route has reduced the morbidity of open surgical repair without compromising the success rate. 12
Laparoscopic repair for VVF was first reported by Nezhat et al 13 in 1994; whereas recurrent VVF laparoscopic repair was first reported by Miklos et al. 14 Although the laparoscopic VVF repair has many advantages in form of excellent results along with reduced morbidity, its biggest drawback is the steep learning curve associated with it. This drawback has been overcome by incorporating the assistance of robots for VVF repair. The advantages associated with robotic repair over laparoscopic repair are three-dimensional visualization (improved depth perception), motion scaling, termer filtration, higher magnification (10 times), and endo-wrist with 7° mobility leading to improved dexterity and absence of fatigue. All these contribute to better reconstruction. The first robot-assisted VVF repair was reported by Melamud et al 15 in 2005 from the University of California in a 44-year old woman.
Sundaram et al 16 reported their series of five patients with robotic repair of VVF in 2006. Although their success rate was 100% similar to the present series, the present series was much larger (n = 12). All the five patients in their series had fistula of gynecological origin (four after vaginal hysterectomy and one postmyemectomy), whereas in the present series eight had obstetric (six due to obstructed labor and two due to cesarean) and four had gynecological causes (posthysterectomy). The other important factor was that all the patients included in the present series had recurrent fistula causing technical difficulty in contrast to their series in which all had primary VVF. Still, we achieved 100% success rate. The blood loss was comparable in both the series (70 vs. 88 mL), but the hospital stay was significantly less in the present series as compared with their series (3.1 vs. 5 days). The other technical differences between the two series were as follows. The access for creating pneumo-peritoneum was either by inserting Veress in left hypochondrium or by open access, because all the patients in the present series had previous open surgical repair. We had to perform extensive adhesion lyses before repairing the fistula. We used a 5 mm assistant port instead of 10 mm used in their series.
To our knowledge, this is the first series comparing robotic VVF repair with open surgical repair. Till now, the largest series of robotic VVF repair was reported by Hemal et al 12 (n = 7) from the same department in 2008, but it was restricted to the experience of robotic VVF repair; whereas the present series is a comparative one between robotic and open surgical repair of VVF.
The present study may have some lacunae due to its retrospective nature. We need to perform a prospective study for precisely testing the results of the present study.
In a nut shell, robotic surgical repair is as efficacious, easy to perform, and safe as open surgical repair with less morbidity, blood loss, hospital stay with nearly equal success rate, and operating time. The last point needs further clarification by conducting a prospective study with more number of patients.
Conclusion
The present study suggests that robotic repair of recurrent VVF results in reduced morbidity and excellent success rate. The suturing part of repair becomes very easy by its use. It is an excellent option for recurrent fistulas, which are otherwise difficult to manage; but the cost is a major hindrance to its routine use for VVF repair.
Footnotes
Disclosure Statement
No competing financial interests exist.