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Robotic Surgical Management of Urinary Fistulae

  • René Javier Sotelo Noguera
  • Roberto Garza Cortés
  • Lee Richstone
Chapter

Abstract

In this chapter, we discuss the robotic handling of urinary fistulas, mainly three types of fistulae: vesicovaginal, ureterovaginal, and rectourinary fistula. Vesicovaginal fistula (VVF) is mostly secondary to urogynecologic procedures in developed countries, abdominal hysterectomy being the main cause of this condition. Conservative management has been described for this type of fistula, where low success rates (7–12%) have been reported. Surgical management includes open, laparoscopic, as well as robotic surgery. Robotic-assisted laparoscopic vesicovaginal fistula repair is feasible and associated with distinct advantages. Although direct comparisons to an open transabdominal, vaginal, or laparoscopic approach are lacking, preliminary data suggests that this technique is at least as effective. Ureterovaginal fistulas may occur following pelvic surgery, particularly gynecological procedures, or as a result of vaginal foreign bodies or stone fragments after shock wave lithotripsy. Patients typically present with global and persistent urine leakage through the vagina; this causes patient discomfort, distress, and typically protection is used to stay dry. Several techniques for the management of ureterovaginal fistulae have been described. Initial management is often conservative but typically fails. When conservative and/or endoscopic approaches fail, formal repair with an open, laparoscopic, or robotic approach is warranted. In this chapter, we will describe the surgical technique of robotic-assisted ureterovaginal fistula repair. Rectourinary fistulae (RUF) are uncommon and can be difficult to manage clinically. Although they may develop in patients with inflammatory bowel disease and perirectal abscesses, they most frequently result as an iatrogenic complication of extirpative or ablative prostate procedures. Rectourethral fistulae can also develop following ablative therapies or surgery for benign prostatic hyperplasia, typically between the prostatic urethra and the rectum. Rectovesical fistula usually develops following radical prostatectomy, and occurs along the vesicourethral anastomotic line or along the suture line of a posterior “racquet-handle” closure of the bladder. Conservative management consisting of urinary diversion, broad spectrum antibiotics, and parenteral nutrition is often initially attempted, but these measures often fail. Timing of repair is often individualized mainly according to the etiology, delay of diagnosis, size of fistula, the first or subsequent repairs, and the general condition of the patient. More than 40 surgical techniques for the management of RUF have been described and there is no data clearly favoring one approach. Transanal, transanorectal, transsphincteric, transabdominal, perineal, and combined approaches are frequently used. Encouraged by our experience in robotic surgery, and having demonstrated feasibility with the laparoscopic approach, we duplicate the fundamental principles of fistula repair with robotic assistance.

Keywords

Vesicovaginal fistula Ureterovaginal fistula Rectourinary fistula Rectourethral fistula Robotic surgical management of urinary fistulae 

