Surgical Techniques

Robotic vesicovaginal fistula repair: A systematic, endoscopic approach

OBG Manag. 2013 July;25(7)
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FIGURE 2: Ideal port placement
Place the camera port supraumbilically, with two 8-mm robot ports to the left side of the umbilicus and one to the right. Separate each port by approximately 10 cm. Place an assistant port to the far right for passing and retrieving sutures.

Figure 2. Ideal port placement
Place the camera port supraunbilically, with two 8-mm robot ports

3. Place a vaginal stent to aid dissection

The stent should be a sterile cylinder and have a diameter of 2 cm to 5 cm (to match the vaginal caliber). The tip should be rounded and flattened, with an extended handle available for manipulating the stent. The handle can be held by an assistant or attached to an external uterine positioning system (FIGURE 3); I use the Uterine Positioning SystemTM (Cooper Surgical, Trumbull, Connecticut).

FIGURE 3: Stent and uterine positioning
The rounded and flattened tip of the stent should have an extended handle
available for manipulation by an assistant or for attachment to an external
uterine positioning system.

4. Incise the vaginal cuff

Transversely incise the vaginal cuff with the monopolar scissors (VIDEO 1).

This allows entry into the vagina at the apex. The blue stent in the fistula should be visible at the anterior vaginal wall, as demonstrated in FIGURE 4.

FIGURE 4: Visualization of the fistula stent
The blue stent in the fistula should be visible at the anterior vaginal wall. The larger silver stent, shown here in the vagina, also acts to preserve the pneumoperitoneum.

5. Dissect the vaginal wall

Dissect the anterior vaginal wall down to the fistula, and dissect the bladder off of the vaginal wall for about 1.5 cm to 2 cm around the fistula tract (FIGURE 5 and VIDEO 2).

FIGURE 5: Dissect the vaginal wall
Dissect the anterior vaginal wall down to the fistula, and dissect the bladder off of the vaginal wall for about 1.5 cm to 2 cm around the fistula tract.

6. Cut the stent

Cut the stent passing thru the fistula, to move it out of the way.

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