fistulas inaccessible from the vagina may require abdominal repair ; we sought to evaluate the robotic - assisted laparoscopic approach for this procedure .
a 41-year - old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy , and office evaluation identified a vesicovaginal fistula .
after discussion with the patient regarding the surgical options , the robotic approach was chosen to facilitate precise dissection , fine visualization , and suturing .
a stent was placed from the bladder into the vagina , and no intentional cystotomy was made .
the bladder was dissected away from the anterior vaginal wall at the fistula site , and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon .
total operative time was approximately 4 hours , and robotic time was about 2.5 hours .
the robotic - assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated .
most vesicovaginal fistulas in the united states today are the result of abdominal gynecologic surgery and may not have been detected or predictable based on the original surgery .
patients typically complain of incontinence of urine , particularly upon standing . after confirming the absence of urinary tract infection , a careful speculum examination
should be done to look for vaginal mucosa defects . additionally , use of medication to dye the urine while a tampon is in the vagina may confirm the presence of a connection .
, imaging should be used to investigate for involvement of the upper urinary tract . if conservative options fail and after allowing postoperative inflammation to subside , traditional surgical options have included vaginal repair , usually using the latzko technique , or an abdominal incision for open repair .
patients are typically offered an abdominal repair if the defect is large , multiple , involves other pelvic structures including the ureters , or if there is poor descent of the vaginal cuff causing the defect to be inadequately visualized from a vaginal approach .
prior reports , however , have often included the use of an intentional cystotomy to facilitate dissection . because of the morbidity and recovery required for an abdominal incision
, we sought to evaluate the role of the da vinci robotic system ( intuitive surgical , sunnyvale , ca , usa ) to facilitate repair of a vesicovaginal fistula .
a 41-year - old , nulliparous woman presented with urinary incontinence after an emergent total abdominal hysterectomy with bilateral salpingectomy .
there was no difficulty with dissection of the bladder or cystotomy noted at the time of the procedure . a phenazopyridine tampon test in the office 2 weeks after the surgery confirmed a connection from the bladder to the vagina .
a 1 cm opening was identified on the base of the bladder above the trigone to the right of the midline and 2 cm posterior to the interureteric ridge .
the ureteral orifices did not appear to be compromised by the fistula and outflow was seen from both .
the patient declined prolonged drainage with a catheter after counseling that this might promote healing .
given the difficulty in visualizing the lesion and the lack of cuff descent in this nulliparous woman , an abdominal rather than vaginal approach for repair was recommended .
after discussion with the patient regarding the risks and benefits of an open abdominal procedure , a laparoscopic repair , or a robotic approach , the patient chose the robotic surgery .
the similarities and differences between the 3 procedures were discussed with the patient , along with the attending surgeon 's experience with robotic surgery , which spans 4 years .
the patient was aware that the surgery could be converted to laparoscopy or an open procedure should there be any difficulty with the robotic approach .
the surgery was scheduled approximately 3 months after the hysterectomy had been performed . in the operating room
, the patient was positioned in the dorsal lithotomy position similar to that used in standard laparoscopy .
on cystoscopy , the fistula was noted , and a 5-french pollack stent was placed from the bladder through the fistulous tract into the vagina .
double j ureteral stents were placed over guide wires , given the close proximity of the ureteral orifices to the fistula and repair .
the hasson technique was chosen for umbilical port access due to the patient 's previous surgery .
the camera was placed through a 12 mm port located superior to the umbilicus and approximately 18 cm superior to the symphysis pubis .
twelve mm and 5 mm assistant ports were placed on the right side , and 8 mm robotic trocars were inserted on the lateral edge of the rectus muscles bilaterally ( figure 1 ) .
lysis of omental and small bowel adhesions in the area of the previous incision was performed using hook cautery and the 30-degree  up  lens .
port placement for robotic - assisted vesicovaginal fistula repair : c = 12 mm camera port ; r = 8 mm robotic ports located on lateral edge of rectus muscles ; s = 5 mm suction port ; a = 12 mm assistant port located superior and medial to anterior superior iliac spine .
