Robot-assisted laparoscopic repair of supratrigonal vesicovaginal fistulae with peritoneal flap inlay

Abstract

Vesicovaginal fistulae have always been a highly problematic complication. Nowadays, most cases are complications after hysterectomy or obstetric surgery, whereas obstructed labour is the main aetiology in underdeveloped countries. The localisations and dimensions of the fistulae are very different dependent on their aetiology. Obstructed labour leads to necrosis of the anterior vaginal wall and consequently to a lower, urethrovaginal, vesicovaginal or combined fistula. After hysterectomy, we know that fistulae occur in about 1/1800 cases. At a rate of 600,000 hysterectomies in the United States in 2003, we can assume approximately 330 fistulae had to be treated in that year. This makes it not only a social but also an economic issue. These fistulae are usually found to be supratrigonal and sometimes located high on the bladder dome. This fact makes it very demanding or even impossible to operate transvaginally. They occur after inadvertent lesion of the bladder or ureters, operation-site infection or tumourous diseases. The success rate of either repair is between 75 and 97% depending on the method and complexity. Smaller fistulae can be treated by transurethral drainage and sometimes by transurethral coagulation of the bladder wall, depending on their aetiology. However, the long-term results are not very impressive (7-12.5%). A valuable alternative to conservative treatment is the use of fibrin glue. In case of failure, the operative access is still available.