References

  1. 1.
    Miller EA, Webster GD. Current management of vesicovaginal fistulae. Curr Opin Urol. 2001;11:417-421.PubMedCrossRefGoogle Scholar
  2. 2.
    Phipps J. Laparoscopic repair of posthysterectomy vesicovaginal fistula. Two case reports. Gynecol Endosc. 1996;5:123-124.Google Scholar
  3. 3.
    Raz S, Bregg K, Nitti V, Sussman E. Transvaginal repair of vesicovaginal fistula using a peritoneal flap. J Urol. 1993;150:56-59.PubMedGoogle Scholar
  4. 4.
    Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol. 1995;153:1110-1112.PubMedCrossRefGoogle Scholar
  5. 5.
    Raz S. Editorial comment on: early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol. 1995;153:1112-1113.CrossRefGoogle Scholar
  6. 6.
    Eilber KS, Kavaler E, Rodriguez LV, Rosenblum N, Raz S. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol. 2003;169:1033-1036.PubMedCrossRefGoogle Scholar
  7. 7.
    Nezhat CH, Nezhat F, Nezhat C, Rottenberg H. Lapa-roscopic repair of a vesicovaginal fistula: a case report. Obstet Gynecol, part 2. 1994;83:899-901.Google Scholar
  8. 8.
    von Theobald P, Hamel P, Febbraro W. Laparoscopic repair of a vesicovaginal fistula using an omental J flap. Br J Obstet Gynecol. 1998;105:1216-1218.CrossRefGoogle Scholar
  9. 9.
    Miklos JR, Sobolewski C, Lucente V. Laparoscopic management of recurrent vesicovaginal fistula. Int Urogynecol J. 1999;10:116-117.CrossRefGoogle Scholar
  10. 10.
    Nabi G, Hemal AK. Laparoscopic repair of vesicovaginal fistula and right nephrectomy for nonfunctioning kidney in a single session. J Endourol. 2001;15:801-803.PubMedCrossRefGoogle Scholar
  11. 11.
    Ou CS, Huang UC, Tsuang M, Rowbotham R. Laparoscopic repair of vesicovaginal fistula. J Laparoendosc Adv Surg Tech A. 2004;14:17-21.PubMedCrossRefGoogle Scholar
  12. 12.
    Sotelo R, Mariano MB, Garcia-Segui A, et al. Laparoscopic repair of vesicovaginal fistula. J Urol. 2005;173:1615-1618.PubMedCrossRefGoogle Scholar
  13. 13.
    Chibber PJ, Shah HN, Jain P. Laparoscopic O’Conor’s repair for Vesico-vaginal and Vesico-uterine fistulae. BJU Int. 2005;96(1):183-186.PubMedCrossRefGoogle Scholar
  14. 14.
    Melamud O, Eichel L, Turbow B, Shanberg A. Laparoscopic vesicovaginal fistula repair with robotic reconstruction. Urology. 2005;65(1):163-166.PubMedCrossRefGoogle Scholar
  15. 15.
    Sundaram BM, Kalidasan G, Hemal AK. Robotic repair of vesicovaginal fistula: case series of 5 patients. Urology. 2006;67:970-973.PubMedCrossRefGoogle Scholar
  16. 16.
    Schimpf MO, Morgenstern JH, Tulikangas PK, Wagner JR. Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report. JSLS. 2007;11:378-380.PubMedGoogle Scholar
  17. 17.
    Gill IS, Zippe CD. Laparoscopic radical prostatectomy: technique. Urol Clin North Am. 2001;28:423-436.PubMedCrossRefGoogle Scholar
  18. 18.
    Hosseini SY, Roshan YM, Safarinejad MR. Uretero vaginal fistula after vaginal delivery. J Urol. 1998;160:829.PubMedCrossRefGoogle Scholar
  19. 19.
    Selzman AA, Spirnak JP, Kursh ED. The changing management of ureterovaginal fistulas. J Urol. 1995;153:626-628.PubMedCrossRefGoogle Scholar
  20. 20.
    Mongiu AK, Helfand BT, Kielb SJ. Ureterovaginal fistula formation after oocyte retrieval. Urology. 2009;73:444. e1-e3.PubMedCrossRefGoogle Scholar
  21. 21.
    Patil NN, Mottrie A, Sundaram B, Patel VR. Robotic assisted laparoscopic ureteral reimplantation with Psoas Hitch: a multi-institutional, multinational evaluation. Urology. 2008;72(1):47-50; discussion 50. Epub 2008 Apr 2.PubMedCrossRefGoogle Scholar
  22. 22.
    Modi P, Gupta R, Rizvi SJ. Laparoscopic ureteroneocystostomy and Psoas Hitch for post hysterectomy ureterovaginal fistula. J Urol. 2008;180:615-617.PubMedCrossRefGoogle Scholar
  23. 23.
    Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol. 1994;152(6 pt 1):2057-2059.PubMedGoogle Scholar
  24. 24.