the vaginal cuff was identified by a sponge stick in the vagina and dissection proceeded along the anterior vaginal wall .
the bladder was dissected away from the anterior vaginal wall by using hook cautery and the 0-degree lens for the robotic camera .
fluid containing indigo carmine was instilled into the bladder and was seen coming from the fistula site .
the bladder was repaired by using a running stitch of 3 - 0 vicryl on an rb needle using the da vinci robot .
a second layer of closure was performed in an imbricating fashion with the same suture .
the vagina was closed using a running stitch of 2- 0 monocryl on an sh needle .
the ureteral stents were removed without difficulty , and backfill of the bladder again using indigo carmine failed to reveal any interruption of bladder integrity . a fatty epiploica from the sigmoid colon
total operative time , including patient positioning , cystoscopy for ureteral stents , and fistula identification , was approximately 4.5 hours .
she returned for a follow - up 3 weeks after surgery and reported no continuing symptoms of urinary incontinence .
as in this patient , abdominal hysterectomy is the most common cause of vesicovaginal fistula in developed countries , while obstetric causes are much less common .
although conservative management is successful in some patients , and others are candidates for vaginal repair , some patients may not be candidates or may be unsatisfied with these options .
the laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated . as with other laparoscopic surgeries , this provides superior magnification of tissue , visualization of any additional pathology , and requires no large abdominal incision .
additionally , laparoscopic and robotic surgery may result in a shorter hospital length of stay and improved cosmesis as compared with open abdominal surgery .
however , this may be an obstacle to surgeons without laparoscopic suturing or advanced dissecting skills .
the da vinci robotic tower includes 1 camera arm and 2 to 3 instrument arms that are controlled remotely by the surgeon sitting at a nonsterile console .
once a surgeon is trained to use the robotic - assisted approach , the da vinci robot can be used to facilitate the laparoscopic repair .
its advantages include improved dexterity with increased degrees of freedom giving the surgeon the sensation of having wrists rather than lever arms , enhanced magnification , 3-dimensional visualization providing depth perception similar to that of open surgery , increased surgeon comfort with a seat and decreased surgeon hand fatigue compared with traditional operative laparoscopy . a successful robotic - assisted technique has been described . in both of these previous reports of this surgical technique ,
intentional cystotomies were made in a healthy area of the posterior wall of the bladder to facilitate identification and repair .
a stent placed cystoscopically from the bladder into the vagina , as explained here , may obviate the need to make an intentional cystotomy .
this may decrease the risk of recurrence and length of postoperative catheterization . because robotic surgery is relatively new to gynecology , its ultimate role is still evolving .
procedures that involve a high degree of precision and technical skill like suturing appear to be the first areas of application of this technology , given the advantages of robotic surgery over traditional laparoscopy .
given the extent of gynecologic surgery that is performed laparoscopically at this point , it is reasonable to believe that robotic surgery could have an expanding list of uses .
as the case volume grows , additional studies should be carried out to assess the benefits of robotic assistance over traditional laparoscopy or other surgical approaches .
although the vaginal approach is the most common for repair of vesicovaginal fistulas , the robotic - assisted laparoscopic approach can also be a successful option in patients for whom the vaginal approach is not possible .
 background and objectives : fistulas inaccessible from the vagina may require abdominal repair ; we sought to evaluate the robotic - assisted laparoscopic approach for this procedure.methods:a 41-year - old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy , and office evaluation identified a vesicovaginal fistula . 
 after discussion with the patient regarding the surgical options , the robotic approach was chosen to facilitate precise dissection , fine visualization , and suturing . 
 a stent was placed from the bladder into the vagina , and no intentional cystotomy was made . 
 the bladder was dissected away from the anterior vaginal wall at the fistula site , and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon . 
 total operative time was approximately 4 hours , and robotic time was about 2.5 hours.results:at 3 months after surgery , the patient had no recurrent symptoms.conclusions:the robotic - assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated . 
Background and Objectives:
Methods:
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INTRODUCTION
CASE REPORT
CONCLUSION