Pediatric Single-port, Robotic, Transvesical Vesicovaginal Fistula Repair
Brendan Frainey, MD, Annaliese Ionson, MD, Lauren Gleich, DO, Audrey Rhee, MD, Sandip Vasavada, MD, Zeyad Schwen, MD.
Cleveland Clinic, Cleveland, OH, USA.
BACKGROUND: Vesicovaginal fistula (VVF) is a rare condition in the pediatric population. While there has been an increase in the use of minimally invasive surgery within pediatric urology, this has rarely been applied to VVF repair in children. In this video, we describe a unique approach to pediatric VVF repair utilizing a single-port, robotic, transvesical approach in a young female patient.
METHODS: The patient is a 9-year-old otherwise healthy female with known vesicovaginal fistula and continuous urinary incontinence secondary to a bony spicule within the bladder and vagina following a pelvic fracture. She presented to our institution with recurrence of her fistula following attempted robotic, converted to open, fistula repair at an outside hospital.
Prior to definitive repair, the patient underwent exam under anesthesia, cystogram, cystoscopy, vaginoscopy, and bilateral retrograde pyelograms. Cystogram demonstrated immediate pooling of contrast within the vaginal fault. Cystoscopy and vaginoscopy confirmed the presence of a 5 mm to 1 cm VVF at the location of the midline bladder neck. Retrograde pyelogram did not demonstrate concomitant ureterovaginal fistula. No residual bony fragments were noted.
On the day of transvesical repair, the patient was placed in the dorsal lithotomy position. Cystoscopy confirmed the presence of the fistula. The bilateral ureteral orifices were cannulated with ureteral catheters. Transvesical access was obtained through a 3.0 cm midline vertical suprapubic skin incision using her previous scar. A vertical midline cystotomy was made. A wound retractor was placed into the bladder. A Da Vinci Access Port was introduced with the associated 8 mm AirSeal trocar in place. The bladder was then insufflated to 8 mmHg. The DaVinci Single-port robot was then docked. A camera, monopolar scissors, bipolar Maryland, and Cadiere forceps were utilized.
Via the transvesical approach, the fistula was easily visualized along the midline bladder neck and cannulated with a Glidewire. Using the Glidewire to guide dissection, the fistula was circumferentially dissected with monopolar scissors, elevating the bladder and vaginal mucosa away from the fistula tract. The fistula tract was excised. The vagina and bladder were then each closed separately with interrupted 4-0 Vicryl ensuring non-overlapping suture lines. The repair was tested and noted to be water-tight. The robot was undocked and the cystotomy was closed in two layers. A 16 Fr suprapubic catheter (SPT) was placed and left to gravity drainage.
RESULTS: Operative time was 320 minutes. Estimated blood loss was 10 cc. The patient did well post-operatively and was discharged within 24 hours of her procedure. She only required a single dose of oxycodone peri-operatively and was discharged with only acetaminophen and ibuprofen for post-operative pain control. Voiding cystourethrogram 2 weeks after discharge demonstrated a normal cystogram with no evidence of fistula recurrence. Her SPT was removed at that time and she was voiding well per urethra without leakage at 1 month post procedure
Conclusion: Single-port, robotic VVF repair via a transvesical approach is a novel, safe and feasible approach in select pediatric patients with VVF, particularly in younger patients with limited transvaginal access and/or prior abdominal procedures.
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