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abstract

414 - ROBOTIC REPAIR OF SUPRATRIGONAL VESICOVAGINAL FISTULA WITH SIGMOID EPIPLOICA APPENDAGE INTERPOSITION: A CASE SERIES

414

ROBOTIC REPAIR OF SUPRATRIGONALVESICOVAGINAL FISTULA WITH SIGMOID EPIPLOICA APPENDAGE INTERPOSITION:A CASE SERIES

D. SANDERSON1, K. FAN1, J. RUTKOWSKI 2, A. EDDIB 2;
1Millard Fillmore Suburban Hosp., Williamsville, NY,2Western New York Urology Associates, Cheektowaga, NY.

Introduction: Surgicalcorrection of vesicovaginal fistulae (VVF) has been burdensome toboth the patient and surgeon (1-3). Successful repair is dependentupon a multitude of factors including fistula size, location, timingof antecedent injury, previous radiation, use of interposition flaps,surgeon skill and technique, surrounding tissue quality, andpost-operative bladder drainage (1-3). Although controversial, theuse of tissue interposition during primary repair of VVF has beenadvocated to improve healing and decrease the risk of recurrence(2,3). Vascularized omentum is the most commonly used tissue forinterposition, but requires access to the upper abdomen and creationof a J flap to facilitate mobilization and maintenance of vascularity(2,3). Interposition of sigmoid epiploica appendage(s) during VVFrepair has been successful and avoids the technical challenges posedby interposition of omentum.
Objective: The aim of thisstudy is to present our experience with sigmoid epiploicainterposition during robotic repair of supratrigonal VVF using anintraperitoneal, extravesical technique.
Methods: Clinicaland surgical data was abstracted from June of 2015 to September of2016. Features of the surgical technique include: 1) cystoscopy withplacement of bilateral retrograde ureteral catheters, 2)cannulization of the fistula with an open-ended catheter exitingthrough the vagina, 3) 5 port peritoneal access with the da Vinci®Surgical System (Intuitive Surgical, Sunnyvale, CA) with a bedsideassistant port, 4) adhesiolysis if needed for exposure, 5)mobilization of the bladder from the vagina, 6) removal of theepithelialized edges of the fistulous tract, 7) single-layer closureof the vagina, 8) tension-free layered closure of the bladder, 9)pressure testing the bladder repair with 300 mL of sterile water, 10)interposition of sigmoid epiploica appendage(s), and 11) prolongedbladder drainage with indwelling transurethral catheter.
Results:In the group of 5 VVF repairs identified during the study period,abdominal hysterectomy was the most common antecedent surgicalprocedure. At time of repair, patients had an average age of 51.8years and a body mass index (BMI) of 32.4 kg/m2. Theaverage operative time was 218 minutes with robotic console time of147 minutes on average. Patients experienced an average estimatedblood loss (EBL) of 49 mL and received 5.4 morphine milligramequivalents (MME) in the post anesthesia care unit (PACU). Most thepatients were discharged to home on post-operative day 1. To date,all repairs have been successful without recurrence at 5 to 19months.
Conclusions: The use of sigmoid epiploicaappendages for tissue interposition during robotic repair of VVFappears safe and efficient with low morbidity. The use of epiploicamay increase the number of patients eligible for interposition due tothe proximity of the tissue to the operative field.
References:

  1. Flores-CarrerasO, Cabrera JR, Galeano PA, Torres FE. Fistulas of the urinary tractin gynecologic and obstetric surgery. Int Urogynecol J Pelvic FloorDysfunct. 2001; 12(3):203-14.

  2. Evans DH,Madjar S, Politano VA, Bejany DE, Lynne CM, Gousse, AE.Interposition flaps in transabdominal vesicovaginal fistula repairs:are they really necessary? Urology. 2001 Apr;57(4):670-4.

  3. Miklos JR,Moore RD, Chinthakanan O. Laparoscopic and robotic-assistedvesicovaginal fistula repair: a systematic review of the literature.J Minim Invasive Gynecol. 2015 Jul-Aug;22(5):727-36.