    Yohannes P, Chiou RK, Pelinkovic D. Pure robot assisted laparoscopic ureteral reimplantation for ureteral stricture disease. Case report. J Endourol. 2003;17(10):891-893.PubMedCrossRefGoogle Scholar
  25. 25.
    Rajesh Laungani, Nilesh Patil, Louis S.Krane, Ashok Hemal, Sahabuddin Raja, Hahendra Bhandari, Mani Menon. Robotic-Assited ureterovaginal fistula repair: report of efficacy and feasibility. Journal of laparoendoscopic and advanced surgical techniques. 2008;18(5): 731-734CrossRefGoogle Scholar
  26. 26.
    Naeyer GD, Migem PV, Schatteman P, et al. Pure robot assisted psoas hitch ureteral reimplantation for distal-ureteral stenosis. J Endourol. 2007;21:618-620.PubMedCrossRefGoogle Scholar
  27. 27.
    Thomas R, Davis R, Ahuja S. Toward out-patient radical prostatectomy: a cost effective cost management of patients with localized prostate cancer. Br J Urol. 1997;80(suppl 2):261.Google Scholar
  28. 28.
    Benoit RM, Naslund MJ, Cohen JK. Complications after radical retropubic prostatectomy in the Medicare population. Urology. 2000;56:116-120.PubMedCrossRefGoogle Scholar
  29. 29.
    Chrouser K, Leibovich BC, Sweat SD, et al. Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer. J Urol. 2005;173:1953-1957.PubMedCrossRefGoogle Scholar
  30. 30.
    Badalament RA, Bahn DK, Kim H, et al. Patient-reported complications after cryoablation therapy for prostate cancer. Urology. 1999;54:295-300.PubMedCrossRefGoogle Scholar
  31. 31.
    Blandy JP, Singh M. Fistulae involving the adult male urethra. Br J Urol. 1972;44:632.PubMedCrossRefGoogle Scholar
  32. 32.
    Al-Ali M, Kashmoula D, Saoud IJ. Experience with 30 posttraumatic rectourethral fistulas: presentation of posterior transsphincteric anterior rectal wall advancement. J Urol. 1997;158:421-424.PubMedCrossRefGoogle Scholar
  33. 33.
    Shin P, Foley E, Steers W. Surgical management of rectourinary fistulae. J Am Coll Surg. 2000;191:547-553.PubMedCrossRefGoogle Scholar
  34. 34.
    Garofalo TE, Delaney CP, Jones SM, Remzi FH, Fazio VW. Rectal advancement flap repair of rectourethral fistula: a 20-year experience. Dis Colon Rectum. 2003;46:762-769.PubMedCrossRefGoogle Scholar
  35. 35.
    Noldus J, Graefen M, Huland H. An “old technique” for a new approach for repair of rectourinary fistulas. J Urol. 1997;157(suppl 4):1547.Google Scholar
  36. 36.
    Bukowski T, Chakrabarty A, Powell I, Frontera R, Perlmutter A, Montie J. Acquired rectourethral fistula: methods of repair. J Urol. 1995;153:730-733.PubMedCrossRefGoogle Scholar
  37. 37.
    Zinman L. Managing complex rectourethral fistulas. Contemp Urol. 2005;17:30-38.Google Scholar
  38. 38.
    Harpster LE, Rommel FM, Sieber PR, et al. The incidence and management of rectal injury associated with radical prostatectomy in a community based urology practice. J Urol. 1995;154:1435-1438.PubMedCrossRefGoogle Scholar
  39. 39.
    Gibbons RP. Radical perineal prostatectomy. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s Urology. 7th ed. Philadelphia: Sanders; 1997:2589-2603.Google Scholar
  40. 40.
    Sotelo R, Garcia A, Yaime H, Rodríguez E, Dubois R, De Andrade R. Laparoscopic rectovesical fistula repair. J Endourol. 2005;19:603-607.PubMedCrossRefGoogle Scholar
  41. 41.
    Sotelo R, De Andrade R, Carmona O, et al. Robotic repair of rectovesical fistula resulting from open radical prostatectomy. Urology. 2008;72:1344-1346.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • René Javier Sotelo Noguera
    • 1
  • Roberto Garza Cortés
    • 2
  • Lee Richstone
    • 3
  1. 1.Department of UrologyLa Floresta Medical InstituteCaracasVenezuela
  2. 2.Section of Laparoscopic Minimally Invasive Surgery and RoboticsLa Floresta Medical InstituteCaracasVenezuela
  3. 3.The Smith Institute for UrologyThe North Shore – Long Island Jewish HospitalNew Hyde ParkUSA

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